65E-11.007. Practice Guidelines for Behavioral Health Services to Ensure Cost-Effective Treatment and to Prevent Unnecessary Expenditures

(1) Treatment Plan. A written treatment plan shall be developed within 10 working days of enrollment into the Behavioral Health Network for each enrolled child. At a minimum, the plan shall include clear time-limited treatment objectives, related interventions, clinical criteria for discharge, and evidence that the child and family, consistent with the statutes and rules of the department for family involvement, has been included in the development of the treatment plan.

(a) A board certified child psychiatrist or a Licensed Practitioner of the Healing Arts with experience treating children who have mental or substance-related disorders shall serve as the authorizing authority for necessary services. The Lead Agency shall communicate the details of the plan to the local Children’s Medical Services Area Office. The plan shall be reviewed and updated no later than ninety (90) days apart.

(b) Notwithstanding paragraph 65E-11.007(1)(a), F.A.C., above, if the provider can demonstrate that a board certified child psychiatrist or a Licensed Practitioner of the Healing Arts with experience treating children who have mental or substance-related disorders is not available for participation due to the lack of availability, a psychiatrist with experience treating children who have mental disorders or a medical doctor with experience treating children for substance-related disorders shall serve as the authorizing authority for necessary services.

(2) Behavioral health services financed through the Behavioral Health Network shall not begin until after the child’s enrollment as defined in Rule 65E-11.003, F.A.C.

(3) Written Policies and Procedures. The department shall not enter into any contract with a Provider of Behavioral Health Services unless the provider has developed written policies and procedures to comply with the requirements of this rule.

(4) Written policies and procedures shall be approved by the department prior to implementation of said policies and procedures and shall be based on the standards described in Rule 65E-11.005, F.A.C., for treating behavioral health disorders and shall additionally address the following:

(a) The operation of the utilization management program;

(b) An annual review by a quality improvement committee;

(c) Documentation required for specific service approvals and denials, along with the timeframes for communicating decisions to the appropriate Behavioral Health Services provider;

(d) Collection of data to review the criteria and process used to evaluate services for medical necessity as described in subsection 65E-11.002(18), F.A.C.;

(e) Collection of data measuring lengths of stay, utilization of services, and the procedures to be followed when the data indicates patterns of deviation from the norm;

(f) The review of procedures to be used in formulating recommendations for admission, discharge, and disenrollment consistent with subsections 65E-11.005(2) and 65E-11.007(4), F.A.C.;

(g) The review of client service utilization data in the aggregate, with a targeted focus on high users and low users of service as compared to the norm. Such client service data shall minimally include length of service by treatment modality, office visits, days per intake, and the penetration and length of stay in intensive outpatient and acute inpatient services;

(h) Procedures to ensure that a professional described in Chapter 397, 490, or 491, F.S., and who also has 5 years experience in the diagnosis and treatment of children with mental or substance-related disorders supervise utilization management decisions;

(i) A comprehensive quality assessment and performance improvement program consistent with the provisions of Section 394.907, F.S. Such program shall include an analysis of a representative sample of both current and closed cases to determine whether:

1. The intake assessments performed after enrollments are thorough, timely, complete, and appropriate to the child’s presenting condition,

2. The service goals and objectives are based on the results of the intake assessments and include the concerns of the enrolled child and his family,

3. The services delivered are consistent with the service goals and objectives outlined in the Treatment Plan,

4. The services delivered are appropriate based on the enrolled child’s presenting condition and are in compliance with the Lead Agency’s clinical policies, scope of services and practice guidelines as indicated,

5. The management information system tracks how client data is monitored and reported, ensures it is complete and accurate based on the presenting conditions of the children being served, and is utilized in performance improvement,

6. The process for grievances and appeals is accessible, and affords the child and his family due process in circumstances where behavioral health services were denied, suspended or reduced and that a child and his family grievances and appeals are documented, implemented, and resolved within 45 days of the filing of the grievance or appeal; and,

7. All protocols developed or adopted by the Lead Agency for the provision, monitoring and reporting of services, are being followed by its network members and subcontracted Providers of Behavioral Health Services.

(5) Continuity. Lead Agencies shall ensure continuity and coordination of services throughout their Behavioral Health Care Network in order to improve access and quality of care for enrolled children by:

(a) Coordinating available services within and without the Lead Agency’s Behavioral Health Network;

(b) Sharing and exchanging information across all levels of care and all behavioral health providers, to the extent authorized by the child and the family and allowed under state statute and federal regulation;

(c) Developing written policies and procedures approved by the department to ensure that enrolled children and their families receive timely access to and follow-up with appropriate behavioral health providers, including a psychiatrist for medication management and psychiatric assessment;

(d) Developing written policies and procedures approved by the department in conjunction with Children’s Medical Services to ensure that enrolled children receive continuity and coordination of behavioral health services with general medical care;

(e) Developing written policies and procedures approved by the department to ensure continuity of services for children being disenrolled by the network as well as children being received or transferred to and from out-of-network providers upon entry into service and disenrollment is accomplished without disruption of services to the child; and,

(f) Developing written policies and procedures approved by the department to ensure prior authorization for all urgent and routine care provided outside of any contracted or subcontracted out-of network arrangement. These policies and procedures shall include provisions for the enrolled child’s access to and payment for Behavioral Health Services provided out-of-network.

