CurrentIndiana Department of InsurancePolicy N/A

HIV Services Program Outpatient/Ambulatory Health Services Service Standard

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This service standard governs outpatient and ambulatory medical services for clients receiving HIV Services Program support, including diagnostic, therapeutic, preventive, behavioral-health, medication-management, and specialty-care activities in outpatient settings.

Policy Summary

PayerIndiana Department of Insurance

PolicyHIV Services Program Outpatient/Ambulatory Health Services Service Standard

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRecord services in the CAREWare service-tracking system no later than 20 days after the end of each month in which services were provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14 daysNew-client appointment timeframe

30 daysInitial assessment timeframe

20 daysCAREWare reporting timeframe

12 monthsNo-contact period for possible case closure

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CurrentIndiana Department of InsurancePolicy N/A

HIV Services Program Outpatient/Ambulatory Health Services Service Standard

Customize your policy alerts

Sign up for all Indiana Department of Insurance policy alerts

Know when Indiana Department of Insurance releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerIndiana Department of Insurance

PolicyHIV Services Program Outpatient/Ambulatory Health Services Service Standard

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRecord services in the CAREWare service-tracking system no later than 20 days after the end of each month in which services were provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14 daysNew-client appointment timeframe

30 daysInitial assessment timeframe

20 daysCAREWare reporting timeframe

12 monthsNo-contact period for possible case closure

2Listed OAHS subservices

Allowable Services and Coverage Requirements

Allowable outpatient/ambulatory services

Covered when the HIV-related service is delivered directly to the client by a licensed healthcare provider in an outpatient medical setting and consists of one or more of the following:

Allowable OAHS activities: Medical history; physical examination; diagnostic testing, including HIV confirmatory or viral-load testing; laboratory testing; treatment or management of physical or behavioral health conditions; behavioral risk assessment, counseling, or referral; preventive care or screening; pediatric developmental assessment; prescription or medication-therapy management; treatment adherence; education or counseling on health and prevention; or specialty care related to HIV diagnosis, including audiology or ophthalmology.

Personnel qualifications

All of the following personnel requirements must be met:

Care is provided by healthcare professionals certified in Indiana to prescribe medications in an outpatient setting, such as a clinic, medical office, or mobile van.
Providers have specific experience and appropriate training in caring for clients living with HIV or have access to that expertise through consultations.

Eligibility criteria

The subrecipient must meet all of the following eligibility requirements:

Subrecipient eligibility requirements

The subrecipient has established criteria for providing outpatient ambulatory medical services.
The criteria include eligibility verification consistent with recipient requirements and the Part B Program.
Current eligibility documentation is maintained for clients receiving HIV services reimbursable under the Ryan White HIV/AIDS Program.

Initial intake and assessment

For each new client, all of the following intake and assessment requirements must be met:

Initial access and assessment

An appointment with a medical provider is provided within 14 days of contact with the provider or provider agency.Within 14 days of client contact
A comprehensive medical history and physical assessment is performed by the outpatient medical care provider.Within 30 days of client contact
The new-client chart reflects the completed medical history and physical assessment.

Service delivery and treatment

All of the following service-delivery and treatment requirements apply:

Treatment plan

A treatment plan appropriate to the client's age, gender, and specific needs exists and has been reviewed by both the provider and client.
The plan includes diagnostic information and appropriate referrals.
The plan includes discussion of risk reduction, HIV education, secondary prevention, and behavior modification when appropriate.
The plan includes prophylaxis against opportunistic infections.
The plan includes age-, gender-, and health-status-appropriate preventive care, such as mammograms, Pap smears, or prostate screenings.

Behavioral health referral and follow-up

When psychosocial, mental-health, or substance-abuse needs are identified, all of the following requirements apply:

Identified support needs

The client is referred to a case manager.
Medical visits address barriers and reschedule missed appointments when applicable.
The record documents the referrals and related follow-up efforts.
Psychosocial, mental-health, and substance-abuse needs are screened within 30 days of the initial client visit and reassessed annually.Within 30 days of the initial visit and annually thereafter

Discharge and case closure

Case closure requires a documented allowable reason and, when applicable, documented attempts to provide continuity of care, including linkage with another service, client-contact attempts, referrals, or an after-care plan.

