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COMMONWEALTH OF PENNSYLVANIA

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Pennsylvania Code



CHAPTER 1153. OUTPATIENT PSYCHIATRIC SERVICES

GENERAL PROVISIONS

Sec.


1153.1.    Policy.
1153.2.    Definitions.

COVERED AND NONCOVERED SERVICES


1153.11.    Types of services covered.
1153.12.    Outpatient services.
1153.14.    Noncovered services.

SCOPE OF BENEFITS


1153.21.    Scope of benefits for children under 21 years of age.
1153.22.    Scope of benefits for adults 21 years of age or older.
1153.23.    [Reserved].
1153.24.    [Reserved].

PROVIDER PARTICIPATION


1153.41.    Participation requirements.
1153.41a.    Medication prescription—statement of policy.
1153.42.    Ongoing responsibilities of providers.

PAYMENT FOR OUTPATIENT BEHAVIORAL
HEALTH SERVICES


1153.51.    General payment policy.
1153.52.    Payment conditions for various services.
1153.53.    Limitations on payment.
1153.53a.    [Reserved].
1153.54.    Noncompensable services and items.

UTILIZATION REVIEW


1153.71.    Scope of claims review procedures.

ADMINISTRATIVE SANCTIONS


1153.81.    Provider misutilization.

Source

   The provisions of this Chapter 1153 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267, unless otherwise noted.

Cross References

   This chapter cited in 55 Pa. Code §  1101.31 (relating to scope); 55 Pa. Code §  1101.95 (relating to conflicts between general and specific provisions); and 55 Pa. Code §  1221.2 (relating to definitions).

GENERAL PROVISIONS


§ 1153.1. Policy.

 The MA Program provides payment for specific medically necessary psychiatric outpatient clinic services, MMHT services and psychiatric outpatient partial hospitalization services rendered to eligible MA beneficiaries by psychiatric outpatient clinics and psychiatric outpatient partial hospitalization facilities enrolled as providers under the program. Payment for behavioral health services is subject to the provisions of this chapter, Chapter 1101 (relating to general provisions) and the limitations established in Chapter 1150 (relating to MA Program payment policies) and the MA Program Fee Schedule.

Authority

   The provisions of this §  1153.1 amended under section 201(2) of the Human Services Code (62 P.S. §  201(2)).

Source

   The provisions of this §  1153.1 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial page (375582).

§ 1153.2. Definitions.

 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

   Adult partial hospitalization program—A program licensed by the Department, Office of Mental Health and Substance Abuse Services, to provide partial hospitalization services to individuals 15 years of age or older.

   Advanced practice professional—A person who holds a current Pennsylvania license as a certified registered nurse practitioner or a physician assistant and:

   (1)  Holds a mental health certification, or

   (2)  Obtains a mental health certification within 2 years of being hired by the psychiatric outpatient clinic or by July 30, 2020, whichever is later.

   Children and youth partial hospitalization program—A program licensed by the Department, Office of Mental Health and Substance Abuse Services, to provide partial hospitalization services to individuals under 15 years of age.

   Clinical staff—A psychiatrist or a mental health professional or mental health worker under the direct supervision of a psychiatrist.

   Collateral family psychotherapy—Psychotherapy provided to the family members of an individual receiving psychiatric outpatient clinic services in the absence of the individual.

   Department—The Department of Human Services.

   Facility—A mental health establishment, hospital, clinic, institution, center or other organizational unit or part thereof, the primary function of which is the diagnosis, treatment, care and rehabilitation of individuals with mental illness or emotional disturbance.

   Family—A person living alone or the following persons: spouses; parents and their unemancipated minor children and other unemancipated minor children who are related by blood or marriage; or other adults or emancipated minor children living in the household who are dependent upon the head of the household.

   Family psychotherapy—Psychotherapy provided to two or more members of a family. At least one family member shall have a diagnosed mental illness or emotional disturbance. Sessions shall be conducted by a clinical staff person.

   Group psychotherapy—Psychotherapy provided to no less than 2 and no more than 12 persons with diagnosed mental illness or emotional disturbance. These sessions shall be conducted by a clinical staff person.

