Smokey Mountain Provider Network Bulletin
Mental Health and Substance Abuse providers: Home Based Therapy (90837 SR)
Smoky has identified a need in the Smoky Benefit Plan(s) for a Mental Health/Substance Abuse (MH/SA) clinical service that can be provided in a consumer’s home to maximize effectiveness of care for individuals who face certain barriers to office-based therapy. Effective January 1, 2015, basic benefit 60 minute therapy (90837 + SR) will be available in both the Medicaid and State Benefit Plans at a rate of $112 for all license types. This specialized service will be made available to Medicaid and State funded consumers in all disability groups (MH/SA/IDD) who are unable to benefit from traditional office based treatment and who meet all General, Entrance, Continued Stay and Discharge Criteria as required for Outpatient Behavioral Health Services in DMA Clinical Coverage Policy 8C.
Home Based Therapy (90837 SR) requires face-to-face service delivery and may be used when a consumer’s need requires outpatient level-of-care. The service is not intended to address cognitive or intellectual/developmental issues that would not benefit from outpatient therapy services. This 60-minute psychotherapy code requires the focus of the service delivery to be on the individual; however, it can be used with the occasional involvement of family members. In addition, providers of this service must be trained in and follow a rehabilitative best practice or evidence-based treatment model consistent with community practice standards. The selected treatment model must produce positive outcome for the consumer’s diagnosis and needs.
State funded consumers may access this service through Smoky’s regional Comprehensive Care Centers. Smoky will continue to evaluate the need for further expansion of this service; Network Providers who would like to have this code added to their contract are encouraged to contact their Account Specialist for consideration.
In addition to meeting all Entrance, Continued Stay and Discharge Criteria found in Clinical Coverage Policy 8C the following criteria are required:
- A Comprehensive Clinical Assessment must be completed prior to the delivery of Home Based Therapy and must demonstrate necessity for Home Based Therapy to meet the consumer’s treatment needs.
- The consumer cannot be safely and effectively treated in a provider’s office, and reasonable attempts at office based or community based treatment are documented in the consumer’s record. A failure to attempt office based or community based treatment prior to accessing this service will result in denial of authorization or recoupment. Examples of where this criteria are met include the following:
- A consumer who is considered high risk, for example with multiple Emergency Department or after hours crisis visits, who fails to maintain/engage in routine office based treatments.
- A consumer with a phobia or other MH/SA condition that impedes access to traditional office based therapy.
- A consumer who has received a high level enhanced service (i.e. ACTT) for an extended period of time and who has been stabilized but who will not engage in office based treatment.
- A child who is deemed at risk for out of home placement but does not meet other qualifiers for Intensive In Home Services. In addition, all attempts at engagement with parent or guardian have been unsuccessful.
- A consumer with co-occurring IDD/MH diagnosis who presents with physical conditions that impede access to traditional office based treatment.
- A consumer who requires treatment for a MH/SA condition but is unable to access office treatment due to lack of transportation. If the service is required due to a lack of transportation to attend office based treatments, all transportation alternatives, including use of public transportation, Medicaid transportation for Medicaid recipients, and natural supports must be unavailable to the recipient.
- This service can be reasonably expected to be effective in addressing the recipient’s diagnosed mental health or substance use disorder.
- Without Home Based Therapy Service, there is an identified, specific, significant health and/or safety risk to the individual OR an identified, specific, significant risk of physical or mental harm to immediate family or community; or the consumer is at risk of out of home placement and/or may require a higher level of care.
Consumers who meet eligibility requirements for this specialized Home Based Therapy may receive up to 8 unmanaged visits. All applicable documentation requirements must be met for all visits, including the 8 unmanaged visits, and must demonstrate the alternatives that were accessed prior to utilizing Home Based Therapy. To request beyond the 8 unmanaged visits providers must submit a Service Authorization Request (SAR) along with the CCA. Authorization guidelines will permit up to 26 sessions for a 90 day period as medically necessary. This is viewed as a time limited service to be titrated as a consumer becomes engaged in traditional community based services.
If this service is added to your contract, any questions about authorization should be directed to the Care Management Department at 1-800-893-6246 ext. 1513. Providers with questions about contracts please contact your Account Specialist or call 866-990-9712.