Allowable closure reasons

The client requested termination of services.
The goals of the treatment plan were achieved by mutual agreement between the provider and client.
The client moved out of the service area or is otherwise no longer eligible.
The agency had no contact with the client for 12 months or more.12 months or more without contact
The client is deceased.

Non-HIV-related urgent care visits are not allowable costs within the Outpatient/Ambulatory Health Services (OAHS) category and should not be billed as OAHS services.

Emergency room visits are not allowable costs within the Outpatient/Ambulatory Health Services (OAHS) category.

Provider Documentation and Billing Actions

Documentation Required

Maintain Current Client Eligibility Documentation

Maintain documentation of current client eligibility when providing HIV services reimbursable under the Ryan White HIV/AIDS Program (RWHAP).

Documentation Required

Maintain Personnel Credentials

Ensure care is provided by health care professionals certified in Indiana to prescribe medications in an outpatient setting and with specific experience and appropriate training in caring for clients living with HIV, or access to that expertise through consultation.

Maintain documentation of all applicable licensures, certifications, registrations, or accreditations for review by the Indiana Department of Health (IDOH) upon request.

Documentation Required

Document Training and Consultation

Maintain personnel-file documentation demonstrating relevant training, certification, consultation relationships, and continuing education for staff providing HIV services.

Outpatient/Ambulatory Health Services Overview

Outpatient/Ambulatory Health Services (OAHS) provide diagnostic and therapeutic-related activities directly to clients by licensed healthcare providers in outpatient medical settings. The service standard applies to HIV-related outpatient care delivered in settings such as clinics, medical offices, mobile vans, telehealth settings, and qualifying urgent care facilities.

The scope of OAHS may include HIV diagnostic and viral-load testing, laboratory services, treatment and management of physical or behavioral health conditions, preventive care and screening, medication management, treatment-adherence support, risk-reduction counseling, and HIV-related specialty referrals. Services must be consistent with current DHHS treatment guidelines and include required HIV-related screening, prevention, and psychosocial assessment.

Key Terms and Service Classifications

Outpatient/Ambulatory Health Services (OAHS)

Service categoryOutpatient/Ambulatory Health Services (OAHS)

ActivitiesDiagnostic and therapeutic-related activities provided directly to a client

Provider requirementServices are provided by a licensed healthcare provider

Care settingAn outpatient medical setting

Outpatient Medical Settings

ClinicsCovered outpatient setting for HIV-related visits

Medical offices

Policy Summary

PayerIndiana Department of Insurance

PolicyHIV Services Program Outpatient/Ambulatory Health Services Service Standard

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRecord services in the CAREWare service-tracking system no later than 20 days after the end of each month in which services were provided.

SourceLink

On This Page

The plan includes a current list of prescribed medications or an explanation for the absence of prescriptions.

The plan includes education related to treatment adherence and management of side effects when appropriate.

HIV-specific treatment and monitoring

Specific treatment is consistent with current DHHS Guidelines.
Hepatitis B and C screening is performed at least once since diagnosis.At least once since diagnosis
The hepatitis B vaccination series is completed when recommended by the medical provider, or the record explains the delay.
PCP prophylaxis is provided as indicated.
A HAART prescription is offered within the previous year.Within the previous year
Pregnant individuals are prescribed antiretroviral therapy.
Syphilis testing is performed within the previous year.Within the previous year
TB testing is performed at least once since diagnosis.At least once since diagnosis
Psychosocial, mental-health, and substance-abuse needs are screened in the context of outpatient/ambulatory medical care within 30 days of the initial client visit and reassessed annually.Within 30 days of the initial visit and annually thereafter
HIV risk-reduction counseling is provided during the previous year.Within the previous year
An oral-health history and dental treatment plan are completed or updated once in the previous year.Once in the previous year

Laboratory services

Laboratory tests are integral to the treatment of HIV or related complications and are necessary based on established clinical practice.
Laboratory tests are ordered by a registered, certified, or licensed provider.
Laboratory tests are consistent with medical and laboratory standards.
Laboratory tests are FDA-approved and performed under CLIA certification.

