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1 INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE MODULE Medicaid Rehabilitation Option Services LIBRARY REFERENCE NUMBER: PROMOD00016 PUBLISHED: DECEMBER 14, 2017 POLICIES AND PROCEDURES AS OF SEPTEMBER 1 , 2017 VERSION: Copyright 2017 DXC Technology Company. All rights reserved. Library Reference Number: PROMOD00016 iii Published: December 14, 2017 Policies and procedures as of September 1, 2017 Version: Revision History Version Date Reason for Revisions Completed By Policies and procedures as of October 1, 2015 Published: February 25, 2016 New document FSSA and HPE Policies and procedures as of September 7, 2016 CoreMMIS updates as of February 13, 2017 Published: May 16, 2017 Scheduled and CoreMMIS update FSSA and HPE Policies and procedures as of September 1, 2017 Published: December 14, 2017 Scheduled update.

2 Reorganized and edited text as needed for clarity Changed Hewlett Packard Enterprise references to DXC Technology Combined psychiatrist and physician under a single bullet in the Licensed Professional section (and made a corresponding update in Appendix C) Updated the MRO Service Requirements section, including clarifying information about PA for additional Services and replacing the federal definition of MRO Services with the IAC definition (and made a corresponding update in Appendix C) Added references to CANS service package 6 in all applicable Service Unit Limitations subsections of the MRO Service Requirements section Added LON criteria to all Target Population subsections of the MRO Service Requirements section Updated the Service Package Assignment Process section.

3 Clarified that CoreMMIS receives updated member data every business day Revised the Member Data Match and Criteria Validation steps, including updating reason codes Updated status responses, noted that only CMCS providers can access MRO coverage details, and corrected the description of the Provider field, and in the Verifying Eligibility for MRO Services on the Provider Healthcare Portal section Medicaid Rehabilitation Option Services Revision History iv Library Reference Number: PROMOD00016 Published: December 14, 2017 Policies and procedures as of September 1, 2017 Version: Version Date Reason for Revisions Completed By Updated the PA Submission section: Added a reference to the 278 transaction Clarified PA submission instructions Added system update information for modifying a member s existing MRO benefit package Expanded information in the PA Decision section about options for obtaining PA status information Added introductory text to the Psychosocial Rehabilitation (Clubhouse Services ) Documentation section Removed provider specialty information from the Managed Care Considerations section Added CareSource as an MCE to the Healthy Indiana Plan section Removed the Hoosier Care Connect section Library Reference Number: PROMOD00016 v Published.

4 December 14, 2017 Policies and procedures as of September 1, 2017 Version: Table of Contents Section 1: Introduction .. 1 Section 2: Medicaid Rehabilitation Option Services .. 3 MRO Provider Agency Requirements .. 3 MRO Provider Staff 3 Licensed Professional .. 4 Qualified Behavioral Health Professional .. 4 Other Behavioral Health Professional .. 4 MRO Service Requirements .. 5 Addiction Counseling (Individual or Group Setting) .. 5 Adult Intensive Rehabilitative Services .. 8 Behavioral Health Counseling and Therapy (Individual or Group Setting) .. 9 Behavioral Health Level of Need Redetermination .. 12 Case Management .. 13 Child and Adolescent Intensive Resiliency Services .

5 15 Crisis Intervention .. 17 Intensive Outpatient Treatment .. 20 Medication Training and Support (Individual or Group Setting) .. 22 Peer Recovery Services .. 24 Psychiatric Assessment and Intervention .. 26 Psychosocial Rehabilitation (Clubhouse Services ) .. 28 Skills Training and Development (Individual or Group Setting) .. 30 HCBS Waiver Programs and MRO Services .. 33 1915(i) HCBS Benefits and MRO Services .. 33 Child Mental Health Wraparound .. 33 Behavioral and Primary Healthcare Coordination .. 34 Adult Mental Health Habilitation .. 35 Noncovered Services .. 35 Individualized Integrated Care Plan Requirements .. 36 MRO Clinical and Service Supervision Standards .. 37 Section 3: Diagnosis and Level of Need.

