Project S - ABH
Substance
Abuse
Family
Evaluation
Preferred Practice Standards
Key Contact Information 5
Welcome to Project SAFE 6
History 6
Program Overview 6
Project S.A.F.E Covered Services 7
Evaluation 8
Adolescent Evaluation: 9
Comprehensive Evaluation: 9
Individual Therapy 10
Group Therapy 10
Family Therapy 10
Intensive Outpatient Therapy (IOP) 10
Partial Hospitalization Program (PHP) 10
Urine Drug Screens 11
Hair Testing 11
Treatment Levels of Care 11
Service Limitations and Exclusions 12
Level of Care Guide (Table I) 13
Level I: (SA I.1 & SA I.1) Outpatient 13
Level of Care Guide (Table II) 14
Level II: (SA II.1 & MH II.1) Intensive Outpatient (IOP) 14
Level of Care Guide (Table III) 15
Level II: SAII.5 & MH II.5 Partial Hospital & SA Day/Evening 15
Referral and Authorization Process 16
Service Authorization and Referral Process for Covered Services 17
Referral and Authorization Process (CHART) 23
Type of Service/Level of Care 23
Information Needed From DCF 23
Information Need from the Provider 23
Information needed or provided by ABH 23
Authorization Requirements 23
Reimbursement Protocol 24
Provider Credentialing 25
Reimbursement 25
Reimbursement for Evaluation 26
DCF Responsibilities 26
Provider Responsibilities 26
ABH Project S.A.F.E. Will 26
Reimbursement for Treatment 27
DCF Responsibilities 27
Provider Responsibilities 27
ABH Project S.A.F.E. Will 28
Reimbursement for IOP or PHP Levels of Care 29
DCF Responsibilities 29
Provider Responsibilities 29
ABH Project S.A.F.E. Will 29
Reimbursement for Hair Testing 30
DCF Responsibilities 30
Provider Responsibilities 30
ABH Project S.A.F.E. Will 30
Reimbursement for Random Urine Drug Screens Only 31
DCF Responsibilities 31
Provider Responsibilities 31
ABH Project S.A.F.E. Will 31
Requests for Court Cost Reimbursement 33
DCF Responsibilities 33
Provider Responsibilities 33
ABH Project S.A.F.E. Will 33
Special Exceptions 34
Six Tab Web Base Claim System 36
Complaints, Grievances, and Appeals 38
Appendix A 42
CLIENT REFERRAL FORM (page 1) 42
CLIENT REFERRAL FORM (page 2) 43
Appendix B 44
CLIENT REPORT FORM 44
PROJECT SAFE 44
Appendix C 45
Needs Assessment Form 45
Appendix D 46
TANF ELIGIBILITY SCREENING FORM 46
Appendix E: Outpatient Treatment Request Downloading Procedure 47
Outpatient Treatment Request Downloading Procedure (page 2) 48
Outpatient Treatment Request Downloading Procedure (page 3) 49
Appendix G 51
Special Exception 51
FAQ for Project SAFE Special Exceptions 52
(Formerly Regional Administrator’s Approval) 52
Appendix H: 54
Screen Shot of Web-Based Claims System 54
Key Contact Information
Advanced Behavioral Health
213 Court Street
Middletown, CT 06457
Referral Hotline:…………………………1-800-272-0097
Main Number:……………………………1-860-638-5309
Billing Department……………………….1-860-704-6144
Fax:………………………………………..1-860-638-5302
Advanced Behavioral Health Website:
Online access to information and materials, such as newsletters, alert memos, and forms.
Department of Children and Families Website:
Online access to a wide variety of information related to the Department of Children and Families such as newsletters, other publications, and forms.
Department of Mental Health and Addiction Services Website:
Online access to a wide variety of information related to the Department of Mental Health and Addiction Services such as newsletters, publications, and forms.
Welcome to Project SAFE
Welcome to the Advanced Behavioral Health (ABH) Project S.A.F.E. Provider network. As a member of the Project S.A.F.E. Provider network you have joined a group of highly respected behavioral health professionals. We recognize that you share our commitment to improve the quality of life for clients by providing a continuum of high quality accessible behavioral health care services.
This Preferred Practice Standards handbook has been developed to inform you of standard practice of participants in the ABH Project S.A.F.E. network The handbook begins with an introduction, states policies and procedures for referral, authorization, claims submission, and the complaints, grievances, and appeal process. Finally, the necessary forms are included, along with a glossary and index for your convenience. Services provided for ABH Project S.A.F.E. clients must be consistent with the practices encompassed in this handbook Should you have any questions, please contact ABH Project S.A.F.E. at:
1-800-272-0097
History
The Department of Children and Families (DCF) initiated Project S.A.F.E. (Substance Abuse Family Evaluation) in 1995 as a way to connect its child protection system with the adult substance abuse treatment system. DCF contracted with ABH to coordinate central intake and priority access to drug screening, evaluation, and ambulatory treatment for substance abusing primary caregivers of children receiving protective services. DCF began collaborating with the Department of Mental Health and Addiction Services (DMHAS) in October 1999 to identify and address more effectively substance abuse issues and to coordinate and blend state, federal, and private resources to meet the needs of these populations.
Program Overview
Project S.A.F.E. is a program, jointly funded by DCF and DMHAS, designed to provide priority access to substance abuse evaluation and outpatient treatment services. Clients are eligible for Project S.A.F.E. services if they meet the following criteria:
• Parents or Primary Caregiver involved in child Protective Services
• The completed DCF Substance Abuse Screen has identified that substance use/abuse may be effecting the ability to parent effectively and substance abuse treatment or further evaluation is needed;
• A Referral has been made by DCF Social Worker prior to any treatment and \or evaluation service
Funding for Project S.A.F.E. services is provided by DCF and DMHAS, and administered by ABH. This funding system is designed as a payer of last resort. The term ‘payer of last resort’ indicates that the Project S.A.F.E. funds are used to reimburse providers on a fee-for-service basis when there is no other source of reimbursement available.
Project S.A.F.E. Covered Services
There are a variety of services that are reimbursed under Project S.A.F.E.’s payer of last resort system. In the following section, we will outline identify and define all services covered by Project SAFE.
Project S.A.F.E Covered Services
There are eight basic treatment services that are reimbursable within Project S.A.F.E.
• Evaluation
• Individual Therapy (SA I.1)
• Group Therapy (SA I.1)
• Family Therapy (SA I.1)
• Intensive Outpatient Therapy (IOP) (SA II.1)
• Partial Hospitalization Program (PHP) (SA II.5)
• Urine Drug Screens
• Hair Testing
The following section contains a description of these services.
Evaluation
Clients are referred for a Project S.A.F.E evaluation because the DCF Social Worker has completed the DCF substance abuse screen (DCF form 2110) and found reason to believe that the individual’s ability to parent effectively is impaired as a result of his/her use. The evaluation is conducted by an approved Project S.A.F.E Provider and consists of a bio-psycho-social assessment focusing on the following areas:
• Demographic Information
• Family composition and history
• Substance abuse history
• Trauma history
• Medical history and current medical status
• DSM IV TR Diagnostic formulation
• Drug screen results
• Summary and recommendations
Each evaluation should contain a written narrative in the aforementioned areas.
Once the evaluation is completed by the provider, the results of the evaluation should be verbally communicated to the DCF Social Worker within twenty-four (24) hours (one business day) of its completion. A written clinical summary will be forwarded to both the Social Worker and the DCF Substance Abuse Specialist within five (5) business days of the evaluation.
In specific cases there are two different evaluation subtypes that may be completed. They are an adolescent evaluation or a comprehensive evaluation.
Adolescent Evaluation:
Project S.A.F.E. also has capacity to conduct adolescent specific evaluations. The Project S.A.F.E. Adolescent Evaluation Project was initiated in (the then )Region IV to provide Substance Abuse Evaluations to adolescents who are suspected of substance abuse, but do not meet the basic Project S.A.F.E. criteria. DCF Region IV Social Workers who believe that an adolescent would benefit from a Project S.A.F.E. evaluation should complete the following forms prior to contacting the North Central Region ARG:
• Adolescent Screening Form
• Project SAFE Referral Form
These two forms are then reviewed by the ARG, and approved if clinically appropriate. Once approved, the ARG or designee will call the ABH Intake Coordinator at 1-800-272-0097, and make the referral.
Comprehensive Evaluation:
The Comprehensive Evaluation Pilot Project began in March 2002, with the following objectives:
• To develop and standardize a comprehensive bio-psycho-social evaluation for Project S.A.F.E. clients;
• To collect comprehensive information about the clients served by Project S.A.F.E.;
• To provide a process for efficient and effective distribution of substance abuse evaluation results.
There are ten (10) providers that are participating in the Comprehensive Evaluation Pilot Project. The referral process for this pilot project is as follows:
1. Make an evaluation referral by calling the 1-800 Project S.A.F.E line
2. Once referred, the provider utilizing a specifically designed Bio-Psycho-social Evaluation that has been standardized will evaluate the client.
3. The form itself is used to collect data and should be completed entirely by the evaluating clinician.
4. Once it is completely filled out, the form is faxed to ABH within thirty (30) days of the date of service for processing.
