Chapter 5101:3-27 Community Mental Health Agency Services

(A) An “eligible provider” for purposes of this chapter is one of the following:

(1) The Ohio department of mental health, when providing a community mental health service that meets the requirements set forth in section 5111.022 of the Revised Code and Chapters 5122-23 to 5122-29 of the Administrative Code; or

(2) An agency meeting the requirements set forth in section 5111.022 of the Revised Code that has negotiated a contract with a community mental health board as defined in rule 5122-24-01 of the Administrative Code. For such an agency that is a government entity which receives nonfederal public funds, including but not limited to county departments of human services, county children’s services boards and local education agencies, eligibility is further contingent upon demonstration by the agency, as requested by the department of mental health, that sufficient state and/or local public funds not otherwise encumbered to match other federal funds will be committed to match Title XIX funds for reimbursement of the contracted services.

(3) In addition to the requirements of paragraph (A)(1) or (A)(2) of this rule, any medicaid covered service as set forth in rule 5101:3-27-02 of the Administrative Code must be provided.

(B) An eligible provider may subcontract for services. For such services to be billable, the services must be certified in accordance with section 5119.61 of the Revised Code and provided in accordance with the provisions set forth in Chapter 5101:3-27 of the Administrative Code.

R.C. 119.032 review dates: 4/16/2002 and 04/16/2007

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.022

Prior Effective Dates: April 20, 1982 (Temp.), August 1, 1982, March 19, 1987, September 1, 1991

(A) The following describes those services reimbursable as medicaid community mental health services when they are both rehabilitative and rendered by eligible medicaid providers. Rehabilitative services provide for the maximum reduction of mental illness and are intended to restore an individual to the best possible functional level. The services shall meet the principles set forth in rule 5101: 3-1-02 of the Administrative Code.

(1) Behavioral health counseling and therapy services as defined in rule 5122-29-03 of the Administrative Code.

(2) Mental health assessment services as defined in rule 5122-29-04 of the Administrative Code.

(3) Pharmacologic management services as defined in rule 5122-29-05 of the Administrative Code. All psychiatric/mental health medical interventions billed through this service must be used to reduce, stabilize and/or eliminate psychiatric symptoms of the person served.

(4) Partial hospitalization services as defined in rule 5122-29-06 of the Administrative Code and which meet the following requirements:

(a) Partial hospitalization services provided in social, recreational or education settings (internal or external to the partial hospitalization site) are allowable only if there are documented mental health interventions that address the specific individualized mental health treatment needs as identified in the individual service plan (ISP) of the person being served.

(b) Partial hospitalization services include activity therapies, group activities, or other services and programs which are designed to enhance skills needed for living in the least restrictive environment are allowable.

(c) Unallowable partial hospitalization activities are listed in paragraph (H)(7) of this rule.

(5) Crisis intervention mental health services as defined in rule 5122-29-10 of the Administrative Code.

(a) Crisis intervention mental health service must be face to face interventions that are responding to emergent situations with the intended result of crisis stabilization or prevention of crisis escalation.

(b) Routine monitoring of clients in a crisis residential facility is not considered a crisis intervention mental health service.

(6) Community psychiatric supportive treatment (CPST) services as defined in rule 5122-29-17 of the Administrative Code and are subject to the following limitations:

(a) All CPST services provided in social, recreational or educational settings are allowable only if they are documented mental health service interventions that address the specific individualized mental health treatment needs as identified in the ISP of the person served.

(b) A billable unit of service for CPST service may include either face-to-face or telephone contacts between the mental health professional and the client or an individual essential to the mental health treatment of the client.

(c) Consultation between staff in a multi-service agency is not a billable CPST unit of service when the client is not present. The following exceptions apply:

(i) The consultation occurs between the CPST worker and the staff of a distinct residential treatment program; and/or

(ii) The consultation occurs between the CPST worker and the staff of a distinct partial hospitalization program; and

(iii) The CPST services are not time limited or site specific.

(B) All medicaid community mental health services are to be billed on a unit rate basis in accordance with definitions, standards and eligible providers of service requirements as set forth in Chapter 5101:3-27 of the Administrative Code.

(C) Medicaid community mental health services must be recommended by an individual who is qualified to supervise the specific service. The identification of individuals qualified to supervise each specific service is set forth in each applicable rule of Chapter 5122-29 of the Administrative Code and as defined in rule 5122-24-01 of the Administrative Code. Provisions set forth in rule 5122-25-06 of the Administrative Code do not affect the provisions of this paragraph.

