Behavioral Health Overlay Services

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Behavioral Health Overlay Services

• DOCUMENTATION
• Department of Juvenile Justice
• Presented by Monica Owens, First Health, Inc.
• Vikki
  Nardozzi, First Health, Inc.

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Documentation Requirements

• Resources
• Medicaids Community Behavioral Health Coverage
  and Limitations Handbook
• Chapter 2,Section 1, page 2-1-2
• Chapter 2, Section 4, BHOS Juvenile
  Justice Setting
• First Health Services Review Tool
• Interpretive Guidelines

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Documentation RequirementsChapter 2, Section 1,
page 2-1-2

• Recipients Name
• Date service was rendered
• Start and end times for procedures with specified
  time frames and procedures billed on a per unit
  basis
• Identification of setting in which service was
  rendered
• Identification of the specific problem, behavior,
  or skill deficit for which service is being
  provided

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Documentation RequirementsChapter 2, Section
1,page 2-1-2

• Identification of the service rendered, including
  the specific intervention
• Updates regarding the recipients progress toward
  meeting goals and objectives identified in
  treatment plan and
• Original, legible signature and credential or
  functional title of the person rendering the
  service

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Treatment Plan

• Medicaids Community Behavioral Health Coverage
  and Limitations Handbook
• Chapter 2, Section 1, Community Behavioral Health
  Services, Required Components of Treatment Plan,
• page 2-1-15

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DocumentationBHOS DJJ Service Requirements

• Initial Screening by a counselor or licensed
  clinician at time of admission to residential
  program (or prior to). If counselor completes
  screening a licensed clinician must also sign the
  Certificate of Eligibity for BHOS
• Assignment of a primary counselor
• Face to face interview by licensed clinician
  prior to development of treatment plan
• Treatment team meeting within 30 days of
  admission to develop individualized treatment
  plan

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DocumentationBHOS DJJ Service Requirements

• Psychiatrists or licensed practitioners review
  and dated signature with certification that
  services are medically necessary for the
  recipient, on the treatment plan
• Provision of individualized treatment
  interventions as authorized in the treatment plan
• Provision of discharge, transition, and aftercare
  planning

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BHOS DocumentationMedical Records Requirement

• The following components must be documented in
  the recipients medical record
• Name of primary counselor
• Recipients initial Certification of Eligibility
  prior to provision of behavioral health overlay
  services new Certification every six months
  must be signed by a licensed practitioner

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BHOS DocumentationMedical Records Requirements

• Signed copy of psychosocial assessment and
  evaluation completed by a licensed practitioner
  prior to the development of individualized
  treatment plan
• Interview by a licensed practitioner completed
  prior to completion and signing of individualized
  treatment plan
• Individualized treatment plan that meets criteria
  for treatment plans as specified in Chapter 2,
  Section I of Handbook

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BHOS DocumentationMedical Records Requirements

• Behavioral health aftercare plan for any child
  receiving BHOS services at time of release from
  DJJ program
• A detailed discharge plan with specified criteria
• Treatment plan reviews to determine the
  effectiveness of the current plan or the need for
  revision if child is not making progress
  document according to Medicaid policy
• Weekly progress notes

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BHOS DJJDOCUMENTATION

• WEEKLY PROGRESS NOTES

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BHOS - DJJWEEKLY PROGRESS NOTES

• Primary counselor must complete and sign BHOS
  weekly progress notes. The notes must include the
  following

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BHOS - DJJWEEKLY PROGRESS NOTES

• Summary of the services and treatment
  interventions delivered
• Recipients response to interventions
• Recipients progress related toward reaching
  individualized goals
• Information that the services authorized in the
  treatment plan were delivered in accordance with
  the plan

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BHOS - DJJWEEKLY PROGRESS NOTES

• Review of documentation that substantiates the a
  BHOS service was delivered each day that the
  services are billed AND
• Therapeutic responses and actions of the primary
  counselor or direct care staff are being provided
  to the recipient based on the recipients
  treatment plan.

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BHOS - DJJWEEKLY PROGRESS NOTES

• Summary of significant events occurring with the
  child during the week
• Documentation on contacts and visits with family
  and other agencies.
• The observations of direct care staff
  implementation of the treatment plan
• The clinical record must document that the family
  members were involved in the behavioral health
  treatment plan development and treatment
  interventions AND must include the goals and
  objectives for family counseling OR
  justification if family is not involved.

