BEHAVIORAL HEALTH SERVICES PROVIDER MANUAL
BEHAVIORAL HEALTH SERVICES PROVIDER MANUAL
Chapter Two of the Medicaid Services Manual Issued March 14, 2017
State of Louisiana Bureau of Health Services Financing
LOUISIANA MEDICAID PROGRAM
ISSUED:
02/23/22
REPLACED: 02/21/22
CHAPTER 2: BEHAVIORAL HEALTH SERVICES
SECTION: TABLE OF CONTENTS
PAGE(S) 11
BEHAVIORAL HEALTH SERVICES
TABLE OF CONTENTS
SUBJECT
OVERVIEW
PROVIDER REQUIREMENTS
BED BASED SERVICES
Therapeutic Group Homes
Components Provider Qualifications Additional Organizational Requirements Agency Staffing Qualifications Allowed Provider Types and Specialties Eligibility Criteria Service Utilization Service Exclusions Allowed Mode(s) of Delivery Additional Service Criteria TGH Cost Reporting Requirements
Psychiatric Residential Treatment Facilities
Plan of Care Provider Qualifications Agency Additional Organizational Requirements Staff Staffing Treatment Model and Service Delivery Allowed Provider Types and Specialties Eligibility Criteria Limitations/Exclusions
SECTION SECTION 2.0 SECTION 2.1 SECTION 2.2
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Table of Contents
LOUISIANA MEDICAID PROGRAM
ISSUED:
02/23/22
REPLACED: 02/21/22
CHAPTER 2: BEHAVIORAL HEALTH SERVICES
SECTION: TABLE OF CONTENTS
PAGE(S) 11
OUTPATIENT SERVICES
SECTION 2.3
Behavioral Health Services in a Federally Qualified Health Center or Rural Health Center
Provider Qualifications Agency or Group Practice Allowed Provider Types and Specialties Eligibility Criteria Allowed Mode(s) of Delivery
Crisis Services
Crisis Response Services for Adults Common Components
Preliminary Screening Assessments Interventions Care Coordination Service Delivery Provider Responsibilities Supervision of Non-Licensed Staff Documentation Reporting Requirements Provider Qualifications Agency/Facility Staff Mobile Response Components Eligibility Criteria Service Utilization Allowed Modes of Delivery Staffing Requirements Response Team Staffing Requirements Allowed Provider Types and Specialties Exclusions Billing Behavioral Health Crisis Care Components Eligibility Criteria Service Utilization Allowed Mode(s) of Delivery Staffing Requirements Allowed Provider Types and Specialties
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Table of Contents
LOUISIANA MEDICAID PROGRAM
ISSUED:
02/23/22
REPLACED: 02/21/22
CHAPTER 2: BEHAVIORAL HEALTH SERVICES
SECTION: TABLE OF CONTENTS
PAGE(S) 11
Community Based Agency (new or current provider type) Exclusions Community Brief Crisis Support (CBCS) Components Eligibility Criteria Service Utilization Allowed Mode(s) of Delivery Allowed Places of Service Staffing Requirements Allowed Provider Types and Specialties Exclusions Billing
Individual Placement and Support
Evaluation of the Evidence Based Practice Components Eligibility Criteria Service Utilization Service Delivery
Staff Ratios
Allowed Provider Types and Specialties Allowed Modes of Delivery Provider Responsibilities
Supervision Provider Qualifications
Agency IPS Fidelity Standards New Teams Existing Teams IPS Specialist IPS Peer Specialist (Optional staff, but recommended) IPS Supervisor IPS Training and Recertification Limitations/Exclusions Billing
Outpatient Therapy by Licensed Practitioners
Provider Qualifications Agency or Group Practice Allowed Provider Types and Specialties
Eligibility Criteria Limitations/Exclusions Allowed Mode(s) of Delivery
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LOUISIANA MEDICAID PROGRAM
ISSUED:
02/23/22
REPLACED: 02/21/22
CHAPTER 2: BEHAVIORAL HEALTH SERVICES
SECTION: TABLE OF CONTENTS
PAGE(S) 11
Additional Service Criteria Telehealth
Peer Support Services
Evaluation and Evidence Based Practices Components Eligibility Criteria Allowed Modes of Delivery Service Utilization Service Delivery Staff Ratios Provider Responsibilities
Supervisions Provider Qualifications
Agency Staff CPSS Training and Certification Allowed Partner Types and Specialties Limitations/Exclusions
Personal Care Services
Components Eligibility Criteria Service Utilization Service Delivery Allowed Mode(s) of Delivery Provider Responsibilities Service Documentation Service Logs Back-Up Staffing & Emergency Evacuation Plans Provider Qualifications
Agency Staff Allowed Provider Types and Specialties Limitations/Exclusions Billing
Rehabilitation Services for Children, Adolescents, and Adults