(D) Medicaid community mental health services must be performed by an individual who is qualified to perform the specific service. The identification of individuals qualified to perform each specific service is set forth in each applicable rule of Chapter 5122-29 of the Administrative Code and as defined in rule 5122-24-01 of the Administrative Code. Provisions set forth in rule 5122-25-06 of the Administrative Code do not affect the provisions of this paragraph.

(E) With the exception of the limitations in paragraphs (C) and (D) of this rule, the provisions set forth in rule 5122-25-06 of the Administrative Code apply.

(F) For the purposes of medicaid community mental health services, a billable unit of service is defined as the following:

(1) A face-to-face contact between a client and a professional authorized to provide medicaid reimbursable services as described in this rule; or

(2) A face-to-face contact with family members, parent, guardian and/or significant others as defined in rule 5122-24-01 of the Administrative Code for children or adolescents receiving behavioral health counseling and therapy, pharmacologic management, mental health assessment, or crisis intervention mental health services, when the purpose of the contact is directed to the exclusive benefit of the medicaid eligible beneficiary; or

(3) A face-to-face contact with family members or significant others of adults receiving crisis intervention mental health services, when the purpose of the contact is directed to the exclusive benefit of the medicaid eligible beneficiary; or

(4) Community psychiatric supportive treatment interventions provided to individuals other than the client as allowed in paragraphs (A)(6)(b) and (A)(6)(c)of this rule; or

(5) Services rendered via interactive video conferencing as described in rules 5122-29-03, 5122-29-04, 5122-29-05, and 5122-29-17 of the Administrative Code.

(G) All medicaid community mental health services contacts must be documented in the individual client record (ICR) of the person served and clearly relate to the mental health assessment, crisis assessment, or psychiatric diagnostic interview. Such documentation shall include the following:

(1) The date of the service contact; and

(2) The time of day of the service contact; and

(3) The duration of the service contact; and

(4) The signature and discipline of the provider of the service and the date of the signature; and

(5) The description of the activities of the service; and

(6) The therapeutic interventions, as defined in rule 5122-24-01 of the Administrative Code, rendered by the provider; and

(7) The behavior and the response to the intervention of the person served.

(H) Non-reimbursable community mental health services include:

(1) Community meetings or group sessions that are not designed to provide specific mental health treatment services to clients. Examples of such activities include, but are not limited to, orientation sessions for new clients, mental health presentations to community groups (high school classes, parent teacher associations, etc.), and informal presentations about the community mental health program.

(2) Monitoring clients while they are sleeping.

(3) Observing clients when not performing a therapeutic intervention (e.g., when client is watching television, resting, eating, etc.)

(4) Transportation in and of itself.

(5) Unallowable vocational job training activities include, but are not limited to, job shadowing, job coaching, teaching computer skills, math skills, or other trade skills.

(6) Services which are considered mental health residential treatment facility services as set forth in Chapter 5122-30 of the Administrative Code.

(7) Unallowable partial hospitalization activities include, but are not limited to, crafts, general non-therapeutic art projects, recreational outings purely for recreational purposes, exercise groups, etc.

(8) Other than consultation authorized in paragraph (A)(6)(c) of this rule, consultation between staff of the same agency without the client present is not reimbursable.

(I) Services rendered via interactive video conferencing technology must be provided in accordance with rules established by Ohio department of mental health (ODMH). All services rendered via interactive video conferencing technology must also meet the following conditions:

(1) The services rendered via interactive video conferencing technology are consistent with rules 5122-29-03, 5122-29-04, 5122-29-05, and 5122-29-17 of the Administrative Code; and

(2) The documentation requirements of the interactive video conferencing technology contacts remain the same as the face-to-face contacts; and

(3) The purpose of the interactive video conferencing technology contact is not the scheduling of appointments.

(J) The provisions contained in this rule will be effective July 1, 2008.

Effective: 07/01/2008

R.C. 119.032 review dates: 06/01/2012

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.02, 5111.023, 5111.025

Prior Effective Dates: 4/30/82(Temp), 8/1/82, 7/1/84, 1/1/86, 3/19/87, 7/1/91, 11/1/93, 6/30/95 (Emer.), 9/28/95, 7/15/01, 6/1/07

Rescinded eff 6-1-07

(A) This rule sets forth the reimbursement and rate setting for the following medicaid covered community mental health services:

(1) “Behavioral health counseling and therapy services” as described in rule 5122-29-03 of the Administrative Code.