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BHOS - DJJWEEKLY PROGRESS NOTES

• Documentation must reflect coordination and
  linkages with family, the childs school, primary
  medical care providers, community services, child
  welfare caseworker, and if indicated, Department
  of Juvenile Justice probation officers in
  accordance with the recipients treatment plan
  and permanency plan.

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First Health ServicesDocumentation Review
ToolWEEKLY PROGRESS NOTES

• C1
• Documentation is available that specifies
  the behavioral
• health service was received by the
  recipient each day
• C2
• Weekly progress notes, completed and signed
  by the primary counselor, are in the recipients
  record
• C3
• Weekly progress notes report on the course
  of treatment and relate progress directly to
  individual goals and objectives included in the
  behavioral health treatment plan.

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First Health ServicesDocumentation Review
ToolWEEKLY PROGRESS NOTES

• C4
• Progress notes address the clients response
  to behavioral health treatment interventions
• C5
• Progress notes document family is included in
  the treatment process, when applicable
• C6
• Progress notes include any significant events
  that occurred during the week and summarize
  contacts with family or other involved agencies

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First Health ServicesDocumentation Review
ToolWEEKLY PROGRESS NOTES

• C7
• If an unmet behavioral health service need is
  identified, the notes reflect actions taken to
  revise the plan for the client
• Note If progress notes reflect a need for a
  modification/change in the treatment plan, the
  treatment plan should be reviewed for
  substantiation

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First Health ServicesDocumentation Review
ToolWEEKLY PROGRESS NOTES

• C8
• Progress notes document that the counselor
  observes direct care staffs implementation of
  the treatment plan
• C9
• Progress notes document behavioral health
  services are integrated into the activities of
  daily living associated with structured
  residential care

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First Health ServicesDocumentation Review
ToolWEEKLY PROGRESS NOTES

• C10
• Progress notes document behavioral health
  care is coordinated and linkages made with
  program schools, primary medical care providers,
  community services as indicated in the treatment
  plan.
• C11
• Progress notes substantiate that medically
  necessary services authorized on the treatment
  plan were delivered each day BHOS was billed to
  Medicaid
• C12
• Progress notes reflect the delivery of
  services according to the behavioral health
  treatment plan

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Interpretive GuidelinesH2020HK BHOS DJJStandard
Quality Items

• SQ1 Is documentation available to support
  
• that the service was rendered?
• (1) The documentation does not support that the
  service was rendered.
• (2) The documentation is absent in the record for
  the date billed.

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Interpretive GuidelinesH2020HK BHOS DJJ

• SQ2 Does service meet policy definition
• (1) Face to face
• (2) Service definition requirement
• (a through h)
• (3) Provider/Staff Requirement Primary
  counselor must be bachelors level practitioner

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Interpretive GuidelinesH2020HK BHOS DJJ

• SQ3 Does the documentation support the service?
• (1) Recipient Name
• (2) Date of service
• (3) Services provided related to the treatment
  plan goals and objectives
• (4) Specific service and clinical interventions

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Interpretive GuidelinesH2020HK BHOS DJJ

• SQ3 Does the documentation support the service?
• (5) Updates regarding progress towards
  treatment plan goals and objectives
• (6) Legible Signature/Credential/Title of
  Individual rendering service
• SQ4 Is the certification present?
• Certification obtained prior to provision of
  services renewed every six months
• (1) Certification documentation is not found in
  record
• (2) Certification documentation is incomplete
  or does not meet policy requirements

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General Reminders

• The weekly progress note must include all of
  Medicaids requirements for documentation
• The Weekly Progress Note domain on the First
  Health Services documentation review tool, is
  evaluated by reviewing ONLY the weekly progress
  note.

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General Reminders

• Treatment plan must specify the therapeutic
  activities delivered under the BHOS code,
  including frequency, amount, and duration of
  timed activities
• Date your signature signatures should be legible
  and include credentials and/or functional titles

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General Reminders

• Consult with your local AHCA representatives as
  needed
• First Health Services Web Site
• http//florida.fhsc.com

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The End