   Individual psychotherapy—Psychotherapy provided to one person with a diagnosed mental illness or emotional disturbance. These sessions shall be conducted by a clinical staff person.

   Inpatient services—Treatment provided to an individual who has been admitted to a treatment institution or an acute care hospital or psychiatric hospital on the recommendation of a physician and is receiving room, board and professional services in the facility on a continuous 24-hour-a-day basis.

   Intake—The first contact with an individual for the initiation of or re-admission to outpatient behavioral health services covered by this chapter.

   Interactive audio and video—Real-time two-way or multiple-way communication.

   LPHA—Licensed Practitioner of the Healing Arts—A person who is licensed by the Commonwealth to practice the healing arts. This term is limited to a physician, physician’s assistant, certified registered nurse practitioner, licensed clinical social worker, licensed marriage and family therapist, licensed professional counselor or psychologist.

   MMHT—Mobile Mental Health Treatment—One or more of the following services provided in an individual’s residence or approved community site:

     (i)   Assessment.

     (ii)   Individual, group or family therapy.

     (iii)   Medication visits.

   Mental health professional—A person who meets one of the following:

     (i)   Has a graduate degree from a college or university that is accredited by an agency recognized by the United States Department of Education or the Council for Higher Education Accreditation (CHEA) in a generally recognized clinical discipline in which the degree program includes a clinical practicum.

     (ii)   Has an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. (AICE) or the National Association of Credential Evaluation Services (NACES). The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.

     (iii)   Is licensed in a generally recognized clinical discipline that includes mental health clinical experience.

   Mental health worker—A person acting under the supervision of a mental health professional to provide services who meets one of the following:

     (i)   Has a bachelor’s degree from a college or university that is accredited by an agency recognized by the United States Department of Education or the CHEA in a recognized clinical discipline including social work, psychology, nursing, rehabilitation or activity therapies.

     (ii)   Has a graduate degree in a clinical discipline with 12 graduate-level credits in mental health or counseling from a program that is accredited by an agency recognized by the United States Department of Education or the CHEA.

     (iii)   Has an equivalent degree from a foreign college or university that has been evaluated by the AICE or the NACES. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.

   Mental illness or emotional disturbance—A mental disorder that meets the diagnostic criteria within the current version of the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases (ICD).

   Outpatient services—Medical or behavioral health services provided to an individual by a psychiatric outpatient clinic or partial hospitalization outpatient facility that does not provide room, board and professional services on a continuous 24-hour-a-day basis.

   Psychiatric clinic clozapine monitoring and evaluation visit—A visit for the monitoring and evaluation of an individual’s physical and mental condition during the course of treatment with clozapine. The term includes only a visit provided to an eligible individual receiving clozapine therapy, and only by a psychiatrist, physician, certified registered nurse practitioner, registered nurse or physician assistant.

   Psychiatric clinic medication visit—A visit only for administration of a drug and evaluation of an individual’s physical or mental condition during the course of prescribed medication. This visit is provided to an eligible individual only by a psychiatrist, physician, certified registered nurse practitioner, physician assistant, registered nurse or licensed practical nurse.

   Psychiatric evaluation—An initial mental status examination and evaluation of an individual provided only by a psychiatrist in a face-to-face interview or through the use of interactive audio and video communication that conforms to industry-wide technology standards and is in compliance with State and Federal privacy and security laws. It must include a comprehensive history and evaluation of pertinent diagnostic information necessary to arrive at a diagnosis and recommendations for treatment or further diagnostic studies or consultation. The history must include individual, social, family, occupational, drug, medical and previous psychiatric diagnostic and treatment information.

   Psychiatric outpatient clinic provider—A facility enrolled in the MA Program to provide psychiatric outpatient clinic services and licensed by the Department, Office of Mental Health and Substance Abuse Services, to provide specific medical, psychiatric and psychological services for the diagnosis and treatment of mental illness or emotional disturbance.

   Psychiatric outpatient clinic services—Outpatient medical, psychiatric and psychological services listed in the MA Program Fee Schedule furnished to an individual with mental illness or emotional disturbance while the individual is not a resident of a treatment institution, provided by or under the direction of a psychiatrist.