5. ABH enters all of the information into a database, and then distributes a data processed form to the following:
• Referring DCF Social Worker;
• Treatment Provider;
• Regional Substance Abuse Specialist (if requested).
Individual Therapy
Individual therapy consists of one to one therapy in duration of up to one hour, with a frequency of no more than once weekly and no less than once per month. Treatment focuses on reducing symptoms, improving function, maintaining abstinence and relapse prevention.
Group Therapy
Group therapy consists of therapy in duration up to one and a half hours, with a frequency of once weekly. Treatment focuses on reducing symptoms, providing psycho-education, improving functioning, relapse prevention and maintenance of abstinence. Groups should be limited to no more than twelve (12) clients per group session.
Family Therapy
Family therapy consists of therapy sessions with a client and one or more individual(s) identified by the client as family, with duration of up to one hour, a frequency of no more than once weekly. Treatment focuses on building and maintaining supports for recovery, repairing relationships, reducing symptoms, providing psycho-education and maintenance of abstinence.
Intensive Outpatient Therapy (IOP)
A non-residential service provided in a general hospital, private freestanding psychiatric hospital, state operated facility or in a facility licensed by the Department of Public Health as a “Psychiatric Outpatient Clinic for Adults”. IOP services provides each client with three to four (3-4) hours per day, three to five (3-5) days per week of clinically intensive programming based on an individualized treatment plan. Treatment focuses on reducing symptoms, improving functioning, maintaining community connection and relapse prevention. As a client is preparing for discharge, titration of IOP may occur, decreasing the frequency to less than three (3) times per week. IOP must include one therapy session per day, inclusive of (at least) one individual therapy session per week. Random drug screens can be completed on the same day that a patient attends and are reimbursed separately.
Partial Hospitalization Program (PHP)
A non-residential service provided in a general hospital, private freestanding psychiatric hospital, state operated facility or by a provider that is a non-profit entity that involves ambulatory intensive psychiatric and/or substance abuse treatment services. PHP services are designed to serve individuals with significant impairment resulting from substance abuse as well as co-occurring psychiatric disorders. These services target adults who have recently been discharged from inpatient facilities, or whose admission to inpatient care may be prevented by treatment in PHP program. PHP consists of therapeutic programming of a minimum of four (4) hours per day, at least four (4) days per week, based on a comprehensive and coordinated individualized treatment plan involving the use of multiple concurrent treatment services and modalities. Treatment focuses on reducing symptoms, improving functioning, maintaining community connection, and relapse prevention. As a client is preparing for discharge, titration of PHP may occur, decreasing the frequency to less than four (4) times per week. PHP must include one therapy session per day, inclusive of (at least) one individual therapy session per week. Random drug screens can be completed on the same day that a patient attends and are reimbursed separately.
Urine Drug Screens
Urine drug screens are used to determine the recent use/abuse of substances. Random urine drug screens are defined as two (2) urine drug screens per week for a period of six (6) weeks. Random screens should not occur on the same day and time each week. In order for the screens to be random, the client may be contacted by the treatment provider and asked to come in within the next twenty- four (24) hours for a drug screen, provided it is not on a day when treatment services are provided. Random drug screens can also be requested for a client who is not in active treatment under the following circumstances:
• In response to a court ordered request or;
• Has had an evaluation within the past six (6) months.
Hair Testing
Hair testing is utilized to determine a three-month history of substance use/abuse history prior to the hair test. Careful collection of samples by authorized treatment providers following collection guidelines is necessary to ensure effective use of hair testing. Positive hair test results can be further analyzed to determine if the client’s use/abuse of substances occurred within 30/60/90 days prior to collection. This multi-sectional testing can be performed on a positive sample per request of the referring DCF Social Worker. A hair test may be requested for some of the following reasons:
• Family reunification planning is expected to occur in the immediate future.
• DCF or provider staff has reason to believe that client has attempted to alter the urine drug screens or failed to keep scheduled appointments.
• Central or Area Office has concerns about a particular high risk or high profile case.
• DCF staff identifies cases in which domestic violence is connected with substance abuse.
• The Court requires documentation of historical drug use during a 30/60/90 day period
• DCF staff identifies abuse/neglect cases in which the primary caregivers are said to be in recovery from substance abuse.
Treatment Levels of Care
In this section guidelines adapted from the ASAM Patient Placement Criteria for the Treatment of Substance Related Disorders, Second Edition Revised (ASAM PPC-2R), published by the American Society of Addiction Medicine ASAM in 2001 are used to define treatment levels of care. Each level of care has general characteristics and criteria. Project S.A.F.E provides reimbursement to providers for all of the outpatient levels of care:
• Outpatient Services – Level I SA1.1
Individual Counseling, Family Counseling, Group Counseling, Urine Screens, and Hair test
• Intensive Outpatient Services – Level II, SA II.1
• Partial Hospitalization Program Services – Level II, SA II.5
In an effort to provide general guidelines, we have included a level of care (page 13-15) table in this Preferred Practices document. It is intended as a guide for clinical practice rather than a set of rules.
Service Limitations and Exclusions
A. The following limitations shall apply to substance abuse services performed under Project S.A.F.E
a. Covered services and procedures are limited to those listed in the Project S.A.F.E. fee schedule
b. At the time of initial referral from the DCF Social Worker the following types of visits can be authorized:
i. One (1) evaluation
ii. One (1) urine drug screen
iii. Twelve (12) random drug screens
iv. One (1) hair test
v. Undisclosed number of outpatient SA I.1 levels of care
c. Medication Management is not a reimbursable service under Project S.A.F.E.
B. Reimbursement for the following behavioral health services is excluded under Project S.A.F.E
a. Psychiatric evaluation
b. Medication Management
c. Psychological Assessment
d. Services that Project S.A.F.E., DCF and DMHAS determine are not directly related to the diagnosis and treatment of a behavioral health disorder or those that do not reduce symptoms and/or psychological distress.
e. Services, consultation or information provided over the telephone
f. Services that Project S.A.F.E., DCF and DMHAS determine are primarily for vocational or educational guidance or that is related solely to a specific employment opportunity, work skill work setting and/or the development of an academic skill.
g. Breathalyzer
h. Methadone Maintenance
C. Project S.A.F.E. shall not reimburse for inpatient or residential levels of care.
D. Project S.A.F.E. does not reimburse for psychiatric evaluation or medication management.
E. Project S.A.F.E. does not reimburse for any required spend-down funding, and/or co-payment requirements
Level of Care Guide (Table I)
Level I: (SA I.1 & MH I.1) Outpatient
|Level of Care Guide |
|Level of Care |ASAM Dimension |Description of general criteria |
|Level I: (SA I.1 & MH I.1) |Dimension 1 |Patient has no signs and symptoms of withdrawal. |
|Outpatient | | |
| |Dimension 2 |If any biomedical conditions are present, they are |
| | |sufficiently stable to permit participation in outpatient |
| | |treatment. |
| |Dimension 3 |Any symptoms of a co-occurring disorder are generally |
| | |stable, may require some monitoring, and do not interfere |
| | |with the patient’s ability to focus on addiction treatment |
| | |issues. Mental status does not preclude ability to |
| | |understand information, and participate in treatment. |
| |Dimension 4 |Patient is willing to participate and cooperate with |
| | |treatment, acknowledges that he or she has a |
| | |substance–related problem and wants to change. If having |
| | |difficulty with the above, the patient may need monitoring. |
| |Dimension 5 |Patient is able to achieve abstinence and/or an awareness of|
| | |a substance related problem |
| |Dimension 6 |The patient’s psychosocial environment is sufficient to |
| | |support treatment feasibility. |
Level of Care Guide (Table II)
Level II: (SA II.1 & MH II.1) Intensive Outpatient (IOP)
|Level of Care Guide (continued) |
|Level of Care |ASAM Dimension |Description of general criteria |
|Level II: (SA II.1 & MH II.1) |Dimension 1 |Patient has no signs and symptoms of withdrawal. |
|Intensive Outpatient (IOP) | | |
| |Dimension 2 |If any biomedical conditions are present, they are |
| | |sufficiently stable to permit participation in outpatient |
| | |treatment. |
| |Dimension 3 |Patient engages in abuse of family or significant others, |
| | |and requires intensive outpatient treatment to reduce the |
| | |risk of further deterioration, or the patient has a |
| | |diagnosis requiring intensive outpatient monitoring to |
| | |minimize distractions from recovery. Patients meeting |
| | |Dimension 3 description require dual diagnosis treatment. |
| |Dimension 4 |Efforts at outpatient level (SA I.1 or MH I.1) have failed |
| | |to promote recovery, or although the patient is willing to |
| | |participate, their perspective inhibits ability to make |
| | |behavior change with repeated structured intervention. |
| |Dimension 5 |The patient has been an active participant at a less |
| | |intensive level of care, he or she is experiencing an |
| | |intensification of symptoms, and his or her level of |
| | |functioning is deteriorating. |
| |Dimension 6 |The patient lacks social contacts so as to jeopardized |
| | |recovery and/or continued exposure to school, work, or |
| | |living environment will render recovery unlikely. |
|Level of Care Guide (continued) |
|Level of Care |ASAM Dimension |Description of general criteria |
|Level II: (SA II.5 & MH II.5) |Dimension 1 |Patient has no signs and symptoms of withdrawal. |
|Partial Hospital & SA Day/Evening | | |
| |Dimension 2 |If any biomedical conditions are present, they are |
| | |sufficiently stable to permit participation in outpatient |
| | |treatment, however they may provide distraction from |
| | |recovery efforts. |
| |Dimension 3 |The patient’s mental status history is characterized by a |
| | |mild to moderate psychiatric decompensation on |
| | |discontinuation of the drug(s) of abuse. Patients meeting |
| | |Dimension 3 description require dual diagnosis treatment. |
| |Dimension 4 |Efforts at another treatment level have failed and |
| | |structured programmatic milieu interventions are not likely |
| | |to succeed at Level II.1, or, although the patient is |
| | |willing to participate, their perspective and lack of |
| | |impulse control inhibits ability to make behavior change |
| | |with repeated structured intervention. |
| |Dimension 5 |The patient has been an active participant at a less |
| | |intensive level of care, he or she is experiencing an |
| | |intensification of symptoms, and his or her level of |
| | |functioning is deteriorating; or a lack of awareness of |
| | |relapse triggers creates is a high likelihood of relapse. |
| |Dimension 6 |The patient’s family members or significant others who live |
| | |with the patient are not supportive of recovery goals, and |
| | |continued exposure to school, work, or living environment |
| | |will render recovery unlikely. |
Level of Care Guide (Table III)
Level II: SAII.5 & MH II.5 Partial Hospital & SA Day/Evening
Referral and Authorization Process
There are a variety of procedures in which each party of Project S.A.F.E. is required to follow. In the following section, we will outline what we (ABH) will do, and what DCF and/or the Provider are required to do, in order that our clients receive services in an efficient, professional, and timely manner.
