Currentharvard pilgrim health carePolicy N/A

Co Occurring Enhanced Residential Rehabilitation Services Rrs Performance Specifications

Service-level performance specifications governing program structure, staffing, clinical components, assessment, treatment and discharge requirements for Co-Occurring Enhanced Residential Rehabilitation Services (ASAM Level 3.1) applied to specified Tufts Health Plan products (notably Tufts Health Together and Tufts Health One Care).

Policy Summary

Payerharvard pilgrim health care

PolicyCo Occurring Enhanced Residential Rehabilitation Services Rrs Performance Specifications

Policy CodePolicy N/A

Change TypeClarified / Revised (non-material)

Effective Date

Next Review Date

Key ActionMaintain a standardized intake/admission log tracking applications, admissions, reasons for non-acceptance, and referrals and make it available to the payer upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes were made in this update (has_material_change=false).

5Minimum weekly treatment hours

48Psychiatric/medication visit window (hrs)

Per diemFunding model referenced

2Applicable Tufts products noted

These performance specifications govern program-level structure, staffing, clinical components, assessment, treatment, discharge, and quality management requirements for Co-Occurring Enhanced Residential Rehabilitation Services (ASAM Level 3.1) as applied to specified Tufts Health Plan products, notably Tufts Health Together and Tufts Health One Care. Coverage stance: mixed. The specifications require integrated, 24-hour community-based residential care that combines scheduled, goal-oriented clinical services with psychiatry and medication management to support members with substance use disorders and moderate to severe mental health conditions.

Key Operational Thresholds

Psychiatric/medication diagnostic visit timingwithin 48 hours of admission

Minimum therapeutic contactminimum of five hours per week of individual and/or group treatment sessions

Morning meeting frequencyminimum five times per week

Communal meal frequencyat least one communal meal per day

House/community meeting frequencyat least one per week

Medically Necessary Program Requirements

Core Program Service Requirements / Medically Necessary Components

Covered when ALL of the following program-level requirements are met:

ALL of the following

Program meets ASAM definition for Level 3.1 Co-Occurring Enhanced: 24-hour safe, structured community environment supporting recovery from addiction and moderate to severe mental health conditions with scheduled goal-oriented clinical services.
Provide minimum of five hours per week of individual and/or group treatment sessions.minimum 5 hours/week
ONE of
- Model A: Provider organization operates outpatient services (e.g., opioid treatment center, licensed mental health center, SUD outpatient clinic, health center, primary care practice, bridge clinic, hospital or satellite) and can coordinate psychiatric and clinical services.
- Model B (partnership): Provider uses partnership model codified by formal agreement (e.g., MOU) with organizations operating outpatient services that ensure timely access and coordination; includes medication assessment and diagnostic visit within 48 hours of admission and coordination of psychiatric/clinical services with program staff.medication visit within 48 hours
Provide onsite coordinated psychiatry: psychiatrists and/or mid-level practitioners must spend time with program staff, attend team meetings, review treatment plans, and interact with Members.
On-site nursing to oversee medication administration, compliance, and symptom monitoring; nursing time flexed based on case mix.
Perform medication reconciliation and document results and medication evaluation in Member chart; medication reconciliation to occur to avoid inconsistencies at transition into level of care.
Provide clinical assessments based on ASAM Criteria and supplemental assessments as appropriate.
Develop treatment plan in conjunction with Member including clinical, psychosocial, recovery goals, crisis/safety plan; reassess throughout treatment to track progress.
Provide trauma-responsive treatment addressing intersection of trauma, mental health, and SUD; include treatment planning, clinical interventions, milieu-based therapy, family outreach/support when appropriate.
Facilitate a morning meeting minimum five times per week, at least one communal meal per day, and at least one house/community meeting per week.morning meeting ≥5/week; communal meal ≥1/day; house meeting ≥1/week
Provide care coordination beginning at treatment start, including housing search and linking to community resources, and support establishing/maintaining relationships with community-based prescribers.
Have documented policies/procedures for safe and appropriate self-administration of medications and ensure access to prescribed medications for physical and behavioral health with documentation in chart.
Train staff on ASAM criteria Level 3.1 and use of MA Behavioral Health Access website (MABHAccess.com).
Maintain standardized intake/admission log tracking applications, admission decisions, reasons for non-acceptance, and referrals; make available to payer upon request.
Utilize evidence-based assessment tools for SUD, mental health needs, and ASAM level of care.
Initial biopsychosocial clinical assessment (using ASAM dimensions) completed by clinician before comprehensive service plan, including substance use history, psychological/social/health/economic/vocational status, criminal history, trauma history, HIV and TB risk status, key supportive relationships, list of current medications with pharmacy labels and prescriber info.
Behavioral Health Clinical Assessments must be in writing, dated and signed, and include clinical formulation, rationale for admission/continuance, diversionary/lower level recommendations, and strengths.
Individualized recovery treatment/service plan must include strengths/needs, services to be provided (direct or referral), service goals with timelines, staff and Member responsibilities, discharge and aftercare description; clinical supervisor reviews and approves assessment and plan.
Aftercare plan must include referrals to outpatient aftercare, alcohol/drug-free living environment, vocational/educational opportunities, resources for social benefits, follow-up strategies, connection to community-based prescriber; clinical supervisor approves aftercare plan.