   Psychiatric outpatient partial hospitalization provider—A facility enrolled in the MA Program to provide partial hospitalization outpatient services and licensed by the Department, Office of Mental Health and Substance Abuse Services, to provide psychiatric, medical, psychological and psychosocial services as partial hospitalization for the diagnosis and treatment of mental illness or emotional disturbance.

   Psychiatric partial hospitalization—An active outpatient psychiatric day or evening treatment session including medical, psychiatric, psychological and psychosocial treatment listed in the MA Program Fee Schedule. This service shall be provided to an individual with mental illness or emotional disturbance on a planned and regularly scheduled basis for a minimum of 3 hours but less than 24 hours in any 1 day. The session shall be provided by a psychiatrist or by psychiatric partial hospitalization personnel under the direction of a psychiatrist.

   Psychologist in preparation for licensure—A person who has completed the educational requirements for licensure and is accruing the required postdegree experience for licensing.

   Psychotherapy—The treatment, by psychological means, of the problems of an emotional nature in which a trained person deliberately establishes a professional relationship with an individual with the objective of removing, modifying or relieving existing symptoms of mediating disturbed patterns of behavior and of promoting positive personality growth and development.

   Tele-behavioral health

     (i)   The use of interactive audio and video communication to provide clinical services at a distance using technology that conforms to the industry-wide standards and is in compliance with State and Federal privacy and security laws.

     (ii)   Tele-behavioral health does not include telephone conversation, electronic mail message or facsimile transmission between a psychiatrist or an advanced practice professional and an individual receiving services or a consultation between two health care practitioners, although these activities may support the delivery of tele-behavioral health.

   Treatment institution—A facility approved or licensed by the Department or its agents that provides full-time psychiatric treatment services for resident individuals with mental illness or emotional disturbance, residential facilities for individuals with intellectual disabilities or community residential rehabilitation services are not considered to be mental health treatment institutions.

   Under the direction of a psychiatrist—Receiving oversight and consultation by a psychiatrist in the medical, psychiatric and psychological services provided to individuals by psychiatric outpatient clinic or partial hospitalization personnel.

Authority

   The provisions of this §  1153.2 amended under section 201(2) of the Human Services Code (62 P.S. §  201(2)).

Source

   The provisions of this §  1153.2 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended October 2, 1981, effective October 3, 1981, 11 Pa.B. 3387; amended November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended January 24, 1992, effective November 9, 1991, 22 Pa.B. 361; amended October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial pages (375582) to (375584) and (278529).

COVERED AND NONCOVERED SERVICES


§ 1153.11. Types of services covered.

 Medical Assistance Program coverage for psychiatric outpatient clinics, partial hospitalization outpatient facilities and MMHT services is limited to professional medical and psychiatric services for the diagnosis and treatment of mental illness or emotional disturbance, including a mental illness or emotional disturbance along with an intellectual disability, as specified in the MA Program Fee Schedule provided by psychiatric outpatient clinic providers and psychiatric outpatient partial hospitalization providers to MA beneficiaries.

Authority

   The provisions of this §  1153.11 amended under section 201(2) of the Human Services Code (62 P.S. §  201(2)).

Source

   The provisions of this §  1153.11 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial page (278529).

§ 1153.12. Outpatient services.

 The psychiatric outpatient clinic services specified in the MA Program Fee Schedule and the psychiatric partial hospitalization outpatient services specified in the MA Program Fee Schedule are covered only when provided by licensed psychiatric outpatient clinics or psychiatric partial hospitalization outpatient facilities under the direction of a psychiatrist. MMHT services specified in the MA Program Fee Schedule are covered only when provided by a licensed psychiatric outpatient clinic that has an approved service description for MMHT. Payment is subject to the conditions and limitations established in this chapter and Chapter 1101 (relating to general provisions).

Authority

   The provisions of this §  1153.12 amended under section 201(2) of the Human Services Code (62 P.S. §  201(2)).

Source

   The provisions of this §  1153.12 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial page (278530).

§ 1153.14. Noncovered services.

