ModifiedNevada Health AuthorityPolicy N/A

Federally Qualified Health Centers — Mental and Behavioral Health Encounters

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This document governs Nevada Medicaid reimbursement, coverage, provider qualifications, encounter billing, documentation, and non-covered services for Federally Qualified Health Centers (FQHCs), particularly mental health, substance use disorder, and co-occurring treatment encounters delivered in FQHC settings.

Policy Summary

PayerNevada Health Authority

PolicyFederally Qualified Health Centers — Mental and Behavioral Health Encounters

Policy CodePolicy N/A

Change TypeModified

Effective DateJanuary 31, 2024

Next Review DateN/A

Key ActionDocument all mental and behavioral health encounters according to applicable HRSA and MSM Chapter 100 standards.

SourceLink

POLICY UPDATE CHANGES

The policy clarifies that qualified mental and behavioral health encounters must be provided by independently licensed professionals authorized under the FQHC's applicable HRSA-approved project and Nevada scope-of-practice requirements.

The policy revises eligibility rules for interns, assistants, and trainees delivering mental and behavioral health encounter services.

The policy clarifies that mental and behavioral health treatment may address mental health conditions, substance use disorders, and co-occurring disorders.

The policy adds requirements for behavioral health providers to use appropriate diagnostic tools and to have capacity to provide or refer patients for necessary ancillary or consultative services.

The policy clarifies documentation requirements for all mental and behavioral health encounters.

The policy identifies group therapy and certain services delivered outside the FQHC location as non-covered under an FQHC encounter.

The policy updates ancillary-service and partial hospitalization provisions for FQHCs.

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ModifiedNevada Health AuthorityPolicy N/A

Federally Qualified Health Centers — Mental and Behavioral Health Encounters

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Sign up for all Nevada Health Authority policy alerts

Know when Nevada Health Authority releases new policies or updates existing guidance.

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Policy Summary

PayerNevada Health Authority

PolicyFederally Qualified Health Centers — Mental and Behavioral Health Encounters

Policy CodePolicy N/A

Change TypeModified

Effective DateJanuary 31, 2024

Next Review DateN/A

Key ActionDocument all mental and behavioral health encounters according to applicable HRSA and MSM Chapter 100 standards.

SourceLink

POLICY UPDATE CHANGES

The policy revises eligibility rules for interns, assistants, and trainees delivering mental and behavioral health encounter services.

The policy clarifies that mental and behavioral health treatment may address mental health conditions, substance use disorders, and co-occurring disorders.

The policy adds requirements for behavioral health providers to use appropriate diagnostic tools and to have capacity to provide or refer patients for necessary ancillary or consultative services.

The policy clarifies documentation requirements for all mental and behavioral health encounters.

The policy identifies group therapy and certain services delivered outside the FQHC location as non-covered under an FQHC encounter.

The policy updates ancillary-service and partial hospitalization provisions for FQHCs.

5Qualified provider types listed for mental and behavioral health encounters

Up to 3Maximum reimbursable encounters per patient per day with three established SSPPS rates

6Services expressly listed as non-covered under an FQHC encounter

3Behavioral health assessment tools identified

No PAFQHC encounters requiring prior authorization

Coverage Criteria

Mental/behavioral health encounter coverage

Mental/behavioral health encounters are covered when all applicable provider, service, and clinical requirements are met.

Qualified provider and setting: The service is furnished by an employed or contracted independently licensed professional authorized to provide mental and behavioral health services under the FQHC's applicable HRSA-approved Health Center project and Nevada scope of practice.

Qualified providers include psychiatrists, licensed psychologists, APRNs, LMFTs, and LCSWs.

Clinical appropriateness: Treatment is clinically appropriate, based on client-centered needs, and delivered by the appropriately licensed provider.

Diagnostic assessment: Screening, assessment, and diagnosis use an appropriate behavioral health tool when applicable.Examples include CASII/ESCII, LOCUS, or ASAM Criteria

Ancillary or consultative capacity: The provider has the capacity to provide or refer the patient for necessary ancillary or consultative services.

Documentation: The encounter is documented according to applicable HRSA Health Center Program Compliance Manual and MSM Chapter 100 standards.

Partial Hospitalization Program ancillary services

PHP may be reimbursed as an ancillary service when all applicable requirements are met.

FQHC delivery model: The PHP is provided as an extension of the FQHC delivery model under administrative oversight through a contractual agreement with an organization providing outpatient PHP services.

The organization must meet Certified Mental Health Clinic criteria.