Service Authorization and Referral Process for Covered Services
One of Project S.A.F.E.’s goals is to ensure that adults involved in the child welfare system have priority access to drug screening, substance abuse evaluations and outpatient services. By definition Priority Access means once contacted with an evaluation referral the provider will offer an evaluation appointment within five (5) business days. If requests are urgent, the provider should attempt to offer an appointment within twenty-four (24) hours. The following section sets forth the general requirements for referrals and service authorization for service types and levels of care.
1. Initial Referral An initial referral is the first time DCF Worker has called ABH Project S.A.F.E. regarding an identified client to make a referral.
a. An initial referral must be made to ABH in order for an individual to be considered a Project S.A.F.E. client.
b. The DCF Social Worker must obtain a release of information for ABH prior to making the referral.
c. A referral will only be accepted from a DCF Social Worker or other DCF designated staff (Supervisor, Area Resource Group, Central Office).
d. To make a referral the DCF Social Worker calls the ABH Project S.A.F.E. intake line (1-800-272-0097).
e. The DCF worker will be asked a series of questions including which Provider they would like the client to see.
f. The Project S.A.F.E. Intake Coordinator(s) will enter the information into the database all information asked, creating a Project S.A.F.E. Client ID number and electronic record. The electronic record will include demographic information, substance use concern as identified by the DCF Social Worker and an initial authorization for the service/services being requested.
g. The Project S.A.F.E. intake coordinator will then fax the referral (which also serves as the authorization) to the Project S.A.F.E. Provider.
2. Evaluation: The DCF Social Worker requests an evaluation once the DCF substance abuse screen (DCF form 2110) is completed and there is suspicion that the individuals’ ability to parent effectively is impaired as a result of substance use. To include a urine drug screen as part of the evaluation the DCF Social Worker should also request one (1) urine drug screen.
1. Prior to making the ABH Project S.A.F.E. referral, the DCF Social Worker will obtain a release of information from the client for Advanced Behavioral Health and the provider.
2. The DCF Social Worker calls the Intake Coordinators at 1-800-272-0097.
3. The DCF Social Worker will provide basic demographics, reason for referral and any updated information.
4. Once the Telephonic referral is completed, the Project S.A.F.E. Intake Coordinator will fax the client referral form and substance abuse screening form [Appendix A] to the Project S.A.F.E. Provider. This serves as an authorization for the evaluation.
5. The DCF Social Worker should fax the release of information to the provider. Providers will be unable to schedule an appointment without a signed release of information.
6. The Provider should verify the client’s health insurance using the EDS. If the client has insurance the Provider should submit a claim to both ABH Project S.A.F.E. and the client’s health insurance carrier. ABH Project S.A.F.E. is the payer of last resort.
7. The preferred location for conducting evaluations is at the Provider’s place of business; in addition the provider is expected to conduct a chain of custody (See glossary of terms) urine screen.
8. Upon completing the evaluation, results should be verbally communicated to the DCF Social Worker within twenty-four hours (one business day).
9. A written clinical summary should follow this verbal communication within five (5) business days. The summary should contain the following minimum information:
• Demographic information
• Family composition and history
• Substance abuse history
• Trauma history
• Medical history and current medical status
• DSM IV TR Diagnostic formulation
• Drug screen results
10. Upon completion of the evaluation Providers are responsible for faxing the following forms to Project S.A.F.E. 860-638-5302 claims department
a. Client Report Form [Appendix B]
b. Needs Assessment Form (for females only) [Appendix C]
c. TANF Eligibility Form [Appendix D]
d. OTR completed if the Provider is recommending IOP or PHP levels of care.
11. The Provider must inform the DCF Social Worker within twenty- four hours when a client fails to show for a drug screen and/or evaluation before rescheduling. It should be decided jointly who will contact the client to reschedule. If a client has a history of “no shows” with the assigned Project S.A.F.E. Provider, while reasonable efforts should be made to provide priority access, the Provider may apply their agency’s policy regarding rescheduling.
The appointment has to be rescheduled and the client seen within 45 days of the date of the original referral date. If this does not occur the DCF Social Worker has to make another referral by calling the Project S.A.F.E. Intake Coordinators.
3. Outpatient 1.1 levels of care: There are three (3) basic Outpatient services, which falls under 1.1 levels of care that are reimbursable within Project S.A.F.E. (individual psychotherapy, group counseling, and family counseling).
a. The DCF Social Worker will make a telephonic treatment referral by calling the intake coordinator at the ABH Project S.A.F.E.1-800 272-0097
b. The DCF Social Worker will need to provide:
i. Release of Information
ii. Client Insurance Information
iii. Client Social Security Number
iv. Results of DCF Substance Abuse Screen
v. Basic Demographic Information
vi. Reason for Referral
c. The intake coordinator will enter the referral information into the Project S.A.F.E. data system and fax the referral. This referral also serves as the authorization for the treatment provider.
d. The authorizations will allow the provider to receive reimbursement for the provision of individual, group and /or family/couple counseling treatment.
e. The treatment must begin within forty-five (45) days of the start date of the referral. If the client does not attend treatment within the forty-five (45) days of the start date of the referral, then the DCF Social Worker must make a new treatment only referral. The Provider should notify the DCF Social Worker when a referral lapses beyond the 45-day limit to request that the DCF Social Worker call in a treatment only referral.
f. The Provider is to notify the DCF Social Worker if the client does not show for their treatment appointment.
g. The Provider should regularly report to DCF the course of the client’s treatment.
4. IOP: IOP services provides each client with three to four (3-4) hours per day, three to five (3-5) days per week of clinically intensive programming based on an individualized treatment plan.
a. IOP services may be recommended based on a bio-psycho-social evaluation that has been completed within six (6) months of the service request.
b. The Provider must complete an OTR to ABH via facsimile at 860-638-5302. The OTR can be downloaded from the following web address: (for process see Appendix E).
c. Services will be authorized based on a Utilization Review process
d. Clinical staff at ABH will review all OTR information for clinical appropriateness and provider compliance with submission criteria.
i. Submission criteria
1. The OTR should be completed in its entirety.
2. The OTR should be submitted prior to admission to the IOP level of care.
3. The Provider should promptly respond to any inquires for supporting clinical information.
e. ABH will help to educate treatment providers about clinically appropriate treatment planning and decision-making processes regarding level of care, review OTR within three (3) business days. An OTR will be processed with one of the following four outcomes:
i. Authorization – an authorization will be processed, entered into the ABH system and fax authorization notification will be generated and forwarded to the provider
ii. Request for Additional Information- the clinician submitting the OTR will be contacted telephonically, with a request for additional information;
iii. Administrative Denial – a denial letter will be issued based on procedural exceptions;
iv. Clinical Denial – a clinical denial will be issued based upon a review of clinical information.
f. ABH will provide an appropriate appeal process for all adverse determinations.
5. PHP: PHP consists of therapeutic programming with a minimum of four (4) hours per day, at least four (4) days per week, based on a comprehensive and coordinated individualized treatment plan involving the use of multiple concurrent treatment services and modalities.
a. PHP services may be recommended based on a bio-psycho-social evaluation that has been completed within six (6) months.
b. The Provider must complete an OTR and fax to ABH at 860-638-5302. The OTR can be downloaded from the following web address: (for process see Appendix E).
c. Services will be authorized based on a Utilization Review process
d. Clinical staff at ABH will review all OTR information for clinical appropriateness and provider compliance with submission criteria.
i. Submission criteria
1. The OTR should be completed in its entirety.
2. The OTR should be submitted prior to admission to the IOP level of care.
3. The Provider should promptly respond to any inquires for supporting clinical information.
e. ABH will review the OTR within three (3) business days. An OTR will be processed with one of the following four outcomes:
i. Authorization – an authorization will be processed, entered into the ABH system and an authorization notification will be generated and forwarded to the provider
ii. Request for Additional Information- the clinician submitting the OTR will be contacted telephonically, with a request for additional information;
iii. Administrative Denial – a denial letter will be issued based on procedural exceptions;
iv. Clinical Denial – a clinical denial will be issued based upon a review of clinical information.
f. ABH will provide an appropriate appeal process for all adverse determinations.