 Payment will not be made for the following types of services regardless of where or to whom they are provided:

   (1)  A covered psychiatric outpatient clinic, MMHT or partial hospitalization outpatient service conducted over the telephone.

   (2)  Cancelled appointments.

   (3)  Covered services that have not been rendered.

   (4)  An MA covered service, including psychiatric outpatient clinic, MMHT and partial hospitalization outpatient services, provided to inmates of State or county correctional institutions or committed residents of public institutions.

   (5)  Psychiatric outpatient clinic, MMHT or partial hospitalization outpatient services to residents of treatment institutions, such as individuals who are also being provided with room or board, or both, and services, on a 24-hour-a-day basis by the same facility or distinct part of a facility or program.

   (6)  Services delivered at locations other than licensed psychiatric outpatient clinics with the exception of MMHT under the conditions specified in §  1153.52(d) (relating to payment conditions for various services) or partial hospitalization outpatient facilities.

   (7)  Vocational rehabilitation, occupational or recreational therapy, referral, information or education services, case management, central intake or records, training, administration, program evaluation, research or social services provided in psychiatric outpatient clinics.

   (8)  Case management, central intake or records, training, administration, social rehabilitation, program evaluation or research provided in psychiatric outpatient partial hospitalization facilities.

   (9)  Psychiatric outpatient clinic services, MMHT services and psychiatric partial hospitalization outpatient services provided on the same day to the same individual, with the exception of clinical services not offered by the facility providing services to the individual.

   (10)  Covered psychiatric outpatient clinic services, MMHT services and psychiatric partial hospitalization outpatient services, with the exception of family psychotherapy, provided to persons without a mental diagnosis rendered by a psychiatrist in accordance with the current version of the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases—Chapter V, ‘‘Mental, Behavioral, and Neurodevelopmental Disorders.’’

   (11)  Psychiatric outpatient clinic, MMHT and psychiatric partial hospitalization outpatient services provided to individuals with substance-related and addictive disorders, unless the individual has a primary diagnosis of a mental illness or emotional disturbance.

   (12)  Drugs, biologicals and supplies furnished to an individual receiving services at a psychiatric outpatient clinic or a partial hospitalization outpatient facility during a visit to the psychiatric outpatient clinic or partial hospitalization outpatient facility. These are included in the psychiatric outpatient clinic medication visit fee or partial hospitalization session payment. Separate billings from any source for items and services provided by the psychiatric outpatient clinic are noncompensable.

   (13)  Services not specifically included in the MA Program Fee Schedule are noncompensable.

   (14)  MMHT services not provided in accordance with the conditions specified in §  1153.52(d).

   (15)  Services provided beyond the 30th calendar day following intake, without review and approval of the initial assessment and treatment plan in accordance with §  1153.52(a)(7) and (8).

   (16)  The hours that the individual participates in an education program delivered in the same setting as a children and youth partial hospitalization outpatient program unless, in addition to the teacher, a clinical staff person works with the child in the classroom. The Department will reimburse for only that time during which the individual is in direct contact with a clinical staff person.

   (17)  Group psychotherapy provided in the individual’s home.

   (18)  Psychiatric outpatient clinic and partial hospitalization outpatient services provided to nursing home residents on the grounds of the nursing home or under the corporate umbrella of the nursing home.

   (19)  Electroconvulsive therapy and electroencephalogram provided through MMHT.

   (20)  MMHT services provided on the same day as other home and community-based behavioral health services to the same individual with the exception of clinical services not offered by the psychiatric outpatient clinic.

Authority

   The provisions of this §  1153.14 amended under section 201(2) of the Human Services Code (62 P.S. §  201(2)).

Source

   The provisions of this §  1153.14 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial pages (278530) to (278531).

SCOPE OF BENEFITS


§ 1153.21. Scope of benefits for children under 21 years of age.

 Children under 21 years of age are eligible for the full range of covered psychiatric outpatient clinic, MMHT and psychiatric partial hospitalization services in the MA Program Fee Schedule.

Authority

   The provisions of this §  1153.21 amended under section 201(2) of the Human Services Code (62 P.S. §  201(2)).

Source

   The provisions of this §  1153.21 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial pages (278531) to (278532).