Staffing and Organizational Requirements

Staffing model requirements (ALL):

ALL of the following

Develop integrated staffing model using staff from affiliated outpatient clinics/health centers to address Member needs and meet Components of Service requirements.
Medical staff (psychiatrists, addiction physicians, mid-level practitioners, RNs) must be available through health center/outpatient clinic to support medical and pharmacologic needs.
Medical staff deliver services as allowable under affiliated clinic license and supervisory requirements.
Per diem rate includes overhead to support integration of medical staff with program clinical/direct care staff.
Program staff positions funded through per diem must include full-time program director and full-time clinical director who meets LPHA definition and can supervise clinicians; clinical director must have experience/competency/training in addiction and mental health; distinct full-time recovery specialist supervisor required.

Service Linkages and Collaboration

Service and community linkages that must be maintained and used as appropriate:

ALL of the following

Maintain written affiliation/linkage agreements (QSOA, MOU, BAA, linkage agreements) with local providers that refer high volumes to/from program; agreements include referral process, transition, aftercare, discharge processes.
Be familiar with and able to accept referrals from or refer to specified levels of care/services when clinically indicated (inpatient psychiatric hospitals; general hospitals; ESP; EDs; ATS (3.7); CSS (3.5); TSS (3.1); Co-occurring capable RRS; SOAP/Day Treatment; Partial Hospitalization; CCS; regional court clinics; MAT including OTP and OBOT; transitional/permanent supportive housing; sober housing; licensed community mental health centers; SUD outpatient clinics; recovery support centers; shelters; criminal justice system; outreach sites; MRS; community health centers; ACCS; BHCP; recovery learning centers; recovery coaches; recovery support navigators; CSP; mutual aid programs including AA and NA).
Collaborate in transfer/referral/discharge planning with Member consent to ensure continuity of care; collaborate with Member's PCC with consent per General performance specifications.

Quality Management and Documentation

QM and documentation expectations (ALL):

ALL of the following

Provider complies with all payer QM requirements.
Maintain standardized intake/admission log and facilitate referrals for admission denials; make log available to payer upon request.
Clinical supervisor reviews and approves assessments, individualized recovery treatment/service plans, and aftercare plans.
Utilize evidence-based assessment tools and ensure initial biopsychosocial ASAM-based assessment is completed by clinician before developing comprehensive service plan; assessments must be in writing, dated and signed and include specified elements (substance use history; psychological/social/health/economic/vocational status; criminal history; trauma; HIV/TB risk; key supportive relationships; medication list with pharmacy labels and prescriber info).

Actions Required of Providers

Documentation Required

Maintain intake/admission log

Maintain a standardized intake/admission log that tracks all applications for admission, documents admission decisions, reasons for non-acceptance, and referrals. Keep the log current and make it available to the payer upon request.

Track all applications for admission
Document admission decisions and reasons for non-acceptance
Record referrals made
Provide log to payer upon request

Documentation Required

Complete and document assessments and plans

Complete an initial biopsychosocial clinical assessment using ASAM dimensions prior to developing the comprehensive service plan. Ensure Behavioral Health clinical assessments are written, dated, and signed. Clinical supervisor must review and approve the assessment and the individualized recovery treatment/service plan.

Initial biopsychosocial ASAM-based assessment completed by clinician before service plan
Assessments include substance use history, psychosocial, medical, trauma, medications, and supports
Behavioral Health Clinical Assessments must be in writing, dated, and signed
Clinical supervisor reviews and approves assessment and treatment/recovery plan

Prior Authorization

Payer QM compliance and availability

Comply with all payer quality management (QM) requirements. Be prepared to provide documentation, logs (including intake/admission log), and other QM materials to the payer for review upon request.