Clinical need: The recipient has chronic mental illness and/or substance abuse-related disorders requiring collaborative, intensive assistance normally found in an inpatient setting.

Ancillary Services

Ancillary services may be reimbursed when all applicable requirements are met.

Ancillary service reimbursement: The service is an approved Nevada Medicaid State Plan service; the service is not included within an approved FQHC encounter; the service is provided by a licensed Qualified Health Professional; and the FQHC is enrolled under the appropriate provider type and meets all MSM coverage guidelines for the specific ancillary service.

Ancillary services may be reimbursed on the same date of service as an FQHC encounter.

Partial Hospitalization Program

PHP participation requires all stated organizational and clinical conditions.

FQHC PHP oversight: The FQHC has an administrative oversight arrangement through a contractual agreement with an organization that provides outpatient PHP services and meets Certified Mental Health Clinic criteria; the PHP services address recipients with chronic mental illness and/or substance abuse-related disorders who require collaborative, intensive assistance normally found in an inpatient setting.

PHP policy is governed further by MSM Chapter 400.

FQHCs Dually Enrolled as CCBHCs

FQHC and CCBHC billing must be based on clinical appropriateness and the primary service model.

Dual FQHC/CCBHC billing coordination: Medical necessity and clinical appropriateness are determined by clinical professionals under care coordination; the organization determines the appropriate encounter for reimbursement; care coordination prevents duplicative billing for the same service at the same time; and the applicable rate corresponds to whether the service is primarily CCBHC or primarily FQHC-specific.

Primarily CCBHC services use the CCBHC PPS rate; primarily FQHC-specific services use the FQHC encounter rate.

Medical Necessity

Medicaid reimbursement requires medical necessity.

Medical necessity: All services provided must be medically necessary as defined in MSM Chapter 100.

Medical necessity documentation must be retained in the patient file.

Non-covered under an FQHC encounter: Group therapy, including services delivered in a group rather than individual setting, is not covered. Services rendered outside the FQHC location by a non-contracted agency or independently licensed provider are also non-covered when billed as part of the encounter.

Mental and behavioral health encounter services must be provided by an authorized, employed or contracted independently licensed professional. LCPCs and LCPC interns may not provide these encounter services. Psychological interns, assistants, and trainees may not provide mental or behavioral health encounter services, but may provide ancillary services under a supervising psychologist in accordance with MSM Chapter 400. LMFT and LCSW clinical interns may provide encounter services only under appropriate clinical supervision and applicable Nevada licensing authority requirements.

For FQHCs dually enrolled as CCBHCs, duplicative billing for the same service occurring at the same time is not permitted. The FQHC and CCBHC must use care coordination and internal treatment-placement policies to determine the appropriate delivery model and reimbursement encounter. Services primarily provided under the CCBHC model are billed at the CCBHC PPS rate, while primarily FQHC-specific services are billed at the FQHC encounter rate.

Provider, Documentation, and Billing Actions

Prior Authorization

Non-Contracted FQHC MCO Authorization

Follow the applicable Managed Care Organization (MCO) prior authorization policy for FQHC services when the FQHC is not contracted with that MCO.

Prior Authorization

Ancillary Service Prior Authorization

Ancillary services billed outside an FQHC encounter must follow the prior authorization requirements for the specific service under applicable federal and state regulations.

Documentation Required

Behavioral Health Encounter Records

Document every mental and behavioral health encounter in accordance with applicable HRSA Health Center Program Compliance Manual standards and MSM Chapter 100 medical-record documentation requirements.

Policy Scope and Clinical Context

FQHC mental and behavioral health encounters may address mental health conditions, substance use disorders, and co-occurring disorders. Covered services are client-centered and clinically appropriate and may include screening, assessment and diagnosis using an appropriate behavioral health tool, individual and family psychotherapy, medication management, and substance use counseling. The provider must be appropriately licensed and have the capacity to provide or refer the patient for necessary ancillary or consultative services.

Key Definitions

FQHC Encounter

DefinitionA face-to-face visit or encounter between a patient and one or more approved licensed Qualified Health Professionals and/or certified providers.

Same-day requirementThe encounter must take place on the same day with the same patient for the same service type.

Multiple contactsMultiple contacts with the same provider are included.

Qualified Mental/Behavioral Health Encounter

DefinitionAn additional health service provided by an employed or contracted independently licensed professional authorized to provide mental and behavioral health services, including substance use disorder treatment.

Authorization requirementsThe professional must be authorized under the FQHC’s applicable HRSA-approved Health Center project and the provider’s applicable Nevada regulatory board scope of practice.