§ 1153.22. Scope of benefits for adults 21 years of age or older.

 Adults 21 years of age or older are eligible for the full range of covered psychiatric outpatient clinic, MMHT and psychiatric partial hospitalization services in the MA Program Fee Schedule.

Authority

   The provisions of this §  1153.22 amended under section 201(2) of the Human Services Code (62 P.S. §  201(2)).

Source

   The provisions of this §  1153.22 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial page (278532).

§ 1153.23. [Reserved].


Authority

   The provisions of this §  1153.23 reserved under section 201(2) of the Human Services Code (62 P.S. §  201(2)).

Source

   The provisions of this §  1153.23 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; reserved October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial page (278532).

§ 1153.24. [Reserved].


Authority

   The provisions of this §  1153.24 reserved under section 201(2) of the Human Services Code (62 P.S. §  201(2)).

Source

   The provisions of this §  1153.24 adopted December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995; reserved October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial page (278532).

PROVIDER PARTICIPATION


§ 1153.41. Participation requirements.

 In addition to the participation requirements established in Chapter 1101 (relating to general provisions), psychiatric outpatient clinics and partial hospitalization outpatient facilities shall meet the following participation requirements:

   (1)  Have current licensure as a psychiatric outpatient clinic or partial hospitalization outpatient facility by the Department’s Office of Mental Health and Substance Abuse Services. To remain eligible for MA reimbursement, a psychiatric outpatient clinic or partial hospitalization outpatient facility shall be licensed at all times as a psychiatric outpatient clinic or partial hospitalization outpatient facility.

   (2)  Have medical personnel currently licensed, certified or registered in accordance with laws of the Commonwealth.

   (3)  Have a written referral plan for individuals receiving services that provides for inpatient hospital care and follow-up treatment.

   (4)  Post a current written fee schedule for billing third party and private payors.

   (5)  Appoint an administrator or director responsible for the internal operation of the psychiatric outpatient clinic or partial hospitalization outpatient facility. Appoint a psychiatrist or psychiatrists responsible for the supervision and direction of services rendered to eligible individuals.

   (6)  Notify immediately the Department, Office of Medical Assistance Programs, Bureau of Fee-for-Services, in the manner prescribed by the Department, of facility or clinic name, address and service changes prior to the effective date of change. Failure to do so may result in payment interruption or termination of the provider agreement.

   (7)  Enter into a written provider agreement with the Department.

   (8)  Have each branch location or satellite of a licensed psychiatric outpatient clinic or partial hospitalization outpatient facility also licensed by the Office of Mental Health and Substance Abuse Services as a psychiatric outpatient clinic site or psychiatric hospitalization outpatient facility, whichever is applicable, and enrolled by the Office of Medical Assistance Programs before reimbursement can be made for services rendered at the branch or satellite. Licensure and enrollment of the parent organization does not constitute licensure and enrollment for any branches or satellites of the same organization.

   (9)  Be enrolled as a provider in the Medical Assistance Program.

   (10)  Have medications prescribed by a licensed psychiatrist, physician, certified registered nurse practitioner or physician assistant within the practitioner’s scope of practice.

   (11)  Psychiatric outpatient clinics providing MMHT services shall have a service description approved by the Department under the conditions specified in §  5200.51 (relating to provider service description).

Authority

   The provisions of this §  1153.41 amended under section 201(2) of the Human Services Code (62 P.S. §  201(2)).

Source

   The provisions of this §  1153.41 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046; amended October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial pages (278532) and (348909).

§ 1153.41a. Medication prescription—statement of policy.

 Medications may be prescribed by a certified registered nurse practitioner in outpatient psychiatric clinics and outpatient partial hospitalization facilities as authorized under 49 Pa. Code Chapter 18, Subchapter C (relating to certified registered nurse practitioners) and Chapter 21, Subchapter C (relating to certified registered nurse practitioners).

Source

   The provisions of this §  1153.41a adopted March 26, 2010, effective March 27, 2010, 40 Pa.B. 1644.

§ 1153.42. Ongoing responsibilities of providers.