(2) “Community psychiatric support treatment services” as described in rule 5122-29-17 of the Administrative Code.

(3) “Crisis intervention mental health services” as described in rule 5122-29-10 of the Administrative Code.

(4) “Mental health assessment services” as described in rule 5122-29-04 of the Administrative Code.

(5) “Partial hospitalization services” as described in rule 5122-29-06 of the Administrative Code.

(6) “Pharmacologic management services” as described in rule 5122-29-05 of the Administrative Code.

(B) Each agency shall maintain a fee schedule of usual and customary charges for all community mental health medicaid services it provides. The agency shall bill the community medicaid program it’s usual and customary charge for a medicaid-covered service. The reimbursement rate to each agency shall be the lesser of the agency’s usual and customary charge or the amount established per paragraph (E)(2) of this rule.

(C) The community medicaid program will not pay for community mental health medicaid services for medicaid clients when those same services are routinely provided to non-medicaid clients at no charge, except when medicaid reimbursement for such services are prescribed by federal law or in rule 5101:3-1-03 of the Administrative Code. If a reduced charge or no charge is made, the lowest charge made becomes the medicaid rate for that service. The community mental health medicaid services are not considered to be provided to non-medicaid clients at no charge or at a reduced charge if all of the following requirements are met:

(1) The agency establishes a fee schedule of usual and customary charges (UCC) for each service available and the agency utilizes a sliding fee schedule whereby individuals without third party insurance are charged; and

(2) The agency collects third-party insurance information from all medicaid and non-medicaid clients; and

(3) The agency bills other responsible third party insurers or payers in accordance with rule 5101:3-1-08 of the Administrative Code where such insurers or payers are known.

(D) The agency may enter into arrangements with insurers and other responsible payers for reimbursement at levels that may differ from the published usual and customary fee schedule.

(E) Methods and standards for establishing prospective cost based unit rates for community mental health medicaid services.

(1) A prospective unit rate for each covered service will be calculated in accordance with the uniform cost report as established in rule 5122-26-19 of the Administrative Code and thus may vary from agency to agency.

(2) The prospective unit rate for covered community medicaid mental health services will be the lesser of an agency’s unit rate calculated on the budgeted uniform cost report as established in rule 5122-26-19 of the Administrative Code or the individual service rate ceiling as established below.

(a) Pharmacological management: two hundred ten dollars and eighty-seven cents per unit. One unit of pharmacological management is one hour, fractions of this unit are allowed, reportable in six minute increments represented by tenths.

(b) Mental health assessment (nonphysician): one hundred twenty-nine dollars and ninety-nine cents per unit. One unit of mental health assessment is one hour, fractions of this unit are allowed, reportable in six minute increments represented by tenths.

(c) Mental health assessment (physician): two hundred ten dollars and eightyseven cents per unit. One unit of mental health assessment is one hour, fractions of this unit are allowed, reportable in six minute increments represented by tenths.

(d) Behavioral health counseling and therapy (individual): twenty-two dollars and fifty cents per unit. One unit of behavioral health counseling and therapy is fifteen minutes and there are no fractions of units of this service allowed.

(e) Behavioral health counseling and therapy (group): nine dollars and eightyseven cents per unit. One unit of behavioral health counseling and therapy is fifteen minutes and there are no fractions of units of this service allowed.

(f) Crisis intervention behavioral health services: one hundred fifty-four dollars and thirty-five cents per unit. One unit of crisis intervention behavioral health services is one hour, fractions of this unit are allowed, reportable in six minute increments represented by tenths.

(g) Partial hospitalization: one hundred sixteen dollars and eighty-one cents per unit. One unit of partial hospitalization is a program day as defined by the provider consistent with standards established by rule 5122-26-19 of the Administrative Code and there are no fractions of units of this service allowed.

(h) Community psychiatric supportive treatment (individual): twenty-one dollars and thirty-three cents per unit. One unit of community psychiatric supportive treatment is fifteen minutes and there are no fractions of units of this service allowed.

(i) Community psychiatric supportive treatment (group): nine dollars and eighty-one cents per unit. One unit of community psychiatric supportive treatment is fifteen minutes and there are no fractions of units of this service allowed.