Level of Care Criteria

Partial Hospitalization Program

Admission requires the identified PHP level-of-care need.

PHP clinical need: The recipient has chronic mental illness and/or substance abuse-related disorders requiring collaborative, intensive assistance normally found in an inpatient setting.

PHP is described as an ancillary service extension of the FQHC delivery model.

Partial Hospitalization Program

Admission requires the identified PHP level-of-care need.

PHP clinical need: The recipient has chronic mental illness and/or a substance abuse-related disorder and requires collaborative, intensive assistance normally found in an inpatient setting.

The PHP is outpatient and may be administered through an FQHC contractual oversight arrangement.

Covered Treatment Modalities

Individual and Family Psychotherapy

Covered when clinically appropriate and delivered by an appropriately licensed provider.

Individual and family psychotherapy: Psychotherapy may be provided when clinically appropriate, based on client-centered needs, and delivered by an appropriately licensed provider.

Medication Management

Covered when clinically appropriate and delivered by an appropriately licensed provider.

Medication management may be provided as a clinically appropriate mental/behavioral health encounter service by an appropriately licensed provider.

Substance Use and Co-occurring Disorder Counseling

Covered when clinically appropriate and delivered by an appropriately licensed provider.

Daily Encounter Limits

FQHC with One Established SSPPS Encounter Rate

FQHC statusFQHC with one established Service Specific Prospective Payment Systems (SSPPS) encounter rate.

Daily limitOnly one reimbursable encounter may be billed per patient per day.

Encounter basisThe limit applies to reimbursable service types provided as FQHC encounters.

FQHC with Two Established SSPPS Encounter Rates

FQHC statusFQHC with two established Service Specific Prospective Payment Systems (SSPPS) encounter rates.

Daily limitUp to two reimbursable encounters may be billed per patient per day.

Policy Summary

PayerNevada Health Authority

PolicyFederally Qualified Health Centers — Mental and Behavioral Health Encounters

Policy CodePolicy N/A

Change TypeModified

Effective DateJanuary 31, 2024

Next Review DateN/A

Key ActionDocument all mental and behavioral health encounters according to applicable HRSA and MSM Chapter 100 standards.

SourceLink

On This Page

Documentation Required

Clinical Service Documentation

Provide clinically appropriate, client-centered treatment based on the individual’s needs and document applicable screening, assessment, and diagnostic tools used in behavioral health care.

Examples include CASII/ESCII, LOCUS, and ASAM Criteria.
Services may include psychotherapy, medication management, substance-use counseling, and counseling specific to medication-assisted treatment.

Billing Rule

FQHC and CCBHC Coordination

Use care coordination and clinical judgment to determine the appropriate treatment placement when services may fall within both the FQHC and CCBHC scopes, and coordinate care to prevent duplicate billing for the same service at the same time.

Documentation Required

Medical Necessity Documentation

Maintain patient-file documentation supporting the medical necessity of services provided under federal and state requirements. All services submitted for Medicaid reimbursement must be medically necessary as defined in MSM Chapter 100.

Billing Rule

FQHC/CCBHC Placement Policies

FQHCs dually enrolled as CCBHCs must maintain internal policies governing appropriate treatment placement for their respective recipients and resolving overlapping services through clinical appropriateness, medical necessity, and care coordination.

Denial Risk

Eligible Behavioral Health Provider Required

Do not bill a mental or behavioral health encounter for an ineligible provider type. LCPCs and LCPC interns, as well as psychological interns, assistants, and trainees, may not deliver mental/behavioral health encounter services; psychological interns, assistants, and trainees may provide only ancillary services under a supervising psychologist and in accordance with MSM Chapter 400.

Qualified encounter providers include psychiatrists, licensed psychologists, APRNs, LMFTs, and LCSWs, subject to applicable licensure, scope of practice, and HRSA project requirements.
LMFT and LCSW clinical interns may provide encounter services only under appropriate clinical supervision and Nevada licensing authority requirements.

Documentation Required

Clinical Appropriateness and Referral Capacity

Ensure treatment is clinically appropriate and client-centered, and maintain the capacity either to provide or to refer patients for necessary ancillary or consultative services.

Denial Risk

Non-Covered Encounter Services

Do not include non-covered services in an FQHC encounter claim.

Group therapy or any service delivered in a group rather than individual setting.
Services rendered outside the FQHC location by a non-contracted agency or independently licensed provider and billed as part of the encounter.
Eyeglasses, hearing aids, durable medical equipment, prosthetics, orthotics and supplies, and ambulance services.