 (a)  Responsibilities of providers. Ongoing responsibilities of providers are established in Chapter 1101 (relating to general provisions). Psychiatric outpatient clinics and psychiatric partial hospitalization outpatient facilities shall also adhere to the additional requirements established in this section.

 (b)  Recordkeeping requirements. In addition to the requirements listed in §  1101.51(e) (relating to ongoing responsibilities of providers), the following items must be included in the records of MA beneficiaries receiving psychiatric outpatient clinic, MMHT and psychiatric partial hospitalization outpatient services:

   (1)  The treatment plan must include:

     (i)   The treatment plan goals.

     (ii)   Services to be provided to the individual by the psychiatric outpatient clinic or partial hospitalization outpatient facility or through referral.

     (iii)   Persons to directly provide each service.

   (2)  As part of the progress notes, the frequency and duration of each service provided shall be included.

Authority

   The provisions of this §  1153.42 amended under section 201(2) of the Human Services Code (62 P.S. §  201(2)).

Source

   The provisions of this §  1153.42 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial page (348910).

PAYMENT FOR OUTPATIENT BEHAVIORAL
HEALTH SERVICES


§ 1153.51. General payment policy.

 (a)  Payment is made for medically necessary professional medical and psychiatric services provided by or under the supervision and direction of a psychiatrist by participating psychiatric outpatient clinics and psychiatric partial hospitalization outpatient facilities subject to the conditions and limitations established in this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program Fee Schedule.

 (b)  The Department will publish procedures for the use of tele-behavioral health to provide compensable psychiatric outpatient clinic or psychiatric partial hospitalization services in the Pennsylvania Bulletin.

 (c)  Payment will not be made for a compensable psychiatric outpatient clinic, MMHT or psychiatric partial hospitalization outpatient service if payment is available from another public agency or another insurance or health program.

Authority

   The provisions of this §  1153.51 amended under section 201(2) of the Human Services Code (62 P.S. §  201(2)).

Source

   The provisions of this §  1153.51 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial pages (348910) to (348911).

§ 1153.52. Payment conditions for various services.

 (a)  The following conditions shall be met by psychiatric outpatient clinics and partial hospitalization outpatient programs, as applicable, to be eligible for payment:

   (1)  A psychiatrist shall be present in the psychiatric outpatient clinic and partial hospitalization outpatient facility, as required by the Office of Mental Health and Substance Abuse Services licensing regulations, to perform or supervise the performance of all covered services provided to MA beneficiaries.

   (2)  Psychiatric evaluations shall be performed only by a psychiatrist in a face-to-face interview or using interactive audio and video communication that conforms to industry-wide technology standards with the individual and is in compliance with State and Federal privacy and security laws. Additional interviews with other staff may be included as part of the examination but shall be included in the psychiatric evaluation fee. Separate billings for these additional interviews are not compensable.

   (3)  Psychotherapy—individual, family, collateral family or group—shall be provided only by a clinical staff person.

   (4)  Psychiatric partial hospitalization services shall be provided only by a clinical staff person.

   (5)  Diagnostic psychological and intellectual evaluations shall be administered and interpreted only by a licensed psychologist or by a psychologist in preparation for licensure under the direct supervision of a licensed psychologist.

   (6)  The psychiatric outpatient clinic medication visit shall be provided only by a psychiatrist, physician, certified registered nurse practitioner, physician assistant, registered nurse or licensed practical nurse.

   (7)  Within 30 consecutive calendar days following intake for individuals who continue to participate in the treatment process, a mental health professional or mental health worker under the supervision of a mental health professional, shall:

     (i)   Interview and complete an assessment with each individual receiving services from the psychiatric outpatient clinic.

     (ii)   Develop the initial treatment plan based upon the assessment in collaboration with the individual.

     (iii)   Date and sign the initial treatment plan.

     (iv)   Request the individual to sign and date the treatment plan. In the event the individual does not sign the treatment plan, the mental health professional or mental health worker shall document the request in the record.

   (8)  The initial treatment plan shall be reviewed and approved in accordance with the following:

     (i)   If the individual is receiving psychotherapy and other clinic services, the psychiatrist or advanced practice professional shall review, approve, sign and date the initial treatment plan.