(3) Individual service unit rates shall be established at the beginning of the state fiscal year. The unit rate shall be established consistent with the guidelines for determining these costs contained in rule 5122-26-19 of the Administrative Code. All agencies are required to file the budgeted version of the uniform cost report for medicaid rate setting purposes no later than June first of each calendar year with the Ohio department of mental health (ODMH) and simultaneously send a copy to the ADAMHS/CMH board for the service district in which the agency’s primary place of business is located. The unit rates reported on the budgeted version of the uniform cost report will be used as the agency’s prospective rates for the subsequent state fiscal year. Failure to file a budgeted uniform cost report will result in no change to the prospective unit rates for the stated time period. Any budgeted uniform cost report received after June first will be considered untimely. The untimely budgeted uniform cost report may be resubmitted as a request for rate adjustments in accordance with paragraph (E) (4) of this rule.

(4) Agencies may make rate adjustments to the unit rates within the state fiscal year by submitting a revised budgeted uniform cost report to ODMH and simultaneously send a copy to the ADAMHS/CMH board for the service district in which the agency owner’s primary place of business is located. Budgeted uniform cost reports for adjusted rates will not be accepted by ODMH until on or after July first of any calendar year. Rate adjustments to the current period will not be accepted after May first of any calendar year.

(5) Adjustments to the rate(s) will become effective within ten business days of receipt by ODMH or a later date if requested by the agency. Retroactive rate adjustments will not occur.

(6) Rates for additional services not previously contracted for and listed in paragraph (A) of this rule may be added by an agency at any time during the state fiscal year. The prospective unit rate(s) for additional services will be based upon a budgeted uniform cost report amended to include the additional services.

(a) If the budgeted cost report reflects rate adjustment(s) for existing unit rates, paragraphs (E)(4) and (E)(5) of this rule apply.

(b) An agency must specify a rate effective date for services not previously contracted for and listed in paragraph (A) of this rule. For new services this effective date can be up to three hundred and sixty-five days prior to submission. This is not considered a retroactive rate adjustment.

Replaces: 5101:3-27-05

Effective: 09/01/2005

R.C. 119.032 review dates: 09/01/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.022

Prior Effective Dates: 8/1/82, 12/22/86 (Emer.), 7/1/91

(A) The purpose of this rule is to:

(1) Set forth the duties and responsibilities of mental health boards to conduct annual medicaid compliance reviews on each provider agency that has a medicaid agreement with the board;

(2) To establish minimum service compliance criteria which must be met in order for the provider agency to retain a medicaid agreement;

(3) To establish requirements ODMH and boards must follow prior to a medicaid agreement being terminated by ODMH for a provider agency that fails to meet minimum compliance requirements; and

(4) To establish requirements for medical necessity documentation review procedures.

(B) The provisions of this rule are applicable to each board and mental health agency participating in the ODMH community mental health medicaid program described in Chapter 5101:3-27 of the Administrative Code and are applicable only to services funded through that program.

(C) For the purposes of this rule the following definitions shall apply:

(1) “Mental health agency” means a mental health agency as defined in section 5119.22 of the Revised Code and which participates as a medicaid provider under the provisions set forth in Chapter 5101:3-27 of the Administrative Code.

(2) “Mental health board” or “board” means an alcohol, drug addiction and mental health services board or community mental health board authorized by Chapter 340. of the Revised Code.

(3) “Medically necessary mental health services” mean those mental health services, including but not limited to preventive, diagnostic, therapeutic, rehabilitative and palliative interventions, provided for the symptoms, diagnosis and treatment of a particular disease or condition that:

(a) Is defined under the diagnostic and statistical manual of mental disorders, fourth edition (DSM IV) or international classification of diseases, ninth revision (ICD-9) or their successors;

(b) Without which the person could be expected to suffer prolonged, increased or new psychiatric symptomatology or impairment of function;

(c) Is based on an individualized service plan (ISP) that includes interventions to ameliorate symptoms or achieve treatment goals;

(d) Is provided in the least restrictive setting available to the person;

(e) Reflects consumer participation; and

(f) For children ages zero to eighteen, is developmentally appropriate and designed to address the needs of the child and family.

(4) A “medical necessity documentation review” means the retrospective review of community mental health medicaid services to assure that clinical documentation exists in such cases and are related to the definition of medical necessity as described in paragraph (C)(3) of this rule

(D) General requirements for annual medicaid compliance and medical necessity documentation reviews.

(1) Beginning January 1, 2002, the board shall review annually a number of clinical records for those individuals who have received services reimbursed provided through the community mental health medicaid program during the state fiscal year of the review to assure that minimum service compliance and medical necessity documentation review criteria as defined in paragraphs (E) and (F) of this rule are met.