Examples include Continuing Education Units (CEUs) and Advanced HIV/AIDS Certified Registered Nurse (AACRN) certification for nurse practitioners.
Document consultation relationships through signed memoranda of understanding.

Documentation Required

Establish Subrecipient Eligibility Criteria

Establish and consistently apply eligibility criteria for subrecipients providing outpatient ambulatory medical services.

Criteria must include eligibility verification consistent with recipient requirements for the Part B Program.
Maintain documentation showing that eligibility was verified under the established criteria.

Documentation Required

Document the Initial Assessment

Ensure the client chart reflects completion of a comprehensive medical history and physical assessment by the outpatient medical care provider within 30 days of client contact.

New clients must be provided an appointment with a medical provider within 14 days of contact with the provider or provider agency.

Documentation Required

Document Required Treatment Plan Contents

Maintain a treatment plan appropriate to the client’s age, gender, and specific needs, reviewed by both the provider and client. Document the required treatment-plan elements in the client record.

Diagnostic information.
Appropriate referrals.
Risk-reduction discussion, HIV education, secondary prevention, and behavior modification, as appropriate.
Prophylaxis against opportunistic infections.
Age-, gender-, and health-status-appropriate preventive care, including mammograms, Pap smears, and prostate screenings.
Medications, including a current prescribed-medication list or an explanation for the absence of prescriptions.
Treatment-adherence and side-effect-management education, as appropriate.

Documentation Required

Document Treatment and Follow-Up

Document specific treatment and follow-up activities in the client record and agency records, including treatment-plan implementation, required clinical services, referrals, missed-appointment outreach, and laboratory compliance.

Provide treatment consistent with current DHHS guidelines, including required screenings, prophylaxis, vaccinations, preventive care, and other indicated services.
Document referrals for psychosocial, mental health, or substance abuse services when needs are identified.
Document efforts to contact clients when medical appointments are missed, including efforts to address barriers and reschedule appointments.

Documentation Required

Complete CAREWare Reporting

Record all services provided in the CAREWare service-tracking system no later than 20 days after the end of each month in which the services were provided.

Documentation Required

Document Case Closure and Continuity of Care

Document the reason for case closure and any appropriate continuity-of-care efforts before closure.

Document linkage with another service, attempts to contact the client, referrals made for or on behalf of the client, or an after-care plan, as applicable.
Allowable closure reasons include client-requested termination, achievement of treatment-plan goals by mutual agreement, moving out of the service area or loss of eligibility, no contact for 12 months or more, or death.

Denial Risk

Non-HIV Urgent Care Is Not Allowable

Do not bill non-HIV-related urgent care visits as allowable costs within the Outpatient/Ambulatory Health Services Category.

Denial Risk

Emergency Room Visits Are Not Allowable

Do not treat emergency room visits as allowable costs within the Outpatient/Ambulatory Health Services Category.

Billing Rule

Follow Current DHHS Treatment Guidelines

Ensure specific treatment services are consistent with current Department of Health and Human Services (DHHS) treatment guidelines and document the required treatment-plan and service elements.

Documentation Required

Meet Laboratory Testing Requirements

Ensure laboratory testing is integral to HIV treatment or related complications, medically necessary based on established clinical practice, and ordered by a registered, certified, or licensed provider.

Testing must be consistent with medical and laboratory standards.
Tests must be FDA-approved and performed by a laboratory certified under the Clinical Laboratory Improvement Amendments (CLIA) program.

Covered outpatient setting for HIV-related visits

Mobile vansCovered outpatient setting for HIV-related visits

Telehealth settingsCovered outpatient setting using telehealth technology for HIV-related visits

Urgent care facilitiesCovered for HIV-related visits only

Service Unit

Service unit1 visit/interaction

VisitOne visit constitutes one service unit

InteractionOne interaction constitutes one service unit

Treatment-Adherence Service Classification

OAHS visitTreatment-adherence activities provided during an Outpatient/Ambulatory Health Service visit are classified as OAHS

Medical Case Management visitTreatment-adherence activities provided during a Medical Case Management visit are classified as Medical Case Management services

Classification basisThe setting and service type in which treatment-adherence activities are delivered determines the classification