(6) Out-of-Network Service Utilization. The Lead Agency shall make available its approved policies in accessing out-of-network coverage and ensure all children and their families are aware of its written policies and procedures governing out-of-network service utilization. The Lead Agency shall provide enrollees identification card and outreach materials, the telephone number that an enrolled child and out-of-network provider may call for information about covered service.

(7) The Lead Agency shall ensure that enrolled children and their families are advised that with the exception of emergency services the Lead Agency shall not be liable for the cost of out-of-network services the child accesses that are available through its Behavioral Health Care Network in which the child is enrolled unless specifically authorized by the Lead Agency.

(8) Emergency Out-of-Network Service Utilization. A Provider of Behavioral Health Services shall not require prior authorization for the provision of Emergency Behavioral Health Care to an enrolled child.

(a) The Lead Agency shall not be responsible for payment of services delivered after twenty-four hours of the authorization of admission unless the Lead Agency has specifically authorized the delivery of such services.

(b) The Lead Agency shall reimburse out-of-network providers for properly completed and submitted claims for Emergency Behavioral Health Care provided that such claims are submitted within 90 days of the date of service. The Lead Agency shall adjudicate such claim within 60 days of receipt. A claim shall be considered properly completed and submitted when the following occurs:

1. The claim documents psychiatric admission for the treatment of Emergency Behavioral Health Care as defined in subsection 65E-11.002(12), F.A.C., and includes the date of admission, reason for admission, location of the treatment facility, duration of service noted, and any Behavioral Health Services authorized by the referring Lead Agency.

2. The claim includes documentation of the out-of-network provider’s notification to the Lead Agency of the presenting child receipt of services within 24 hours of learning the child’s identity or its attempts to notify the Lead Agency of the child presenting for Emergency Behavioral Health Care and the circumstances that precluded its attempts to notify the Lead Agency; and,

3. Charges mutually agreed to by the Lead Agency and the provider within 60 days after submittal of the claim.

(9) The Lead Agency shall be liable for charges for Emergency Behavioral Health Care pursuant to the provisions of Section 394.451, F.S., the “The Florida Mental Health Act” also known as “The Baker Act.” with regard to admissions and assessments with reimbursement to the treating facility not to exceed the Medicaid approved rate for Baker Act admissions and assessments.

(10) Lead Agencies shall be responsible for the management of the enrollment pool which shall include the application of screenings and assessments to potential entrants to the pool and the conducting of reverification screenings among existing enrolled children. The costs of such services shall be borne by the Lead Agency.

(11) Service Delivery Location. All Behavioral Health Services shall be accessible in a setting which is located no further than a thirty (30) minute typical drive time from the residence of the enrolled child accessing the care.

(12) Exceptions to the drive-time provision shall be made by the Behavioral Health Network Coordinator to address the lack of specialty providers or other service constraints existing in rural areas.

(13) Service Times. Providers of Behavioral Health Services shall at a minimum, be available during normal business hours to provide direct services to children and to carry out activities related to clinical administration and shall comply with the following service standards:

(a) Emergency Behavioral Health Care shall be unrestricted and directly accessible to the enrolled child, twenty-four (24) hours a day and seven (7) days a week.

(b) Urgent Care as defined in subsection 65E-11.002(27), F.A.C., shall be evaluated and delivered within twenty-four (24) hours.

(c) Routine Care must be provided within ten (10) days of the request from a child or the family.

(14) Records and Documentation. Providers of Behavioral Health Services shall maintain written service documentation to support each service rendered on behalf of the enrolled child. Service documentation must contain all of the following:

(a) Recipient’s name;

(b) Date the service was rendered;

(c) Start and end times for the services;

(d) Identification of the setting in which service was rendered;

(e) Reference to the treatment plan goal and objectives for which service is being provided;

(f) Description of the specific service rendered, including the specific intervention;

(g) Updates regarding the recipient’s progress toward meeting goals and objectives identified in the treatment plan; and,

(h) Original signature, credential and functional title of the person providing the service.

Rulemaking Authority 409.8135(6) FS. Law Implemented 409.8135 FS. History–New 1-17-01, Amended 8-31-03.