Billing Rule

No Duplicate FQHC and CCBHC Billing

Prevent duplicate billing when an FQHC and CCBHC both could bill for overlapping services. Coordinate care and submit the service under only the appropriate delivery model.

Billing Rule

Ancillary Service Enrollment and Coverage

Before billing an ancillary service outside an FQHC encounter, enroll in the appropriate Nevada Medicaid provider type and satisfy all MSM coverage requirements applicable to that service.

Ancillary services must be approved Nevada Medicaid State Plan services not included in an approved FQHC encounter.
A licensed Qualified Health Professional may be reimbursed for an ancillary service on the same date as an encounter.
PHP arrangements must meet applicable criteria and follow MSM Chapter 400 policy.

Denial Risk

Retrospective Duplicate-Billing Review

Expect retrospective review by Medicaid Surveillance and Utilization Review (SUR) for duplication of billing between the FQHC and CCBHC delivery models.

Billing Rule

Correct Encounter Model and Rate

Select the primary service model and bill the applicable rate based on whether the service is primarily CCBHC or FQHC specific, consistent with the CCBHC services grid and applicable billing guidance.

Primarily CCBHC services that are not exclusively FQHC services are billed at the CCBHC PPS rate.
Primarily FQHC-specific services that are not exclusively CCBHC services are billed at the FQHC encounter rate.
Refer to MSM Chapter 2700 and the Billing Guide for Provider Type 17, Specialty 188.

Denial Risk

Medical Necessity Required

Services that do not meet the medical-necessity requirements of MSM Chapter 100 are at risk of denial and are not eligible for Medicaid reimbursement.

Qualified providersPsychiatrist, licensed psychologist, APRN, LMFT, or LCSW.

Supervised internsLMFT and LCSW clinical interns may deliver mental/behavioral health encounter services under appropriate clinical supervision within the FQHC and under Nevada licensing authorities.

Ancillary Services

DefinitionApproved Nevada Medicaid State Plan services that are not included within an approved FQHC encounter.

Same-day reimbursementAncillary services may be reimbursed on the same date of service as an FQHC encounter when provided by a licensed Qualified Health Professional.

FQHC requirementsThe FQHC must enroll within the appropriate provider type and meet all MSM coverage guidelines for the specific ancillary service.

Ancillary Services

Service categoryServices approved under the Nevada Medicaid State Plan.

Excluded from encounterThe services are not included within an approved FQHC encounter.

Qualified providerThe service may be reimbursed when provided by a licensed Qualified Health Professional.

Partial Hospitalization Program (PHP)

Program typeAn outpatient program offering a variety of psychiatric treatment modalities.

Eligible recipientsRecipients with chronic mental illness and/or substance abuse-related disorders.

Level of careRecipients require collaborative, intensive assistance normally found in an inpatient setting.

FQHC arrangementAn FQHC may provide PHP as an extension of its delivery model through administrative oversight under a contractual agreement with an organization that provides outpatient PHP services and meets Certified Mental Health Clinic criteria.

Substance use counseling: Counseling for substance use, including co-occurring disorders, may be provided when clinically appropriate and delivered by the appropriately licensed provider.

Medication-Assisted Treatment Counseling

Covered when clinically appropriate and properly documented.

MAT counseling: Counseling specific to medication-assisted treatment may be provided as a mental/behavioral health encounter service when clinically appropriate and properly documented.

Partial Hospitalization Program

Covered when the organizational and clinical PHP requirements are met.

PHP requirements: PHP must be provided through an eligible contractual outpatient PHP/CMHC arrangement and must address chronic mental illness and/or substance abuse-related disorders requiring intensive collaborative assistance.

Refer to MSM Chapter 400.

Partial Hospitalization Program (PHP)

Covered when the outpatient PHP provides the required psychiatric treatment modalities for the recipient's level of need.

PHP treatment modalities: Psychiatric treatment modalities are provided through an outpatient PHP for recipients with chronic mental illness and/or substance abuse-related disorders who require intensive collaborative assistance.

Refer to MSM Chapter 400 for PHP policy.

The FQHC may bill for each reimbursable service type once per patient per day.

FQHC with Three Established SSPPS Encounter Rates

FQHC statusFQHC with three established Service Specific Prospective Payment Systems (SSPPS) encounter rates.

Daily limitUp to three reimbursable encounters may be billed per patient per day.

Rate-based billingThe FQHC may bill for each reimbursable service type once per patient per day.