(2) The board shall review the number of cases required by this rule of residents of its service district in each agency holding a medicaid agreement with the board, except for agencies identified by ODMH as serving a large number of residents outside the board service districts in which the agencies are located. For each of those specially designated agencies, the board which has the medicaid agreement shall conduct the review. In circumstances where the agency has medicaid agreements with more than one board, the board which has the largest number of board residents receiving services from the agency shall conduct the review.

(3) The sample size for medicaid compliance and medical necessity documentation reviews shall be as follows:

(a) No agency which provides medicaid services to fewer than ten clients during the annual review period shall be selected for review.

(b) For agencies which provide medicaid services to at least ten clients but fewer than one hundred clients during the annual review period, ten cases shall be selected for review. The sample shall include the cases of the five clients who represent the highest per client medicaid costs for the agency. The remaining cases shall be randomly selected.

(c) For agencies which provide medicaid services to at least one hundred clients but fewer than five hundred clients during the annual review period, twenty cases shall be selected for review. The sample shall include the cases of the ten clients who represent the highest per client medicaid costs for the agency. The remaining cases shall be randomly selected.

(d) For agencies which provide medicaid services to at least five hundred but fewer than one thousand clients during the annual review period, thirty cases shall be selected. The sample shall include the cases of the fifteen clients who represent the highest per client medicaid costs for the agency. The remaining cases shall be randomly selected.

(e) For agencies which provide medicaid services to at least one thousand but fewer than two thousand clients during the annual review period, fifty cases shall be selected. The sample shall include the cases of the twenty-five clients who represent the highest per client medicaid costs for the agency. The remaining cases shall be randomly selected.

(f) For agencies which provide medicaid services to two thousand or more clients during the annual review period, seventy cases shall be selected. The sample shall include the cases of the thirty-five clients who represent the highest per client medicaid costs for the agency. The remaining cases shall be randomly selected.

This table represents the sample size requirements

Number of Total High cost Randomly

Agency clients Number of Cases Selected

Receiving Cases Cases

Medicaid services Selected

1 to 9 None N/A N/A

10 to 99 10 5 5

100 to 499 20 10 10

500 to 999 30 15 15

1,000 to 1,999 50 25 25

2,000 and above 70 35 35

(E) Medicaid compliance review procedures and criteria

(1) The compliance review should be done on at least two weeks of service billings from at least one service category for each case selected. The board shall assure that all service categories contained the agency’s medicaid agreement are represented in the review across all cases.

(2) The medicaid compliance review shall determine that:

(a) The clinical records contain individualized service plans for cases with five sessions or within one month of admission, whichever is longer;

(b) The services were provided by individuals meeting the eligibility criteria as identified in Chapter 5122-29 of the Administrative Code;

(c) The services were clinically supervised by individuals meeting the supervision criteria as identified in Chapter 5122-29 of the Administrative Code;

(d) The billing did not contain any time discrepancies (e.g., overlapping service times billed to medicaid by the provider, etc.);

(e) The documented activity of the service is consistent with the service definition contained in rule 5101:3-27-02 of the Administrative Code;

(f) There is evidence of progress note documentation of the billed service;

(2) Following the medicaid compliance review, the board shall accomplish the following:

(a) For all clinical records where there is no individualized treatment plan present as referenced in paragraph (E)(2)(a) of this rule, the board shall seek recovery of funds for all reimbursed medicaid services provided to the person during the period in which this criterion was not met.

(b) For all non-compliant claims in paragraphs (E)(2)(c), (E)(2)(e), and (E)(2)(f), of this rule, the board shall seek recovery of funds for all ineligible reviewed claims.

(c) For cases when a board finds that a medicaid service was provided by a person not meeting the eligibility criteria as identified in Chapter 5122-29 of the Administrative Code, the board shall seek a recovery of all funds for such ineligible services provided by that person during the period of the review.

(d) For all non-compliant claims in paragraph (E)(2)(d) of this rule, the board shall seek recovery of funds for any over-billing. For example, if an agency bills for one hour, and there is documentation for half an hour, the board shall seek repayment for half of the claim.

(e) The board shall notify ODMH if there are duplicate billings in any of the claims reviewed. A duplicate billing is defined as two or more medicaid claims which have been reimbursed by medicaid for the services delivered to the same individual at the same time on the same day.