Adhere to all payer QM requirements
Provide documentation and logs to payer upon request

Documentation Required

Medication reconciliation and documentation

Perform medication reconciliation upon admission and ensure the results of the medication evaluation and reconciliation plan are available to program staff and documented in the Member's chart.

Medication reconciliation at admission to avoid prescribing inconsistencies
Document medication evaluation and reconciliation plan in Member chart
Make reconciliation results available to program staff

Billing Rule

Per diem-funded staffing expectations

Per diem funding is expected to include overhead to support integration of medical staff with program clinical and direct care staff, and to fund specified full-time positions required by the program (e.g., full-time program director, full-time clinical director, and a full-time recovery specialist supervisor).

Per diem covers overhead to integrate medical staff (psychiatrists, mid-levels, RNs) with program staff
Per diem-funded positions include full-time program director, full-time clinical director, and full-time recovery specialist supervisor

Documentation Required

Affiliation agreements

Maintain written affiliation or linkage agreements (e.g., MOU, QSOA, BAA, or linkage agreements) with local providers that refer to or receive high volumes of Members. Agreements must detail referral processes, transition, aftercare, and discharge processes.

Use formal agreements (MOU, QSOA, BAA, linkage agreement)
Specify referral, transition, aftercare, and discharge processes

Background and Quality Management

These performance specifications define the operational, clinical, staffing, documentation, and linkage requirements for programs offering ASAM Level 3.1 Co-Occurring Enhanced RRS to ensure integrated care for Members with substance use disorders and moderate to severe mental health conditions. The purpose is to ensure timely access to psychiatry and addiction pharmacotherapy (including a medication assessment/diagnostic visit within 48 hours of admission), onsite coordinated psychiatry and nursing, integrated staffing from affiliated outpatient services, and program-level operational goals such as full-time program and clinical directors, supervised clinical staff, and per-diem funding to support medical integration.

Quality management expectations extend beyond the written criteria and include maintaining a standardized intake/admission log that tracks applications, admission decisions, reasons for non-acceptance, and referrals; ensuring clinical supervisor review and approval of assessments, individualized recovery treatment/service plans, and aftercare plans; training staff in evidence-based practices and ASAM Level 3.1 (and use of MABHAccess.com); using evidence-based assessment tools for SUD, mental health, and ASAM level of care; and providing supervision and continuing education for staff consistent with payer requirements.

Definitions

Co-Occurring Enhanced RRS (Level 3.1): A 24-hour, safe, structured community-based environment supporting recovery from addiction and moderate to severe mental health conditions, providing scheduled, goal-oriented clinical services together with psychiatry and medication management; clinical services are provided a minimum of five hours per week and additional outpatient levels of care may be accessed concurrently as appropriate.

Revision History

June 2020revised

June 2020: Template Updates.

January 2024clarifiedLatest

January 2024: Tufts Health One Care (a dual-eligible product) name change.

Policy Summary

Payerharvard pilgrim health care

PolicyCo Occurring Enhanced Residential Rehabilitation Services Rrs Performance Specifications

Policy CodePolicy N/A

Change TypeClarified / Revised (non-material)

Effective Date

Next Review Date

Key ActionMaintain a standardized intake/admission log tracking applications, admissions, reasons for non-acceptance, and referrals and make it available to the payer upon request.

SourceLink

On This Page

Program must have mix of clinical, paraprofessional, and recovery specialist staff (LPHA, MA, BA, recovery specialists) with experience/competency in mental health and SUD.

Designate staff roles: HIV/AIDS/HEP C coordinator, tobacco education coordinator (TEC), access coordinator, and CLAS point person.

Ensure all staff receive supervision consistent with payer requirements and have training in evidence-based practices with continuing education opportunities.

Arrange transportation for services external to program when necessary and assist Members identifying transportation options (public transport, PT-1 forms, etc.).

Demonstrate capacity to work collaboratively with multiple systems including SUD providers, primary care, housing, mental health services, human services, criminal justice, etc.

OpenPayer

Co Occurring Enhanced Residential Rehabilitation Services Rrs Performance Specifications

Coverage Summary

Medically Necessary Program Requirements

Actions Required of Providers

Background and Quality Management

Definitions

Revision History