     (ii)   If the individual is receiving medication management services only, the psychiatrist, physician, certified registered nurse practitioner or physician assistant responsible for prescribing and monitoring the use of the medications shall sign and date the initial treatment plan.

     (iii)   The initial treatment plan shall be developed, reviewed, approved, dated and signed prior to the provision of any treatment services beyond the 30th day following intake.

     (iv)   The initial treatment plan shall be kept in the individual record.

   (9)  The treatment plan shall be reviewed and updated at least every 180 days or as may otherwise be required by law throughout the duration of treatment in accordance with the following:

     (i)   The treatment plan updates shall be based upon the assessment, diagnosis and input from the treatment team and individual receiving services.

     (ii)   The treatment plan update shall be signed and dated by the mental health professional, mental health worker under the supervision of the mental health professional, certified registered nurse practitioner or physician assistant providing treatment services to the individual.

     (iii)   The mental health professional or the mental health worker shall request the individual to sign and date the treatment plan update. In the event the individual does not sign the treatment plan, the mental health professional or mental health worker shall document the request in the record.

     (iv)   The treatment plan update shall be kept in the individual record.

   (10)  Treatment shall be provided in accordance with the identified goals in the treatment plan and updates.

   (11)  The treatment plan shall be reviewed on an annual basis by the psychiatrist or advanced practice professional throughout the course of treatment from the psychiatric outpatient clinic and the review documented in the individual record.

   (12)  The psychiatric clinic clozapine monitoring and evaluation visit shall be used only for an individual receiving clozapine therapy.

 (b)  Psychiatric outpatient partial hospitalization. Payment will only be made for psychiatric partial hospitalization outpatient services provided to eligible individuals with mental illness or emotional disturbance in psychiatric partial hospitalization outpatient facilities under the following conditions:

   (1)  Individuals receiving partial hospitalization outpatient services shall meet the following criteria:

     (i)   Have a mental disorder diagnosis that has been verified by a psychiatrist.

     (ii)   Have a psychiatric condition requiring more intensive treatment than that provided by an outpatient clinic.

     (iii)   Be diagnosed with a mental illness or emotional disturbance and prescribed services for a period of at least 3 hours but less than 24 hours in any 1 day to prevent hospitalization or to support the transition from inpatient treatment to outpatient services.

   (2)  The following components shall be available in a psychiatric partial hospitalization outpatient facility and provided to an individual, if necessary, in accordance with the individualized treatment plan:

     (i)   Individual, group and family psychotherapy.

     (ii)   Health education—basic physical and mental health information; nutrition information and assistance in purchasing and preparing food, personal hygiene instruction; basic health care information, child care information and family planning information and referral; information on prescribed medications.

     (iii)   Instruction in basic care of the home or residence for daily living.

     (iv)   Instruction in basic personal financial management for daily living.

     (v)   Medication administration and evaluation provided only by a psychiatrist, physician, certified registered nurse practitioner, physician assistant, registered nurse or licensed practical nurse.

     (vi)   Guided social interaction supervised by psychiatric partial hospitalization personnel.

     (vii)   Crisis management provided by psychiatric partial hospitalization personnel.

     (viii)   Referral.

 (c)  Psychiatric outpatient clinic. Payment will only be made for psychiatric outpatient clinic services or MMHT services provided to eligible individuals with mental illness or emotional disturbance by psychiatric outpatient clinics under the following conditions:

   (1)  Medication visits shall be provided only for the purpose of administering medication and for evaluating the physical and mental condition of an individual during the course of prescribed medication.

   (2)  Individuals receiving psychiatric outpatient clinic services or MMHT services shall have a mental illness or emotional disturbance diagnosis verified by a psychiatrist or LPHA.

   (3)  Family psychotherapy is compensable only if one or more family members has a mental disorder diagnosis.

   (4)  Clozapine monitoring and evaluation visits shall be provided only for an individual receiving clozapine and for monitoring and evaluating the individual’s absolute neutrophil count to determine whether clozapine therapy should be continued or modified.