6 39 Qualifying Diagnosis .. 39 Level of Need .. 39 Diagnosis and LON Exceptions .. 40 Section 4: Medicaid Rehabilitation Option Service Packages .. 41 Service Package Assignment Process .. 41 Verifying Eligibility for MRO Services on the Provider Healthcare Portal .. 44 Section 5: Prior Authorization .. 49 PA Vendor .. 49 Allowable PA Scenarios for MRO Services .. 49 Retroactive PA Policy .. 50 PA and Service Package Assignment .. 51 PA Submission .. 51 PA Policy Requirements .. 52 PA Decision .. 52 PA Exceptions and Limitations .. 53 Section 6: Clinical Record Documentation Requirements .. 55 General Documentation Requirements .. 55 Group Setting Documentation Requirements .. 56 Services Without the Member Present Documentation Requirements.

7 56 Medicaid Rehabilitation Option Services Table of Contents vi Library Reference Number: PROMOD00016 Published: December 14, 2017 Policies and procedures as of September 1, 2017 Version: Service-Specific Documentation Requirements .. 56 Behavioral Health Level of Need Redetermination Documentation .. 56 CAIRS Documentation .. 57 AIRS Documentation .. 58 Crisis Intervention Documentation .. 58 Peer Recovery Services Documentation .. 60 Psychosocial Rehabilitation (Clubhouse Services ) 61 Section 7: Billing and Reimbursement Requirements for MRO 63 MRO Reimbursement .. 63 Claim Format .. 64 Facility Fees .. 64 Time 64 Rounding Minutes to Units .. 65 15-Minute Unit .. 65 One-Hour (60 Minutes) Unit.

8 66 Three-Hour (180 Minutes) Unit .. 66 Place of Service Codes .. 67 Procedure Codes and Modifiers for MRO Services .. 67 Modifiers for MRO Services .. 68 HCPCS Codes .. 68 Third-Party Liability Requirements .. 69 Managed Care Considerations .. 69 Healthy Indiana Plan .. 69 Mailing Address for MRO Claims .. 70 Additional Addresses and Telephone Numbers .. 70 Appendix A: MRO Service Packages .. 71 Appendix B: MRO Acronyms .. 83 Appendix C: MRO Definitions .. 85 Library Reference Number: PROMOD00016 1 Published: December 14, 2017 Policies and procedures as of September 1, 2017 Version: Section 1: Introduction This module provides instructions specifically for Indiana Health Coverage Programs (IHCP) providers enrolled in the Community Mental Health Rehabilitation Services Program, generally known as Medicaid Rehabilitation Option (MRO).

9 For information about clinic-based outpatient mental health Services , as defined under Indiana Administrative Code 405 IAC 5-20-8, see the Mental Health and Addiction Services module. The Indiana Family and Social Services Administration (FSSA) administers the MRO program, with policy and operational oversight provided through the FSSA s Office of Medicaid Policy and Planning (OMPP) and Division of Mental Health and Addiction (DMHA). MRO Services include community-based mental healthcare for individuals with serious mental illness, youth with serious emotional disturbance, and/or individuals with substance use disorders. MRO Services may include clinical attention in the member s home, workplace, mental health facility, emergency department, or wherever needed.

10 A qualified mental health professional, as outlined in 405 IAC (c) must render these Services . Specific rules for MRO Services can be found in 405 IAC Details provided in the applicable IAC are not repeated in this document except to clarify or expand on procedural issues. Unique MRO requirements are outlined based on the following topics: Common service standards Treatment plan requirements Supervising physician responsibilities Medicare and third-party liability (TPL) requirements Prior authorization (PA) status Claim format requirements Procedure code and narrative requirements Library Reference Number: PROMOD00016 3 Published: December 14, 2017 Policies and procedures as of September 1, 2017 Version: Section 2.