Children and Adolescents Adults Service Delivery Assessment and Treatment Planning
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Table of Contents
LOUISIANA MEDICAID PROGRAM
ISSUED:
02/23/22
REPLACED: 02/21/22
CHAPTER 2: BEHAVIORAL HEALTH SERVICES
SECTION: TABLE OF CONTENTS
PAGE(S) 11
Provider Responsibilities Core Services The BHSP Crisis Mitigation Plan Core Staffing Staff Supervision for Non-Licensed Staff
Eligibility Criteria Additional Adult Eligibility Criteria for Community Psychiatric Support and Treatment (CPST) and Psychosocial Rehabilitation (PSR) Adults receiving CPST and/or PSR must have at least Service Utilization Additional Service Utilization Criteria Member Choice Form and Process Limitations/Exclusions Community Psychiatric Support and Treatment
Components CPST Provider Qualifications
Agency Staff CPST Allowed Provider Types and Specialties CPST Allowed Mode(s) of Delivery CPST Additional Service Criteria CPST Staff Ratio(s) Psychosocial Rehabilitation Components PSR Provider Qualifications Agency Staff PSR Allowed Provider Types and Specialties PSR Allowed Mode(s) of Delivery PSR Staff Ratio(s) Crisis Intervention Components Provider Qualifications Agency Staff CI Allowed Provider Types and Specialties CI Eligibility Criteria CI Service Utilization CI Allowed Mode(s) of Delivery CI Additional Service Criteria Crisis Stabilization Components CS Provider Qualifications
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LOUISIANA MEDICAID PROGRAM
ISSUED:
02/23/22
REPLACED: 02/21/22
CHAPTER 2: BEHAVIORAL HEALTH SERVICES
SECTION: TABLE OF CONTENTS
PAGE(S) 11
Agency Staff CS Allowed Provider Types and Specialties CS Limitations/Exclusions CS Allowed Mode(s) of Delivery
ADDICTION SERVICES
SECTION 2.4
ASAM Levels Covered
Provider Qualifications
Agency
Staff
Allowed Provider Types and Specialties
Eligibility Criteria
Allowed Mode(s) of Delivery
Additional Service Criteria
ASAM Level 1 in an Outpatient Setting
Admission Guidelines for ASAM Level 1
Additional Admission Guidelines for Outpatient Treatment
Screening/Assessment/Treatment Plan Review
Provider Qualifications
Agency
Staff
Staffing Requirements
Additional Staffing and Service Components
ASAM Level 2.1 Intensive Outpatient Treatment
Admission Guidelines for ASAM Level 2.1 Intensive Outpatient Treatment
Additional Admission Guidelines for Intensive Outpatient Treatment
Screening/Assessment/Treatment Plan Review
Provider Qualifications
Staffing Requirements
Additional Staffing and Service Components
ASAM Level 2-WM Ambulatory Withdrawal Management with Extended On-Site
Monitoring
Admission Guidelines for ASAM Level 2-WM Ambulatory Withdrawal
Management with Extended On-Site Monitoring
Screening/Assessment/Treatment Plan Review
Provider Qualifications
Staffing Requirements
Additional Staffing and Service Components
Allowed Provider Types and Specialties
Eligibility Criteria
Allowed Mode(s) of Delivery
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LOUISIANA MEDICAID PROGRAM
ISSUED:
02/23/22
REPLACED: 02/21/22
CHAPTER 2: BEHAVIORAL HEALTH SERVICES
SECTION: TABLE OF CONTENTS
PAGE(S) 11
Additional Service Criteria ASAM Level 3.1: Clinically managed low-intensity residential treatment- Adolescent
Admission Guidelines Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components ASAM Level 3.1: Clinically managed low-intensity residential treatment- Adults Admission Guidelines Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components ASAM Level 3.2-WM: Clinically managed residential social withdrawal management ? Adolescent Admission Guidelines Emergency Admissions Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components Minimum Standards of Practice ASAM Level 3.-2WM: Clinically managed residential social withdrawal management ? Adults Admission Guidelines Emergency Admissions Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components Minimum Standards of Practice ASAM Level 3.3: Clinically managed population specific high intensity residential treatment- Adult Admission Guidelines Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components Minimum Standards of Practice Women with Dependent Children Program ASAM Level 3.5: Clinically managed medium intensity residential treatment ? Adolescent Admission Guidelines
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