6. Random Drug Screens: Random urine drug screens are defined as two (2) urine drug screens per week for a period of six (6) weeks and should not occur on the same day and time each week. Urine Screens can be requested for clients who are not in treatment if in response to a court ordered request.
a. The DCF Social Worker makes a telephonic referral. This referral results in an authorization for services
b. ABH Project S.A.F.E. will authorize 12 random urine screens.
c. The screens can be initiated at any time during the next forty-five (45) days. Once the random screens have begun they may continue for a period of no longer than six (6) weeks.
d. The Provider is required to collect all urine samples using the chain of custody protocol as indicated on the reverse side of the chain of custody form.
e. The Provider, to schedule a random screen, will contact the client asking the client to come in within the next twenty-four (24) hours for a drug screen, provided it is not on a day when treatment services are provided.
f. The Provider will verbally communicate all toxicology screen results to the DCF Social Worker within forty-eight (48) hours. Written results should be faxed to the DCF Social Worker within 24 hours of receipt of written correspondence from the lab.
7. Extended Drug Screens (e.g. Opiate Search)
a. The DCF worker consults with the SAS to receive authorization for any extended drug screens, once the standard screen has been completed with a positive result.
b. If a urine screen is positive for heroin an Extended Opiate Search can be conducted by having the Substance Abuse Specialist or designee of the Substance Abuse Division approve this test by calling the ABH Billing Coordinator at 860-704-6144. An Extended Opiate Search can differentiate the positive opiate as heroin, hydrocodone, hydromorphone, morphine and oxycodone.
c. Once this has been obtained the SAS must call the ABH Billing Coordinator at 860-704-6144 with client name, ABH number, and verification of approval from the Substance Abuse Specialist.
d. The provider will then be contacted by the SAS or DCF social worker notifying of approval.
e. The provider will then complete the LabCorp request.
f. When results of the extended drug screen are received, the results should be communicated to DCF upon receipt.
g. When received, the Provider should forward the specific LabCorp Invoice to ABH via mail 213 Court Street, Middletown, CT 06457 or fax to 860-638-5302.
8. Hair Testing: Hair testing is utilized to determine the substance use/abuse history of a client up to three (3) months prior to the sample collection. This ‘standard’ test will indicate whether a client has used any of the following substances during that period:
• Cocaine
• Opiates
• PCP;
• Methamphetamine
• Marijuana/THC
In addition, when a positive result is determined by the standard hair test results, a multi-sectional test can be performed per request of the referring DCF Social Worker.
a. The DCF Social Worker will discuss the necessity and request for approval with the Substance Abuse Specialist and/ or supervisor or designee in the Substance Abuse Division.
b. The DCF Social Worker then calls the ABH Intake Coordinator at 1-800-272-0097 for the hair test referral and provides the following information:
i. Name of person authorizing the test (SAS or designee has to approve before the referral is called into ABH Project S.A.F.E.)
ii. Name and ABH number of the client
c. ABH Project S.A.F.E. identifies the provider performing the test, enters an authorization and faxes notification to that provider.
d. The Provider will complete a Standard Test Request Form (TRF-ST-004) and complete a hair test.
e. The Provider should collect a sufficient quantity of hair (about 2 inches in length and 50 strand of hair cut about ¼ inch from the scalp). If the client has short hair more hairs will be need to meet the collection needs.
f. The hair testing facility will complete a 5-panel hair toxicology screen (Cocaine, Methamphetamine, Opiates, PCP, Marijuana). Results will be reported within 2-6 business days.
g. If there are positive results reported from the Standard Hair Test Screen, the Provider can call the testing facility (Psychmedics at 1-800-522-7424) to request a complete sectional analysis. It is important to clarify that you are calling about an ABH client and requesting the additional testing. Psychmedics will invoice. ABH directly for additional testing.
Referral and Authorization Process (CHART)
|Type of Service/Level of Care |Information Needed From DCF |Information Need from the Provider|Information needed or provided by ABH|Authorization |
| | | | |Requirements |
|Evaluation (up to 90 minutes) |Release of Information from the |Results and recommendations |Client Referral Form, which serves as|Telephonic call from |
| |client. |forwarded to DCF within five (5) |the authorization for the evaluation.|DCF |
| |Telephonic referral to ABH. |business days. |Basic demographic information and | |
| | | |substance abuse information from the | |
| | |Client Reporting Form, TANF, and |DCF worker. | |
| | |Needs Assessment for women. | | |
|Outpatient (Individual, Group, |Telephonic referral if treatment only|Verify client’s insurance, check |Random screens are included. An |There has to be an |
|Family/Couples) |referral or if there has been a 45 |for existing referral |evaluation has been conducted within |evaluation that has |
| |day lapse from the initial referral | |the last six (6) months. |been completed within |
| |call | | |the last six (6) |
| | | | |months. An open |
| | | | |referral must exist. |
|IOP | |An OTR needs to be submitted |Utilization Review of OTR |OTR faxed to ABH |
| | |before services rendered | |directly. |
|PHP | |An OTR needs to be submitted |Utilization Review of OTR |OTR faxed to ABH |
| | |before services rendered | |directly. |
|Urine Drug Screen |Telephonic referral |Random screens have to be done |Will authorize 12 units to be |Telephonic referral by |
| | |within six (6) weeks |conducted within six (6) weeks. |DCF worker needs to be |
| | | | |called in prior to |
| | | | |services |
|Extended Drug Screens |SAS authorization |LabCorp invoice via fax for |Reimbursement for pre-authorized test|Telephonic |
| | |reimbursement | |authorization |
|Hair Test |SAS authorization, Court Order and/or|See Hair testing procedure |Set up a referral upon telephonic |Telephonic |
| |Program Supervisor authorization | |referral |authorization |
Reimbursement Protocol
There are a variety of procedures that each party involved in ABH Project S.A.F.E. is required to follow. In the following section, we will outline what we (ABH) will do, and what DCF and/or the Provider are required to do, in order that client services are reimbursed.
Provider Credentialing
Project S.A.F.E. services will be provided by agencies licensed by the Department of Public Health to provide outpatient substance abuse services and that have an agreement with ABH. Professionals within an agency who hold one of the following qualifications will be eligible to conduct evaluations:
• Certified Alcohol and Drug Counselor (CADC)
• Certified Alcohol Counselor (CAC)
• Licensed Alcohol and Drug Counselor (LADC)
• Masters or doctoral level clinician with at least two years of experience in the treatment of substance abuse
• Connecticut licensed Registered Nurse with at least two years of experience in the treatment of substance abuse
Staff with backgrounds other than those listed above will be considered on a case-by-case basis and approved by the ABH Project S.A.F.E. Program Manager or designee. All non-certified or non-licensed evaluators must be supervised by a licensed masters or doctoral level clinician.
Reimbursement
Project S.A.F.E. provides reimbursement for all authorized evaluations, outpatient treatment services, drug screens/hair tests, and court costs. ABH Project S.A.F.E. offers providers a web based electronic system to submit claims electronically; ABH Project S.A.F.E. encourages providers to make use of this system. ABH offers training twice annually on how to submit claims using the electronic system. ABH Project S.A.F.E. will make itself available to providers for assistance or individual trainings on an ad hoc basis.
ABH Project S.A.F.E. is the payer of last resort and as such clients are expected to use their insurance plan when receiving Project S.A.F.E. services. Providers will be reimbursed the difference between what the insurance company pays, and the approved ABH reimbursement rate. Fee schedules are furnished to provider groups as part of the initial and annual contracting.