(f) The board shall notify ODMH if there is evidence that an entire service (or a majority of a service) is not compliant with the criteria contained in rule 5101:3-27-02 of the Administrative Code.

(g) A board must notify ODMH if the agency fails to meet any of the following compliance thresholds:

(i) Evidence of individual service plans in at least ninety per cent of the clinical records that were reviewed.

(ii) Evidence of eligible providers in at least ninety-five per cent of the claim lines that were reviewed.

(iii) Evidence of eligible clinical supervision in at least ninety per cent of the claim lines that were reviewed.

(iv) Evidence that the duration of the service noted in the progress note is the same as the amount billed in at least eighty-five per cent of the claim lines that were reviewed.

(v) Evidence of progress note documentation in at least ninety-five per cent of the claim lines that were reviewed.

(vi) The documented activity of the billed service must be compliant with the criteria contained in Chapter 5101:3-27 of the Administrative Code in at least ninety per cent of the claim lines that were reviewed.

(h) ODMH shall conduct a follow-up focused review of an agency if it has verified that any of the thresholds identified in paragraph (E)(3)(g) of this rule are not met. Prior to the follow up review ODMH shall provide written notification to an agency that it has been placed on focused review status. A copy of the ODMH notice shall be given to the board.

(i) Agencies placed on focused review must submit a plan of correction to ODMH and the board for review and approval by ODMH within thirty days of notification of being placed on focused review status. ODMH shall provide the agency with written approval or disapproval of the plan of correction within thirty days of receiving the agency’s proposed plan of correction. ODMH shall provide the board with a copy of its approval or disapproval. The medicaid agreement will be retained during this time period.

(ii) ODMH must schedule a follow-up compliance review not later than six months following departmental approval of the agency’s plan of correction. If the follow-up compliance review demonstrates that the agency fails to meet any of the compliance thresholds identified in paragraph (E)(1) of this rule ODMH shall terminate the medicaid agreement with the agency for a minimum of one year.

(iii) If the follow-up focused review identifies additional ineligible billings as defined in paragraph (E)(2) of this rule, an additional recovery of funds as defined in paragraph (E)(2) of this rule must be implemented by the board.

(F) Medicaid medical necessity documentation review procedures and criteria.

(1) Medical necessity documentation reviews shall be performed by staff who are licensed as medical doctors, doctors of osteopathy, psychologists, licenced independent social workers, licenced social workers, licenced professional clinical counselors, licenced professional counselors, registered nurses, or staff certified as utilization review/management specialists. Additionally, such staff must have received training referenced in paragraph (E)(2)(i) of this rule and must possess a certificate of such training issued by ODMH.

(2) A review of medical necessity will be operationalized through a review of the clinical record, which must contain the following:

(a) Documentation that the consumer has participated in the development of the ISP;

(b) Documentation of a DSM IV or ICD-9 or their successor diagnosis codes;

(c) A description of symptoms;

(d) A description of the client’s condition/functioning;

(e) Intervention(s) for each service goal;

(f) An individualized service plan that addresses the client’s symptoms;

(g) Stated outcomes for service goals;

(h) Documentation of consideration of a least restictive setting appropriate to the needs of the client;

(i) Service interventions addressing identified developmental needs for children and adolescents are documented;

(j) Documentation that family has been involved for children and adolescents when the service plan describes need for family involvement or a description as to why the family is not participating as expected.

(3) With respect to medical necessity documentation review, the board shall seek recovery of funds for all reimbursed medicaid services provided in the period of the review in all of the following circumstances:

(a) There is no documentation that the consumer has participated in the development of the ISP as required in paragraph (F)(2)(a) of this rule as indicated by a signature or a progress note or an explanation of why the consumer did not participate;

(b) There is no documentation of a diagnosis code as required in paragraph (F)(2)(b) of this rule;

(c) There is no description of symptoms as required in paragraph (F)(2)(c) of this rule;

(d) There is no description of the client’s condition/functioning as required in paragraph (F)(2)(d) of this rule;

(e) There is no documentation of intervention(s) for each service goal as required in paragraph (F)(2)(e) of this rule;

(f) There is no documentation that the individual service plan addresses the client’s symptoms as required in paragraph (F)(2)(f) of this rule;

(g) There are no stated outcomes for service goals as required in paragraph (F)(2)(g) of this rule;

(h) There is no documentation of consideration of a least restrictive setting appropriate to the needs of the client as required in paragraph (F)(2)(h) of this rule;

(i) That service interventions addressing identified developmental needs for children and adolescents have not been documented when such needs have been identified in the ISP as required in paragraph (F)(2)(i) of this rule; or

(j) There is no documentation that family has been involved for children and adolescents when the ISP describes need for family involvement (or there is no description as to why the family is not participating as expected) as required in paragraph (F)(2)(j) of this rule.

