CurrentOptumPolicy BH00591a_10/2024

Therapeutic Mentoring (TM) services for youth

Defines service, staffing, documentation, referral, treatment planning, service components, community linkages, quality management, and operational expectations for Therapeutic Mentoring services provided to MassHealth-enrolled youth under age 21 by Optum-contracted providers.

Policy Summary

PayerOptum

PolicyTherapeutic Mentoring (TM) services for youth

Policy CodePolicy BH00591a_10/2024

Change TypeNo material change

Effective Date

Next Review Date

Key ActionCreate a written individual action plan within 30 days of service start, sign by required parties, update at least every 90 days, document each session's planned activity/goal/member response, and share progress with treatment providers with consent.

POLICY UPDATE CHANGES

No material clinical or coverage changes.

Youth <21Target Population

30 daysInitial action plan due

90 daysAction plan update interval

5 daysOutreach after referral

Coverage Summary

Overview: Therapeutic Mentoring (TM) is a structured, one-to-one, strength-based support service delivered by Optum‑contracted, Commonwealth‑certified providers to MassHealth enrollees who are youth under age 21. TM addresses daily living, social, and communication needs and is provided in the youth's residence or community settings (including home, foster home, school, child care, respite, and other community settings) or via HIPAA‑compliant telehealth when clinically appropriate and requested by the family.

Coverage stance and scope summary: TM is covered with criteria when it is medically necessary to achieve goals established in an existing behavioral health treatment plan (Outpatient or In‑Home Therapy) or an Individual Care Plan (ICP) for youth in Intensive Care Coordination (ICC). Services must be aligned with the treatment plan/ICP, document progress, support age‑appropriate social functioning, be delivered by certified providers with required infrastructure, and meet operational requirements including creation of a written individual action plan and session documentation.

Key Timelines & Thresholds

Initial action plan timelineInitial individual action plan due within 30 days of TM initiation

Action plan update frequencyIndividual action plan updated at least every 90 days

Provider outreach after referralProvider must outreach parent/caregiver/guardian within 5 calendar days of referral to offer face-to-face initiation appointment

Medicaid timely initiation standardMedicaid standard: services initiated within 14 days from time family has been contacted following referral

Supervisor consultation response timeSenior licensed clinician available for consultation within 1 hour during all hours TM staff provides services (including evenings/weekends)

Provider Actions & Requirements

Documentation Required

Individual Action Plan and Session Documentation

Create a written Individual Action Plan within 30 days of Therapeutic Mentoring initiation. The plan must be signed by the Therapeutic Mentor, the TM supervisor, the parent/caregiver/guardian and the youth when appropriate. Update the action plan at least every 90 days and as needed. Document each TM session to include the planned activity, the goal being targeted, and the member's response. With consent, share progress and session documentation with the youth's other treatment providers.

Initial individual action plan due within 30 days of TM initiation
Action plan updated at least every 90 days
Session record must document planned activity, targeted goal, and member response
Share progress with other treatment providers with consent

Documentation Required

Outreach and Timely Initiation

Outreach the parent/caregiver/guardian within five (5) calendar days of referral (including self-referral) to offer a face-to-face initiation appointment. Make best efforts to initiate services as soon as clinically appropriate; adhere to the Medicaid 14-day timely provision standard from the time the family has been contacted. If unable to initiate services within 14 days of initial contact, maintain a waitlist and contact the family and referral source to explain waitlist procedures.

Outreach within 5 calendar days of referral
Aim to initiate services promptly; 14 days is the Medicaid standard from time family contacted
Maintain waitlist and notify family/referral source if services cannot begin within 14 days

Prior Authorization

Certification/Contracting Requirement

Services must be delivered by providers contracted with Optum and certified by the Commonwealth (outpatient hospitals, community health centers, mental health centers, clinics, and private agencies). Providers must demonstrate required infrastructure including quality management/assurance, utilization management, electronic data collection/IT, clinical/psychiatric expertise, and cultural and linguistic competence.

Optum-contracted and Commonwealth-certified provider required
Provider infrastructure: quality management, utilization management, electronic data/IT, clinical/psychiatric expertise, cultural/linguistic competence

Billing Rule

Telehealth Documentation

If services are delivered via telehealth, document the reason for using telehealth in the youth's record and ensure services conform to all applicable standards of care. Follow current MassHealth and MCE telehealth guidelines when providing TM via telehealth.

Document reason for telehealth in the record
Adhere to MassHealth and MCE telehealth guidelines and applicable standards of care

Documentation Required

Weekly Communication Requirements

Therapeutic Mentors must have at least one contact per week (or more if needed) with the youth's ICC, IHT, or outpatient provider to provide progress updates. If the youth has no open clinical behavioral health service, the Therapeutic Mentor must provide weekly updates to their supervisor and document progress toward action plan goals.

Weekly contact with youth's ICC, IHT, or outpatient provider
If no open BH service, weekly supervisor updates and documentation

Documentation Required

Discharge Plan Distribution

Provide a written discharge plan that documents ongoing strategies, supports, and resources. With required consent, give the discharge plan to the youth and/or parent/caregiver/guardian and to existing behavioral health providers within five (5) business days of the last date of service.

Discharge plan given within five (5) business days of last service (with consent)
Discharge plan documents reasons for discharge and aftercare plans

Documentation Required

Training Records Availability

Maintain documentation of the provider's TM training curriculum and make it available upon request. Ensure Therapeutic Mentors complete the required training upon employment and annually thereafter covering the specified topics.

Training curriculum documentation available upon request
Required initial and annual training covering clinical needs, Systems of Care, Wraparound, role in CPT, cultural competence, behavior management, risk/safety, crisis management, and related topics

Denial Risk

Noncompliance Risk

Failure to meet performance specifications — including staffing/supervision requirements, documentation standards, outreach and initiation timelines, and action plan creation/update timelines — may constitute noncompliance with the performance specifications and is subject to contractual consequences.

Noncompliance may follow failures in staffing, supervision, documentation, outreach/initiations, or action plan timelines

Definitions & Background

Background: Performance specifications establish expectations for contracted providers delivering Therapeutic Mentoring services to MassHealth enrollees to promote transparency and consistency and to ensure compliance with applicable regulations and contractual requirements.

Therapeutic Mentoring (TM): Structured, one-to-one, strength-based support services between a Therapeutic Mentor and a youth to address daily living, social, and communication needs as part of a behavioral health treatment plan or ICP. TM supports, coaches, and trains youth in age-appropriate behaviors, interpersonal communication, problem-solving, conflict resolution, and skill practice in community and residential settings.

Individual Action Plan: A written plan that outlines goals of care, tasks needed to meet those goals, timeframes, modality and location of tasks, and must be signed by the Therapeutic Mentor, the TM supervisor, the parent/caregiver/guardian and the youth when appropriate. The initial individual action plan is due within 30 days of TM initiation and must be updated at least every 90 days and as needed.

Policy Summary

PayerOptum

PolicyTherapeutic Mentoring (TM) services for youth

Policy CodePolicy BH00591a_10/2024

Change TypeNo material change

Effective Date

Next Review Date

On This Page

OpenPayer

Therapeutic Mentoring (TM) services for youth

Coverage Summary

Medically Necessary / Covered Criteria

Service Scope & Activities

Referral, Initiation, Contact & Discharge Requirements

Staffing, Training & Supervision Requirements

Operational Limits & Prohibitions

Provider Actions & Requirements

Coding

Definitions & Background

Revision History