Reimbursement Procedures:
• Evaluation
• Treatment
• IOP and PHP
• Drug Screens
o Urine Screens
o Extended Drug Screens
o Hair Test
• Court Appearances
Reimbursement for Evaluation
| | |
|DCF Responsibilities |The DCF Social Worker will need to call ABH Project S.A.F.E. 1-800-272-0097 to make an evaluation referral. The DCF |
| |Worker will need to provide the following information: |
| |Release of Information |
| |Client’s Insurance Information |
| |Client’s Social Security Number |
| |Results of DCF Substance Abuse Screen |
| |Basic Demographic Information |
| | |
| |It is important to remember that an evaluation referral includes a referral for treatment if the treatment services |
| |begin within 45-days of the date of the referral. |
| |**************************************************************** |
|Provider Responsibilities |The Evaluation provider needs to be aware of any existing referrals. Appointments should be provided within the |
| |priority access guidelines, if the Provider is unable to do so, they should notify ABH Project S.A.F.E. |
| | |
| |The provider needs to contact the DCF Social Worker with verbal results of an evaluation within 24 hours, and with |
| |written results within 5 days. |
| | |
| |A referral will lapse if no service is provided within a forty-five (45) day limit. To determine if the Referral has |
| |lapsed, the Provider will look on the Client Referral Form [Appendix A] review the service(s) requested end date. The|
| |evaluation needs to be conducted before this date; if not the Provider should request that the DCF Social Worker call|
| |ABH Project S.A.F.E. to make a new referral. |
| | |
| |The Provider needs to complete the following information and submit to the ABH claims department: |
| |Client Report Form [Appendix B] |
| |For women only the Needs Assessment Form [Appendix C] |
| |TANF Eligibility Screening Form [Appendix D] |
| | |
| |The Provider must submit claims for reimbursement no more than 30 days following the date the service was provided. |
| |Claims submitted beyond this time frame will be denied reimbursement for “untimely filing”. |
| | |
| |If there is a correction required on any submitted claim, the Provider has 90 days from the service date to correct |
| |the claim. |
| |**************************************************************** |
|ABH Project S.A.F.E. Will |ABH will fax the referral information to the Provider when a DCF Social Worker makes an evaluation referral. This |
| |referral information serves as the authorization. [Appendix A] ABH will maintain an electronic record of every |
| |referral, which will allow reimbursement for an evaluation provided. |
Reimbursement for Treatment
| | |
|DCF Responsibilities |The DCF Social Worker will need to call ABH Project S.A.F.E. 1-800-272-0097 to make a treatment only referral. The DCF |
| |Social Worker will need to provide the following information: |
| |Release of Information |
| |Client’s Insurance Information |
| |Client’s Social Security Number |
| |Results of DCF Substance Abuse Screen |
| |Basic Demographic Information |
| | |
| |It is important to remember that if treatment begins within 45 days of the evaluation referral start date no treatment |
| |referral needs to be called in by the DCF worker. |
| |******************************************************************* |
|Provider Responsibilities |The Treatment provider needs to be aware of any existing referrals. |
| |If the treatment services begin within 45 days of the start date of the evaluation referral, the Provider can submit |
| |claims as described in the claims submission portion of this document. |
| |If a referral lapses because it is beyond the 45 day limit, the provider should contact the DCF Social Worker and request |
| |that he or she call in a new referral. |
| | |
| |The provider should communicate the course of client treatment by contacting the DCF Social Worker regularly. Providers |
| |who create a treatment plan which recommends IOP or PHP must complete an OTR (see following reimbursement section). |
| | |
| |The Provider must submit claims for reimbursement no more than 30 days following the date the service was provided. Claims|
| |submitted beyond this time frame will be denied reimbursement for “untimely filing”. |
| | |
| |Providers should verify the client’s insurance and indicate this information in the claims submission process. If a client|
| |does not have insurance a special exception can be granted. See Special Exception procedure (page 29). |
| | |
| |Treatment-only referrals can be made under the following circumstances: |
| |Treatment-only referrals following an acute care episode; |
| |Treatment-only referrals resulting from the need to transfer a client from one provider to another; |
| |Treatment-only referral following a lapsed forty-five (45) day referral. |
| | |
| |In every case it is required that an evaluation has been completed (within the previous six (6) months) prior to the DCF |
| |Social Worker making a treatment-only referral through contacting the Project S.A.F.E. Referral Hotline at ABH. |
| |***************************************************************** |
|ABH Project S.A.F.E. Will |ABH Project S.A.F.E. will fax the referral information to the Provider when a DCF Social Worker makes the treatment |
| |referral. ABH Project S.A.F.E. will fax the Client Referral Form with Treatment Only indicated in the service(s) |
| |requested section. (Appendix B) ABH will maintain an electronic record of every referral, which will allow |
| |reimbursement for treatment. A separate referral for urine screens is not required under a treatment only referral. |
| |Chain of custody random urine screens will be reimbursed by ABH under the treatment only authorization called in by |
| |the DCF worker. |
Reimbursement for IOP or PHP Levels of Care
| | |
|DCF Responsibilities |Ensure that all necessary information is available to both the treatment provider and ABH. |
| |************************************************************ |
|Provider Responsibilities |IOP and PHP levels of care are authorized based upon a process of Utilization Review (UR). To engage in this |
| |process the Provider must submit an Outpatient Treatment Request Form (OTR) [Appendix E]. |
| | |
| |The OTR form must be completely filled-out, with the necessary demographic and clinical information prior to |
| |admission to the IOP or PHP levels of care. |
| | |
| |An OTR form needs to be completed prior to the expiration or completion of services previously authorized. Any |
| |subsequent OTR forms should be completed with new clinical information and an updated treatment plan. The |
| |provider is required to respond promptly to any inquiries for supporting clinical information. |
| | |
| |Once a it has been determined that the client is no longer in need of IOP or PHP services a Discharge |
| |Notification Form [Appendix F] needs to be completed. |
| | |
| |The Provider must submit claims for reimbursement no more than 30 days following the date the service was |
| |provided. Claims submitted beyond this time frame will be denied reimbursement for “untimely filing”. IOP and |
| |PHP services can also be denied if the client does not meet clinical criteria. |
| |************************************************************* |
| |Help educate treatment providers about clinically appropriate treatment planning, and decision-making processes|
| |regarding level of care decisions as requested. |
| |Receive and process Outpatient Treatment Requests (OTR) for IOP and PHP levels of care through Utilization |
| |Review. In order to assure that the patients who require IOP and PHP levels of care, these services are |
| |authorized based upon a process of Utilization Review (UR). While no effort is being made to restrict access |
|ABH Project S.A.F.E. Will |to these levels of care, the goal of UR ensuring that limited treatment funding provides treatment for those |
| |clients with clinically appropriate need. |
| | |
| |Provide a three-day turnaround time on authorization decisions, with access to urgent authorizations when |
| |clinically necessary. |
| |Provide an appropriate appeal process for all adverse determinations. (See Appeals Process page) |
| |Maintain a copy of the OTR for download at the following web address: |
| | |
| | |
| | |
Reimbursement for Hair Testing
| | |
|DCF Responsibilities |Hair test can be requested by the DCF Social Worker to determine if a client has abused a substance over the |
| |past 90 days. Hair testing is useful for obtaining historical use within a 90-day period. To request a hair |
| |test and receive reimbursement the DCF Social Worker will contact the Substance Abuse Specialist in their |
| |respective offices for approval. Once this approval has been granted DCF should contact ABH Project S.A.F.E. |
| |************************************************************ |
|Provider Responsibilities |The provider is required to collect a sufficient sample for a hair test in accordance with standards for hair |
| |testing as specified in the training. The provider then submits the sample, with a request for a standard |
| |screen to Psychemedics. |
| | |
| |If the results are positive the provider can request a multi-sectional testing of the positive result, by |
| |calling Psychemedics at their toll-free number and requesting a multi-sectional be completed. This |
| |multi-sectional does not require the client to return to the office and will not be reimbursed by ABH. |
| | |
| |Results should be discussed with the DCF Social Worker through telephone contact as soon as possible. |
| | |
| |The Provider must submit claims for reimbursement no more than 30 days following the date the service was |
| |provided. Claims submitted beyond this time frame will be denied reimbursement for “untimely filing”. |
| |************************************************************* |
| |ABH will serve as the coordinator of Hair testing requests, and as the conduit for information between |
| |Psychemedics and other parties involved. |
| | |
| |ABH will help expedite procedures whenever possible, and will provide a forum for annual training for any |
|ABH Project S.A.F.E. Will |provider who is interested. |
| | |
| |ABH will ensure that Psychemedics is meeting the criteria for timely reporting of results, through a monitoring|
| |program. |
| | |
| | |
| |ABH will provide reimbursement to providers, which includes an administrative fee related to collection and |
| |submission of the sample to LabCorp, and the actual cost that LabCorp invoices the provider for completion of |
| |urinalysis. |
| | |
| | |
| | |
| Reimbursement for Random Urine Drug Screens Only |
| |
| |
| |
|DCF Responsibilities |
|The DCF Social Worker will contact ABH with a request for random drug screens. Project S.A.F.E. allows a Provider to perform random urine drug screens for |
|clients who are not engaged in treatment, but require monitoring. |
| |
|Random urine toxicology screens cannot be implemented in the absence of a completed evaluation in the past six months, or a court order, or a client being in |
|active treatment. |
| |
| |
|Provider Responsibilities |
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|ABH Project S.A.F.E. Will |
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|Providers are required to follow the to chain of custody protocol for collecting and forwarding urine specimens. |
| |
|Providers are required to report to the DCF worker the results of all negative drug screens within forty-eight (48) hours and all positive drug screens within |
|seventy-two (72) hours. Written results should be faxed to the DCF Social Worker upon receipt of the results. If there is a positive Opiate result, the DCF |
|Social Worker can request an extended opiate search. (See below for instruction:) |
| |
|Extended Opiate Search has to be approved by the Substance Abuse Specialist in the respective DCF area office. Once this has been obtained DCF needs to |
|call the ABH Billing Coordinator at 860-704-6144 with client name, ABH number, and verification of approval from the Substance Abuse Specialist. The Provider |