(G) General followup requirements for annual medicaid compliance and medical necessity documentation reviews.

Within fifteen working days of the performance of the compliance and medical necessity documentation reviews, the board shall prepare a draft report of all of its review findings including those related to partial compliance, and shall upon its completion immediately provide the agency a copy of the report. The report shall be prepared in a form and manner prescribed by ODMH. The agency shall have the opportunity to respond in writing to the board’s draft report. The agency must provide its written response to the board within fourteen days of receiving the draft report. The agency’s written response should include any information that may support the agency’s position. The board shall amend its draft report if it concurs with the agency’s response. In the event that the board does not concur with any objections raised in the agency’s response, it shall include in its final report each of the agency’s objections and the basis upon which the board made its decision not to accept the agency’s objection. When the board provides the agency with its final report, the board shall also submit a copy to ODMH and shall also provide to the appropriate board a copy of any report containing findings for recovery of funds from a specially designated agency which serves residents of other board service districts referred to in paragraph (D)(2) of this rule. All of the actions cited in this rule are subject to the appeal provisions set forth in paragraph (H) of this rule.

(H) Agency right to appeal

A mental health agency may appeal to ODMH, by providing written notice to the deputy director for administrative services, any finding contained in a final report issued by the board and any proposed or actual adverse determinations arising out of a board’s compliance or medical necessity documentation review activities (e.g., findings, a decision by ODMH to place an agency on focused review status, or proposed recovery of funds). Appeals to ODMH of findings related to paragraph (F)(3) of this rule shall be reviewed by a licensed psychiatrist arranged by ODMH. Recovery of funds will not occur through all administrative appeals.

(I) In addition to the appeal provisions set forth in paragraph (H) of this rule, any mental health agency, board, or person who wishes to express concern regarding implementation of this rule may contact either ODMH or ODJFS in writing. ODMH shall hold at least two meetings open to the public during the first year subsequent to the effective date of this rule to hear and respond to any concerns regarding implementation of this rule.

(J) ODMH shall annually prepare a summary analysis of all of the review findings reported by boards pursuant to paragraph (G)(1) of this rule and all agency comments concerning such reviews. ODMH shall use this analysis to identify circumstances where there may be inconsistent implementation of the board compliance reviews required by this rule and shall conduct any action necessary to assure consistent application of such reviews.

(K) ODMH shall conduct at least four trainings open to all boards and mental health agencies subject to this rule prior to January 1, 2002, and shall conduct training at least once each year in subsequent years. The content of the trainings shall be developed in consultation with boards and mental health agencies subject to this rule. The content of the trainings shall include, but not be limited to, medical necessity documentation review criteria, compliance review criteria and service criteria. Board staff responsible for conducting the compliance and medical necessity documentation reviews shall be required to attend at least one training before conducting any such reviews.

(L) Nothing in this rule precludes a mental health agency from seeking a hearing under Chapter 119. of the Revised Code as described in rule 5101:3-1-57 of the Administrative Code.

(M) Nothing in this rule precludes ODJFS or its designee from reviewing or auditing a provider of medicaid covered services.

HISTORY: Eff 7-15-01

Rule promulgated under: RC Chapter 119.

Rule authorized by: RC 5111.02

Rule amplifies: RC 5111.01, 5111.02, 5111.022, 5119.01

REVIEW DATE: 11 AUG 2000, 11 AUG 2005

(A) Purpose: this rule sets forth the cost reconciliation calculation method to be used by the Ohio department of mental health, the notification of overpayment requirement to and the repayment for medicaid participating mental health agencies.

(B) Definitions:

(1) “Actual uniform cost report” means the uniform cost report completed retrospectively after the close of the state fiscal year (SFY) using actual cost data.

(2) “Actual unit rate” means the unit cost found in column twelve of the actual uniform cost report.

(3) “Agency” means a community mental health provider as defined in section 5122:01 of the Revised Code which has been certified by the Ohio department of mental health in accordance with the requirements of section 5119.611 of the Revised Code.

(4) “Budgeted uniform cost report” means a uniform cost report completed prospectively using anticipated budgeted cost data for an upcoming SFY.

(5) “Full payment” means federal financial participation and match participation.

