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:
02/25/21
REPLACED: 02/09/21
CHAPTER 2: BEHAVIORAL HEALTH SERVICES
SECTION: TABLE OF CONTENTS
PAGE(S) 9
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
Page 1 of 9
Table of Contents
LOUISIANA MEDICAID PROGRAM
ISSUED:
02/25/21
REPLACED: 02/09/21
CHAPTER 2: BEHAVIORAL HEALTH SERVICES
SECTION: TABLE OF CONTENTS
PAGE(S) 9
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
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 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
Rehabilitation Services for Children, Adolescents, and Adults
Children and Adolescents Adults Service Delivery Assessment and Treatment Planning
Page 2 of 9
Table of Contents
LOUISIANA MEDICAID PROGRAM
ISSUED:
02/25/21
REPLACED: 02/09/21
CHAPTER 2: BEHAVIORAL HEALTH SERVICES
SECTION: TABLE OF CONTENTS
PAGE(S) 9
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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Table of Contents
LOUISIANA MEDICAID PROGRAM
ISSUED:
02/25/21
REPLACED: 02/09/21
CHAPTER 2: BEHAVIORAL HEALTH SERVICES
SECTION: TABLE OF CONTENTS
PAGE(S) 9
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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Table of Contents
LOUISIANA MEDICAID PROGRAM
ISSUED:
02/25/21
REPLACED: 02/09/21
CHAPTER 2: BEHAVIORAL HEALTH SERVICES
SECTION: TABLE OF CONTENTS
PAGE(S) 9
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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Table of Contents
LOUISIANA MEDICAID PROGRAM
ISSUED:
02/25/21
REPLACED: 02/09/21
CHAPTER 2: BEHAVIORAL HEALTH SERVICES
SECTION: TABLE OF CONTENTS
PAGE(S) 9
Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components ASAM Level 3.5: Clinically managed high intensity residential treatment- Adult Admission Guidelines Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components ASAM Level 3.7: Medically monitored high intensity inpatient treatment- Adult Admission Guidelines Emergency Admission Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components ASAM Level 3.7: Medically monitored intensive inpatient treatment ? Adolescent Admission Guidelines Emergency Admission Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components ASAM Level 3.7-WM: Medically monitored inpatient withdrawal management- Adult 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 4-WM: Medically managed intensive inpatient withdrawal management Admission Guidelines Screening, Assessment, and Treatment Plan Review Provider Qualifications Staffing Requirements Additional Staffing and Service Components Minimum Standards of Practice Settings
Opioid Treatment Programs (OTPs)
Components Screening
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Table of Contents
LOUISIANA MEDICAID PROGRAM
ISSUED:
02/25/21
REPLACED: 02/09/21
CHAPTER 2: BEHAVIORAL HEALTH SERVICES
SECTION: TABLE OF CONTENTS
PAGE(S) 9
Physician Examination Alcohol and Drug Assessment and Referrals Treatment Planning Process Treatment Services Eligibility Criteria Client Records Additional Provider Responsibilities Provider Qualifications Agency Staff Staffing Requirements Medical Director Pharmacist or Dispensing Physician Clinical Supervisor Physician or APRN Nursing Staff Licensed Mental Health Professional (LMHP) Unlicensed professionals (UPs) Staff Ratios Allowed Provider Types and Specialties Allowed Modes of Delivery
COORDINATED SYSTEM OF CARE
Services Service Limitations Eligibility Parent Support and Training
Components Provider Qualifications
Family Support Organization (FSO) Parent Support Specialist Parent Support Supervisor Allowed Provider Types and Specialties Limitations and Exclusions Allowed Mode(s) of Delivery Additional Service Criteria Youth Support and Training Components Provider Qualifications Family Support Organization (FSO) Youth Support Specialist
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SECTION 2.5
Table of Contents
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