|should then send in the Labcorp Invoice to ABH via mail 213 Court Street, Middletown, CT 06457 or fax to 860-638-5302. (see detail in Reimbursement for |
|Extended Opiate Search ) |
| |
|ABH Project S.A.F.E. will authorize 12 random drug screens over a six-week period. The Provider at the end of this period shall notify the DCF Social Worker to|
|call ABH Project S.A.F.E. for subsequent referrals for urine screens if applicable. |
| |
|The Provider must submit claims for reimbursement no more than 30 days following the date the service was provided. Claims submitted beyond this time frame |
|will be denied reimbursement for “untimely filing”. |
|************************************************************* |
| |
|ABH will authorize a total of twelve (12) random drug screens over a six-week period. ABH Project S.A.F.E. will receive referrals for this service via their |
|toll-free Project S.A.F.E. intake line. |
| |
| |
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|Reimbursement for Extended Drug Screens (extended opiate search) |
| |
|DCF Responsibilities |
|The DCF Social Worker will review the case with the Substance Abuse Specialist (SAS) in their Area Office. The SAS will contact the Project SAFE Billing |
|Coordinator to authorize an extended drug screen. |
| |
| |
|************************************************************ |
| |
|Provider Responsibilities |
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|ABH Project S.A.F.E. Will |
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|Providers are required to follow the to chain of custody protocol for collecting and forwarding urine specimens. |
| |
|Providers are required to report to the DCF worker the results of all negative drug screens within forty-eight (48) hours and all positive drug screens within |
|seventy-two (72) hours. Written results should be faxed to the DCF Social Worker upon receipt of the results. If there is a positive Opiate result, the DCF |
|Social Worker can request an extended opiate search. (See below for instruction:) |
| |
|Extended Opiate Search has to be approved by the Substance Abuse Specialist in the respective DCF area office. Once this has been obtained DCF needs to |
|call the ABH Billing Coordinator at 860-704-6144 with client name, ABH number, and verification of approval from the Substance Abuse Specialist. The Provider |
|should then send in the LabCorp Invoice to ABH via mail 213 Court Street, Middletown, CT 06457 or fax to 860-638-5302. (see detail in Reimbursement for |
|Extended Opiate Search ) |
| |
|ABH Project S.A.F.E. will authorize 12 random drug screens over a six-week period. The Provider at the end of this period shall notify the DCF Social Worker to|
|call ABH Project S.A.F.E. for subsequent referrals for urine screens if applicable. |
| |
|The Provider must submit claims for reimbursement no more than 30 days following the date the service was provided. Claims submitted beyond this time frame |
|will be denied reimbursement for “untimely filing”. |
|************************************************************* |
| |
|ABH will authorize a total of twelve (12) random drug screens over a six-week period. ABH Project S.A.F.E. will receive referrals for this service via their |
|toll-free Project S.A.F.E. intake line. |
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|Requests for Court Cost Reimbursement |
| |
|DCF Responsibilities |
|Project S.A.F.E. providers on occasion are subpoenaed to testify in court regarding DCF cases. In order to support the benefit of such testimony, DCF has |
|agreed to reimburse providers for their time as related to court testimony through Project S.A.F.E. |
|****************************************************************** |
| |
|Provider Responsibilities |
|When a provider receives a subpoena to give testimony in court on a Project S.A.F.E. case, the provider may request to be placed “on call” by contacting the |
|Assistant Attorney General (AAG) at the telephone number listed on the subpoena. If the provider is unable to reach the AAG, the provider may contact the |
|Attorney General’s Office in Hartford at 860-566-3696 and request to be placed “on call” for the specific case. |
| |
|If the provider goes to court on a Project S.A.F.E. case, the provider may bill ABH based on the time spent in the courtroom, whether or not the provider |
|actually testified in the case. |
| |
|To be reimbursed, the provider will type a brief letter to the ABH Project S.A.F.E. Manager identifying the client by name and ABH number, the date of the |
|court appearance, and the name of the clinician with the appropriate rate and final figure (please refer to the fee schedule). Whenever possible the letter |
|should be co-signed by the Executive Director of the agency. |
|**************************************************************** |
| |
|ABH Project S.A.F.E. Will | |
| |ABH will provide reimbursement to providers, for time spent in court. |
| |ABH will remit that reimbursement upon receipt of appropriate written documentation. |
Special Exceptions
ABH is the payer of last resort; the term ‘payer of last resort’ indicates that the Project S.A.F.E. funds are used to reimburse providers on a fee-for-service basis when there is no other source of reimbursement available. DCF and DMHAS recognize that there are circumstances under which a client may not be able to access services under their current payer source or under the structure or function of payer of last resort hence there may be exceptions granted. Exceptions are granted only for the circumstances indicated below:
• ABH provider does not participate in the client’s insurance plan and referring the client to another ABH provider is not an option.
• The client has no reliable transportation to the in-network provider and the client has to be referred to an out of network provider
• Client has insurance but does not want their employer to know they are in treatment
• Insurance company/entitlement does not provide the needed level of care
• After treatment has begun, client’s insurance plan changes
• Client may go from having no insurance to having insurance, with the provider being out-of-network
• Out-of-network provider offers daycare/babysitting and/or transportation services
The intention of granting special exceptions for the aforementioned circumstances is to ensure that services will not be disrupted. The special exceptions system was established to make concessions for special circumstances when appropriate and to track the frequency of such conditions.
To obtain special exception the following steps need to followed:
1. A Special Exception Form [Appendix G] needs to be completed in its entirety.
2. The form should be complete on or before the date of service. ABH will only back date up to five business days.
3. The form is then faxed to ABH at 860-638-5302.
All information must be provided for the exception to be granted and services reimbursed.
Exceptions other than those listed here should be directed to the Project S.A.F.E. Program Manager or designee. Every effort will be made to address any and all unique circumstances in an efficient manner.
V. Claims Process
There are a variety of procedures that each party involved in Project S.A.F.E. is required to follow. In the following section, we will outline steps to assist in claim submission.
Overview
The claim submission process is the system in which ABH Project S.A.F.E. will reimburse network providers for services rendered to clients. ABH utilizes a web based claims submission system. For services to be reimbursed an authorization needs to exist in the ABH Project S.A.F.E. data system (please see referral and authorization section). Once a referral has been made by DCF, Providers must submit claims for reimbursement no more than 30 days following the date the service was provided. Claims submitted beyond this time frame will be denied reimbursement for “untimely filing”. In using the web based claims submission system the provider will need to have a password to access the system.
Each agency will follow their internal procedure for claims submission.
Providers who have submitted a claim electronically in the form of a response code “9”, or who have submitted a claim manually, have a maximum of 90 days from the service date to correct the claim. Should there be a compelling reason why the claims submission may be delayed, a call should be made in advance to the ABH Claims Coordinator (860-704-6144) to explain the reason (staff shortage, vacation schedules, etc.)
In the web based claims system there will be six tabs:
Six Tab Web Base Claim System
[pic]
1. Problem/Unpaid- denials
2. To be paid –authorized payment has been approved payment to be issued by next closing
3. New Claim – claim needs to be submitted
4. Reports – tells who has been paid, denied or is pending payment for a given period of time. This is based on the ABH closing date
5. Change Login – change your log in information
6. Logoff – to exit the system
To complete the electronic claims process the provider will need insurance information, TANF eligibility form and basic demographic information. All fields should be completed [See Appendix H]
All dollar values will pre-populate in accordance with provider rates. Provider rates are updated each fiscal year.
Claims may also be submitted manually. A form can be requested from the ABH Claims Coordinator at 860-704-6144.
Complaints, Grievances, and Appeals
Utilization Review Process
Before authorizing any services for Project S.A.F.E. clients ABH Utilization Review staff must ascertain whether the client’s symptoms meet Service Necessity Criteria for the requested service. The Utilization Review staff may use the ABH Medical Director or his/her designee to assist in making that determination.
In order to make a determination that the requested service(s) meet the Service Necessity Criteria, the service must meet all the following criteria:
• The service is appropriate for the symptoms, diagnosis and treatment of a particular disease or condition that is defined under the DSM IV-TR or its successor.
• The service is provided in accordance with generally accepted standards of mental health and/or substance abuse professional practice and bio-psycho-social approach to rehabilitation.
• The type, level, and length of treatment services are needed to provide safe, adequate and appropriate care, and are intended to improve the individual’s condition. Treatment geared toward simply maintaining the individual’s current level of functioning is appropriate only when, without such treatment, the individual would be likely to suffer a relapse or deterioration of health status. Service Necessity Criteria does not include “custodial care”.
All clinical denials must be based on a review made by a Connecticut licensed clinical reviewer. If during the normal course of the review, a provider decides to withdraw the request for additional services, the case does not have to be subject to clinical review.
If the Utilization Review staff determines that Service Necessity Criteria has not been met, the provider will be notified via certified mail of the decision.
Appeals:
There are two types of appeals that may be lodged regarding denial of service by ABH Project S.A.F.E.: clinical appeals and administrative appeals.
Clinical appeals: A provider, his/her authorized representative or designee may appeal a decision to deny, reduce or terminate a behavioral health service. The appeals process is as follows:
• Upon receipt of the denial, an appeal may be initiated by providing additional justification of the need for service. This appeal must be submitted to ABH no later than seven calendar days after receipt of the denial decision.
• The Provider or his/her authorized representative will be sent notice of the decision on the appeal no later than four business hours after receipt of information required rendering a decision.
• If dissatisfied with the first level appeal decision, a second level appeal must be submitted to ABH no later than seven calendar days after the first level appeal denial.