(6) “Interim unit rate” means the unit cost found in column twelve of a budgeted uniform cost report.

(7) “MACSIS” means multi-agency community services information system.

(8) “Medicaid paid claims” means claims sourced from MACSIS which were submitted to and approved for reimbursement by ODJFS.

(9) “Medicaid participating mental health agency” means an agency that has met the requirements of rule 5101:3-27-01 of the Administrative Code and has received payment for medicaid covered mental health services as defined in rule 5101:3-27-02 of the Administrative Code.

(10) “ODJFS” means the Ohio department of job and family services.

(11) “ODMH” means the Ohio department of mental health.

(12) “Rate ceiling” means the maximum amount per unit of service a medicaid participating mental health agency may be paid for a medicaid covered mental health service listed in rule 5101:3-27-05 of the Administrative Code.

(13) “Uniform cost report” means the cost report as contained in rule 5122-26-19 of the Administrative Code as in effect for the SFY being reconciled.

(14) “Unit of service” means the length of time defined in rule 5122-26-19 of the Administrative Code as in effect for the SFY being reconciled for each medicaid covered mental health service as defined in rule 5101:3-27-02 of the Administrative Code.

(15) “UPI” means the unique provider identification number. This number represents an ODMH certified community mental health program and owner (indicated by a single federal tax identification number) operating at a discrete physical location.

(C) Each medicaid participating mental health agency shall complete all the budgeted uniform cost reports and the actual uniform cost report for any given SFY in accordance with rule 5122-26-19 of the Administrative Code as in effect for the SFY being reconciled. The methods of cost reporting selected when completing the first budgeted uniform cost report submitted in accordance with rule 5101:3-27-05 of the Administrative Code for a SFY must be the same methods the medicaid participating mental health agency shall use when completing and submitting any subsequent budgeted uniform cost report and the actual uniform cost report for that same SFY.

(D) Cost reconciliation process:

(1) The actual allowable amount a medicaid participating mental health agency could have received for medicaid covered mental health services for the state fiscal year being reconciled shall be determined by ODMH as follows:

(a) For each service, the maximum allowable rate will be determined by selecting the lower of the following: the medicaid rate ceiling in effect for the SFY being reconciled or the actual cost. The total allowable payment shall be determined by multiplying the number of service units from MACSIS associated with the medicaid paid claims by the maximum allowable rate. If a medicaid participating mental health agency fails to submit an actual uniform cost report in accordance with rule 5122-26-19 of the Administrative Code as in effect for the SFY being reconciled, the number of service units from MACSIS associated with the medicaid paid claims shall be multiplied by the lowest actual unit cost as documented on all filed actual uniform cost reports for the SFY being reconciled for each service the medicaid participating mental heath agency received medicaid payment. If a medicaid participating mental health agency fails to submit an actual uniform cost report in accordance with rule 5122-26-19 of the Administrative Code as in effect for the SFY being reconciled, the medicaid participating mental health agency’s ODMH certification/license may be revoked in accordance with rule 5122-26-19 of the Administrative Code as in effect for the SFY being reconciled.

(b) From each of the calculations described in paragraph (D)(1)(a) of this rule the value of third party payments, as reported by the medicaid participating mental health agency associated with the service specific medicaid paid claims shall be deducted. The result is the actual allowable amount of medicaid payment for each service for the medicaid participating mental health agency for the SFY being reconciled.

(2) The actual amount of medicaid payment paid to the medicaid participating mental health agency for each service for the SFY being reconciled shall be determined by summing the net amount from MACSIS claims detail associated with medicaid paid claims for that service.

(3) For each service, subtract the result of paragraph (D)(1)(b) of this rule from paragraph (D)(2) of this rule.

(a) If the result of this calculation is greater than zero, the medicaid participating mental health agency has been overpaid for the service for the SFY being reconciled.

(b) If the result of this calculation is equal to or less than zero, no overpayment of the service exists.

(4) The medicaid participating mental health agency is required to repay the full amount of the sum of all overpayments identified in paragraph (D)(3)(a) of the rule to ODMH.

(E) ODMH shall send the medicaid participating mental health agency a notification, by certified mail, of the overpayment amount calculated. ODMH will send a copy to ODJFS.

Replaces: 5101:3-27-05

Effective: 09/01/2005

R.C. 119.032 review dates: 09/01/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.022

Prior Effective Dates: 8/1/82, 12/22/86 (Emer.), 7/1/91