 (d)  MMHT. MMHT services are subject to the conditions and limitations established in this chapter. MMHT services provided in the home or other approved community sites are compensable only if documentation in the individual record substantiates all of the following:

   (1)  The services are provided to an eligible individual with mental illness or emotional disturbance.

   (2)  There is a written recommendation for MMHT services from a LPHA acting within the scope of professional practice.

   (3)  The services if provided in a psychiatric outpatient clinic would be medically necessary.

   (4)  The assessment documents a mental or physical illness that impedes or precludes the individual’s ability to participate in services at the psychiatric outpatient clinic.

   (5)  Treatment plan updates document the continued clinical need for MMHT services.

Authority

   The provisions of this §  1153.52 amended under section 201(2) of the Human Services Code (62 P.S. §  201(2)).

Source

   The provisions of this §  1153.52 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended January 24, 1992, effective November 9, 1991, 22 Pa.B. 361; amended October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial pages (348911), (278535) to (278536) and (313015).

Cross References

   This section cited in 55 Pa. Code §  1153.14 (relating to noncovered services).

§ 1153.53. Limitations on payment.

 Payment is subject to the following limitations:

   (1)  Psychiatric partial hospitalization outpatient service is provided for at least 3 hours per 24-hour period.

   (2)  The partial hospitalization outpatient service fees listed in the MA Program Fee Schedule include payment for all services rendered to the individual during a psychiatric partial hospitalization outpatient session. Separate billings for individual services are not compensable.

   (3)  Partial hospitalization outpatient facilities licensed for adult programs will be reimbursed at the adult rate, regardless of the age of the individual receiving treatment.

   (4)  Partial hospitalization outpatient facilities licensed as children and youth programs will be reimbursed at the child rate only when the individual receiving treatment is under 15 years of age.

   (5)  Family psychotherapy and collateral family psychotherapy are compensable for only one person per session, regardless of the number of family members who participate in the session or the number of participants who are eligible for psychotherapy.

   (6)  MMHT group therapy shall be provided only in an approved community-based site as specified in the treatment plan to individuals receiving MMHT services from the psychiatric outpatient clinic.

Authority

   The provisions of this §  1153.53 amended under sections 201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Human Services Code (62 P. S. § §  201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454).

Source

   The provisions of this §  1153.53 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046; amended December 23, 1983, effective Janaury 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended January 24, 1992, effective November 9, 1991, 22 Pa.B. 361; amended August 26, 2005, effective August 29, 2005, 35 Pa.B. 4811; amended October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial pages (313015) to (313016) and (375585).

§ 1153.53a. [Reserved].


Authority

   The provisions of this §  1153.53a reserved under section 201(2) of the Human Services Code (62 P.S. §  201(2)).

Source

   The provisions of this §  1153.53a adopted November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046; reserved October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial page (375585).

§ 1153.54. Noncompensable services and items.

 Payment will not be made for items and services not listed as compensable in the MA Program Fee Schedule.

Source

   The provisions of this §  1153.54 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended December 23, 1983, effective Janaury 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (86838).

UTILIZATION REVIEW


§ 1153.71. Scope of claims review procedures.

 Claims submitted for payment under the MA Program are subject to the utilization review procedures established in Chapter 1101 (relating to general provisions).

Source

   The provisions of this §  1153.71 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267.

ADMINISTRATIVE SANCTIONS


§ 1153.81. Provider misutilization.

 Providers determined to have billed for services inconsistent with MA Program regulations, to have provided services outside the scope of customary standards of medical practice, or to have otherwise violated the standards set forth in the provider agreement, are subject to the sanctions described in Chapter 1101 (relating to general provisions).

Source

   The provisions of this §  1153.81 adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267.

APPENDIX A. [Reserved]



Source

   The provisions of this Appendix A adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended November 13, 1981, effective November 15, 1981, 11 Pa.B. 4046; reserved December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial page (67880).

APPENDIX B. [Reserved]



Source

   The provisions of this Appendix B adopted January 25, 1980, effective February 1, 1980, 10 Pa.B. 267; amended October 2, 1981, effective October 3, 1981, 11 Pa.B. 3387; reserved December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial page (67881).



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