• The Provider or his/her authorized representative will be sent notice of the decision on the second appeal no later than two business days after receipt by ABH Project S.A.F.E. of information required to render a decision.
• If dissatisfied with the second level appeal decision, a third level appeal must be submitted directly to DMHAS no later than seven calendar days after the second level denial.
• A third level appeal will not be considered if the first or second level appeal is still being reviewed within the established time frames.
Administrative Appeals: A provider may appeal a decision by ABH that is based on non-compliance with administrative procedures. The appeals process is as follows:
• Within seven (7) calendar days of the denial from ABH, the provider or his/her authorized representative may initiate the administrative appeals process by providing additional information or by demonstrating “good cause”.
• The provider will be sent notice of the decision within seven business days following receipt of the appeal by ABH. The notification will include the principal reason (s) for the decision and instructions for requesting a further appeal, if applicable.
• If dissatisfied with the first level decision, the provider or his/her authorized representative may submit a second level appeal directly to DMHAS no later than seven days after the denial of the first appeal. The appeal must be accompanied by information necessary and sufficient to render a decision.
For first level appeals send correspondence to:
Advanced Behavioral Health
Project S.A.F.E.
213 Court Street
Middletown, CT 06457
For second level appeals complaints or grievances, send correspondence to:
DMHAS Department of Mental Health and Addiction Services
Karen Orhenberger
410 Capital Ave., MS#14HCO
P.O. Box 341431
Hartford, CT 06134.
Complaints and Grievances:
A Project S.A.F.E. client may utilize the Providers established grievance procedure to seek resolution of complaints and grievances concerning the quality or level of services provided. Grievances are defined as a complaint against a service provider in matters other than the denial, reduction or termination of services.
Appendices
Appendix A
CLIENT REFERRAL FORM (page 1)
Advanced Behavioral Health, Inc.
Middlesex Corporate Center Date:
213 Court Street, 10th Floor Time:
Middletown, Connecticut 06457 Page:
Social Worker Provider
Name . . . . Name . .
City . . . . . Phone . .
Phone . . . . Address
FAX . . . . . . City . . .
Unit . . . . . Contact .
Supervisor Region .
Client Information Insurance
ABH ID #. . Payor . . . .
Name . . . . Health Plan
Address . . .
City . . . . . .
Gender . .
Link # . . . . Race . . . .
Date of Soc Sec # .
Phone . . . . Language
Substance Abuse Treatment Code .
Suspected Substance(s) Use:
Reason(s) for Suspecting:
Service(s) Requested: # Units Begin Date End Date
Reason for referral
CLIENT REFERRAL FORM (page 2)
Advanced Behavioral Health, Inc.
Middlesex Corporate Center Date:
213 Court Street, 10th Floor Time:
Middletown, Connecticut 06457 Page:
Client ID . .
Name . . . .
Substance Abuse Screening / Information Form
1. Client appeared to be under the influence of drugs and/or alcohol.
2. Client showed physical symptoms of trembling, sweating, stomach cramps, nervousness.
3. Drug paraphernalia was present in the home, i.e., pipes, charred spoons, foils, blunts, etc.
4. Evidence of alcohol was present in the home, i.e., excessive number of visible bottles/cans whether empty or not.
5. There was a report of a positive drug screen at birth ( Mother ( Child
list drugs
6. There was an allegation of substance abuse in CPS Report.
7. The child(ren) reports substance abuse in the home.
8. The client has been in substance abuse treatment.
9. The client has used the following in the last twelve ( Marijuana/Hashis
( Heroin/Opiates ( Cocaine/Crack ( Other Drugs
10. Client shared that s/he has experienced negative consequences from the misuse of alcohol, i.e.,
( DWI/DUI ( Domestic Fights ( Job Loss ( Arrests
( Other:
11. Client shared s/he has experienced trouble with the law due to the use of alcohol or other drugs, i.e.,
( DWI/DUI ( Domestic Violence ( Drug Possession
( Other:
12. There are adults who may be using drugs and/or misusing alcohol who have regular contact with the client's child(ren).
13. The client acknowledged medical complications due to the use of substances.
14. Other Comments
Appendix B
CLIENT REPORT FORM
ABH Contact: Referral Date/Time: Ref #:
ADVANCED BEHAVIORAL HEALTH, INC.
Middlesex Corporate Center, 10th Floor, Middletown, CT 06457
Phone: 860.638.5309 Fax: 860.704.6179
PROJECT SAFE
DCF Substance Abuse Services for Primary Care Givers
To:____________________________ and __________________________________
DCF SOCIAL WORKER ABH INTAKE WORKER
DATE:____________ CLIENT NAME:_____________________________________
ABH CLIENT ID #______________
The above client received: (Check all that apply)
DRUG SCREEN:____________ EVALUATION:______________
TREATMENT RECOMMENDED: CHECK ONE
START DATE FOR BELOW TX:_____________
_____ NO TREATMENT RECOMMENDED
_____ INDIVIDUAL THERAPY
_____ GROUP THERAPY
_____ FAMILY/COUPLE THERAPY
_____ INTENSIVE OUTPATIENT
_____ PHP
_____ EARLY INTERVENTION
_____ METHADONE (Not funded by DCF contract)
_____ INPATIENT DETOX (Not funded by DCF contract)
_____ AMBULATORY DETOX (Not funded by DCF contract)
_____ RESIDENTIAL SERVICES (Check below; not funded by DCF Contract)
With Children________ Without Children________
Clinician Name: _________________________________________ Date:___________
(Please Print/Required field)
SIGNATURE_____________________________________________
Name of Provider __________________________________
Appendix C
Needs Assessment Form
ADVANCED BEHAVIORAL HEALTH, INC.
Residential Services for Substance Abusing Women and Their Children
Client Name:
ABH #:
Date of Evaluation:
Evaluator: Provider:
_____Yes _____No Is this client clinically most appropriate for residential treatment?
(If No, Stop Here, if Yes Continue.)
Please complete the following on all clients for whom residential is assessed as the most clinically appropriate level of care. (Regardless of whether a referral for that level of care is actually made.)
_____Yes _____No Client accepted recommendation for residential treatment.
If No, why not? (childcare, work, etc.) ___________________
_____Yes _____No Bed was available.
Name of Residential Program__________________________
If not admitted to residential treatment, did client accept referral to alternative level of care?
_____Yes _____No
If Yes, specify level of care_____________________________________
DCF-Needs Assessment Form March 2003
Appendix D
TANF ELIGIBILITY SCREENING FORM
|Client Name: |ABH ID #: |
|1: |Does the case involve a foster parent or a parent with a child that has been removed |Write Yes or No |
| |from the home? | |
If the answer to question 1 is yes, you do not need to answer questions 2, 3 and 4. The family is automatically TANF eligible and the worker would need to select the code 01 (TANF eligible) in the appropriate section of the ABH-DCF Weekly Activity Report (i.e. the claims forms). If the answer is no, proceed to 2.
|2: |Is the client a parent or caretaker relative with a minor child living in the home? |Write Yes or No |
If the answer to question 2 is no, you do not need to answer questions 3 or 4. The client is not TANF eligible and the worker would need to select code 02 (not TANF eligible) in the appropriate section of the ABH-DCF Weekly Activity report. If the answer is yes, proceed to 3.
|3: |Is the client currently eligible for Medicaid, HUSKY, Food |Write Yes or No |
| |Stamps, TFA cash assistance or child care assistance? | |
If the answer to question 3 is yes, you do not need to answer question 4. The client is automatically TANF eligible and the worker should select code 01 (TANF eligible) in the appropriate section of the ABH-DCF Weekly Activity Report. If the answer is no, or the worker is unable to determine if the client receives any of these benefits, then the worker should proceed with question 4.
|4: |Number of parents, |75% of |75% of |Is family income below the 75% SMI for that |
| |Children, and relatives |State |State |family’s size? Write Yes, No, or Unable to |
| |living in the home |Median |Median |Determine |
| | |Income |Income | |
| | |(Annual) |(Monthly) | |
| |2 |$38,522 |$3,211 | |
| |3 |$47,586 |$3,966 | |
| |4 |$56,651 |$4,721 | |
| |5 |$65,715 |$5,477 | |
| |6 |$74,779 |$6,232 | |
| |7 |$76,478 |$6,374 | |
| |8 |$78,178 |$6,515 | |
| |9 |$79,877 |$6,657 | |
| |10 and above |$81,577 |$6,799 | |
If the answer to the question is yes, then the worker should select code 01 (TANF eligible) in the appropriate section of the ABH-DCF Weekly Activity Report. If the answer is no, then the worker
should select code 02 (not TANF eligible). If the answer is unable to determine, then the worker should select code 03 (unable to determine).
|TANF Eligibility Status (please circle the appropriate answer): |
|Yes |No |Unable to Determine |
Date:_______________________________ProviderName:_______________________________
Appendix E: Outpatient Treatment Request Downloading Procedure
[pic]
Procedure for Downloading OTR Form
Once you access the ABH website you will see this screen.
Move the cursor to Resources tab. A drop down list will appear.
Move the cursor to ABH Downloads
Outpatient Treatment Request Downloading Procedure (page 2)
[pic]
Double Click ABH Downloads, this will the following screen.
Outpatient Treatment Request Downloading Procedure (page 3)
[pic]
Move the cursor to ABH Project SAFE
Highlight Project SAFE Outpatient Treatment Request Form
Double click
This should open the form.
It is recommended that you Save As and rename the document to a folder on your computer.
Form Completed By: Telephone #:____________________ Date:
Project SAFE
Discharge Notification Form*
|Client Name: | |Provider Name: | |
|Client ABH ID#: | |Provider Service Location: | |
| | |Admission Date: | |
|Client’s Date of Birth: | |Discharge Date: | |
|DIAGNOSIS – AXIS I: (1) (2) |
|DISCHARGE TYPE |
| Regular (Completed Treatment) | Refused Care (Refused Treatment Referrals) | Noncompliance (Did not follow treatment recommendations) |
| AMA (Against Medical or Clinical Advice) | No Care (No Discharge Referrals/Plan Made) | Administrative (Violation of program rules) |
| Transfer (transfer to higher level of care, or same level of care at a different location) | AWOL (Left inpatient level of care without permission/staff knowledge) |
| Other (Please describe): | |
|Did the client complete treatment? Yes No Number of Sessions Attended (if known) _________________ |
|DISCHARGE PLAN |
|Provider Name: | |
|Service/Level of Care: | |
|Date of 1st Appointment: | |
|Discharge Medications: | |
| | |
|If there was no Plan, please | |
|explain : | |
| | |
| | |
| | |
|Living Arrangements at | Homeless Dependent Living (Residential, Halfway house, Supportive Housing, Shelter) Independent |
|Discharge | |
| | |
|DCF Involvement: | Yes No (if yes please complete the questions below): |
| |DCF Case Status: Closed case Active Case |
| |DCF Notified of Discharge Plan Yes No (If yes, the date of notification, _______/_________/________) |
| |mm dd yyyy |
| |Name of DCF Worker: _______________________________________________________________________ |
Form Completed By: Telephone #:____________________ Date:
*Discharge Notifications may be submitted by fax to: Advanced Behavioral Health, Inc. at (860) 638-5302
Project SAFE requires Discharge Notification for all authorized PHP or IOP services.
Appendix G
Special Exception
ABH Project SAFE
Special Exception (formerly Regional Administrator’s Approval)
Date of Request:
Provider Name:
Person Requesting Exception:
Client Name: Client ABH#:
Client DOB: Client SSN: - -
Client’s Insurance Provider:
Reason for Exception:
Provider does not participate in client’s insurance plan
Insurance out of Network
Client refuses to use insurance
Insurance change to out of network
In-network service does not have childcare
Services not covered by client’s insurance plan
No transportation to in-network provider
Type of Treatment Requested:
Individual
# of sessions: Anticipated Start date: Anticipated End date:
Group
# of sessions: Anticipated Start date: Anticipated End date:
Family
# of sessions: Anticipated Start date: Anticipated End date:
Random Urine Drug Screen
# of sessions: Anticipated Start date: Anticipated End date:
Clinician Signature:
FAQ for Project SAFE Special Exceptions
(Formerly Regional Administrator’s Approval)
1. What is a special exception?
The special exception was formerly known as the Regional Administrator’s Approval. It is a means which providers who are unable to access client’s insurance can be reimbursed for services. Special exceptions are granted under the following circumstances:
• Services rendered are not covered by the client’s insurance
• The Provider is out of the client’s insurance network
• The client refuses to use his/her insurance
• The in network provider does not have childcare or transportation available to the client.
No special exception needs to be completed for evaluation services. This only applies to outpatient services including group, individual, family and urine drug screens.
1. When should I fill out a special exception?
A special exception form should be completed after insurance has been verified and the client meets the above criteria. Project SAFE is the payer of last resort; as such the Provider is expected to bill the client’s primary insurance first. If the client refuses to use his/ her insurance this would then require a special exception for continued treatment of group, individual and/or family. No special exception is needed for the evaluation service.
A special exception form should be completed prior to the service start date or the first date of service. Special exceptions submitted more than five calendar days after the date of service will be denied for untimely submission.
2. Who needs to complete the special exception?
The special exception form can be completed by any staff at your agency familiar with the client this includes administrative assistants, case managers, clinicians or billing staff. All the information needs to be included (client name, ABH#, client DOB, Type of treatment, number of sessions being requested, start and end dates of treatment).
3. What services can be requested with the special exception?
Only outpatient services can be requested by special exception. These include: group, individual, family and urine drug screen. If you are requesting group, individual or family urine drug screens are included in this treatment modality. Urine drug screens can be requested but need a prior authorization from the DCF worker.
4. If a client comes in for an evaluation and has a previous evaluation at another facility within the past year will ABH reimburse for the Project SAFE evaluation if the client’s insurance will not?
Project SAFE will cover the substance abuse evaluation if the client’s insurance will not cover the service. A claim should be submitted for the evaluation with a note indicating that the client’s insurance will not cover services. This does not require a special exception and should follow the traditional claims process for evaluations.
5. If there is a denial from SAGA for outpatient services, will Project SAFE reimburse under a special exception?
Yes, Project SAFE would reimburse under a special exception. This would be viewed, as the client’s insurance not covering services. This however only applies to outpatient services including individual, group and family.
6. If a client is on spend down and does not have the money to cover services, will Project SAFE reimburse for services rendered?
Spend down is based on the State Medical Assistance program (Medicaid) operated by DSS. There are certain qualifications that an individual must meet to be eligible for Medicaid. Spend down is used when a person is not eligible based on excess income. In some cases a person can qualify if there income is over limit. This process is spend down and lets the person reduce the excess income to bring them within eligibility for Medicaid.
The provider should verify that the client is on SAGA, but indicate on the Special Exception form that the client refuses to use insurance due to spend down.
7. If a client on private commercial insurance reports that they cannot afford their co-pay will Project SAFE reimburse the provider?
There is a precedent in place regarding reimburse of any co-pay. DCF and DMHAS feel that paying a Medicaid co-pay goes against the spirit of Medicaid regulation likewise with commercial co pay reimbursement of a client’s copy would subverts the payer’s co- pay policy.
8. If the client is in IOP or PHP, but is also receiving other treatment i.e. domestic violence, anger management, and the insurance is paying for IOP or PHP and will not cover the other treatment will Project SAFE reimburse for the other treatment service?
Project SAFE will reimburse for treatment not covered by the insurance, if the client has been provided an Project SAFE evaluation and authorization for services have been called in by the DCF worker or treatment begins with 45 days of the initial referral.
9. If the clinician providing the clinical services is not credentialed with the client’s insurance company, but the Provider agency is in the network will Project SAFE reimburse under a special exception?
Yes, this is listed as one of the reasons for special exception and will be reimbursed by Project SAFE.
Appendix H:
Screen Shot of Web-Based Claims System
|User Name : |
|Trainning, ABH |
| |
| |
|[pic] |
|[pic] |
|[pic] |
|[pic] |
|[pic] |
|[pic] |
| |
|[pic] |
|Service Date: |
|12/28/2005 |
|Service Type: |
|Evaluation |
| |
|ABH ID: |
|42578 |
| |
| |
| |
|Top of Form |
|[pic] |
|[pic] |
|Client Name, DOB, and/or Social Security Number was corrected. Please change applicable ABH Referral information |
| |
|Last Name: |
|K42578 |
|First Name: |
|S |
| |
|DOB : |
|1/1/1968 |
|SSN: |
|000-04-2578 |
| |
|[pic] |
| |
| |
|Payor: |
|[pic] |
|Health Plan: |
|[pic] |
| |
|TANF: |
|[pic] |
| |
|ABH Amount: |
|$[pic] |
|Expected Amount: |
|$[pic] |
|Balance Due: |
|$[pic] |
| |
|Note/Message: |
|[pic] |
| |
|[pic] |
|Client Refused to disclose insurance information |
| |
|[pic] |
|Payor source information corrected - Verification of benefits performed |
| |
|[pic] |
|Client Report Form (complete only on Evaluation Claims) |
|Evaluator Name:[pic] |
|Treatment Recommendations (check all that apply) |
|[pic] |
|No Treatment Recommended |
| |
|Services Funded by DCF |
|[pic] |
|Individual Therapy |
|[pic] |
|Methadone Maintenance |
| |
|[pic] |
|Group Therapy |
|[pic] |
|Family/Couple Therapy |
| |
|[pic] |
|Intensive Outpatient |
|[pic] |
|Early Intervention/Group |
| |
|[pic] |
|Day/Evening Treatment/PHP |
| |
| |
| |
|Services NOT Funded by DCF |
|[pic] |
|Residential Services with Children |
|[pic] |
|Inpatient Substance Abuse |
| |
|[pic] |
|Residential Services without Children |
|[pic] |
|Psychiatric Services |
| |
|[pic] |
|Residential Services - Unspecified |
| |
| |
| |
|[pic][pic] |
|Bottom of Form |
Bottom of Form
|[pic][pic] |
|[pic] |
|General Help: Support@ |
| |
| Web-Based Claims System Help: EbillingSupport@ |
| |
| |
| |
|©Copyright Advanced Behavioral Health, Inc. |
| |
| |
|[pic] |
| |
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Appendix F: Discharge Notification Form
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