|Program Name: ||BadgerCare Plus and Medicaid ||Handbook Area: ||Behavioral Treatment Benefit |
Covered and Noncovered Services : Covered Services and Requirements
The ForwardHealth behavioral treatment benefit covers services designed specifically for adaptive behavior assessment and treatment. Treatment may be authorized for members with autism or other diagnoses or conditions associated with deficient adaptive or maladaptive behaviors.
The behavioral treatment benefit is administered fee-for-service for all Medicaid-enrolled members who demonstrate medical necessity for covered services. The behavioral treatment benefit is carved out of MCOs, which include BadgerCare Plus and Medicaid SSI HMOs and special managed care plans. Special managed care plans include Children Come First, Wraparound Milwaukee, Care4Kids, Family Care, PACE, and the Family Care Partnership Program, with PA requests and claims processed by ForwardHealth instead of the member's HMO.
The primary goal of behavioral treatment is to prepare members and their families for successful long-term participation in normative settings and activities at home, in school, and in the community. Intensive, early intervention behavioral treatment is appropriate to close the developmental gap in young children. Lower-intensity treatment that focuses on specific behaviors or deficits is also available. Providers developing POC for early developmental delays should indicate specific, measurable goals that build toward this outcome.
ForwardHealth expects early, comprehensive behavioral treatment to result in meaningful progress for the member, such as:
- Substantial improvement on age-normed cognitive, communicative, and adaptive performance measures in comparison to same-age peers
- Reduction in interfering behaviors that allows the member to commence or return to participation in normative activities
- Increased independence as evidenced by decreased need for direct support and monitoring by parents, guardians, or paid staff
As the member approaches more age-typical functioning, such as successful participation in group learning and social activities with minimal to no support, fewer hours of treatment are appropriate to allow the member more opportunities for normative community participation. The POC should include treatment in settings and at a frequency that is likely to result in desired gains.
Behavioral treatment is also appropriate to address behaviors that prevent the member from living in the least restrictive, appropriate community setting. For members with ongoing, significant behavioral needs for whom early intervention is no longer appropriate, treatment should result in skill acquisition and behavioral improvement that allows the member to transition to a system of care without ongoing behavioral treatment (e.g., family, personal care, supported employment). Providers developing POC for these members should prioritize the following:
- Addressing behavioral challenges that are preventing other professionals and caregivers from teaching new skills or supporting the member's day-to-day functioning
- Enhancing the member's safety
- Preparing the member for their next living or occupational environment
The plan must include an anticipated timeline with time or skill acquisition benchmarks that will result in a progressive transition to the member's next system of care.
ForwardHealth presumes that an extended course of behavioral treatment typically establishes the member's expected rate of behavior change. The number of goals and requested hours on the PA request must be realistic, given the member's established rate of behavioral change and ForwardHealth's expectation of meaningful behavioral improvement within 12 months. Goals must be consistent with the member's demonstrated needs and priorities, functionally useful for the member, and aimed at skills identified in the provider's transition/discharge criteria. Caregiver goals should address management of the member's behavior and increase the member's independence with self-care skills. Providers are reminded that not all beneficial skills are considered medically necessary.
If an extended course of behavioral treatment has not effectively reduced the member's need for direct support and monitoring, ForwardHealth may regard this as failure to prove the medical value or usefulness of the service. ForwardHealth will only authorize services that meet the standard of medical necessity as defined under Wis. Admin. Code § DHS 101.03(96m).
Covered services within the following categories are covered under the behavioral treatment benefit:
A list of allowable procedure codes and modifiers is available.
Note: The behavioral treatment benefit does not include screening or diagnostic services such as developmental screening, psychological testing, neuropsychological testing, genetic testing, or other necessary medical evaluations. ForwardHealth covers these services through existing benefits for physician services or outpatient mental health. A comprehensive diagnosis precedes a referral for behavioral treatment services. The behavior identification assessment covered under the behavioral treatment benefit includes only those activities necessary to identify and define the behaviors to be addressed, establish the member's baseline performance, and develop a POC.
Behavior Identification Assessment and Plan of Care Development
ForwardHealth covers clinical assessment activities used to identify target behaviors and to develop a POC (i.e., treatment plan, protocol) for the member. Covered assessment activities include:
- Administration of assessments
- Discussion of findings and recommendations
- Analyzing data
- Scoring and interpreting assessments
- Preparing the report/POC
These assessment activities must be conducted by licensed supervisors, although behavior identification supporting assessments may be designed by the licensed supervisor and implemented by a treatment therapist. Behavior identification assessment services generally do not require PA. ForwardHealth covers up to 96 units/24 hours of behavioral identification assessment services within a calendar year without PA. This service includes a combination of face-to-face and non-face-to-face activities. Providers conducting behavior identification assessments should spend at least half of the assessment time in a face-to-face setting with the member.
If more non-face-to-face time is needed, providers must document the unique clinical circumstances that justify the additional non-face-to-face time relative to the face-to-face assessment services. Providers are required to submit a Prior Authorization Amendment Request for additional units beyond 96 units/24hours.
Behavior identification supporting assessments may be conducted by licensed supervisor to finalize or fine-tune the baseline results or POC. Supporting assessment may be provided for up to two hours may be billed per DOS and do not count towards the 24-hour limit for behavior identification assessments.
Behavioral Treatment With Protocol Modification
For both comprehensive and focused treatment, ForwardHealth covers services where the licensed supervisor or treatment therapist resolves issues with, or otherwise makes changes to, the existing treatment protocol or POC in order to improve outcomes for the member.
Adaptive behavioral treatment with protocol modification is administered by the licensed supervisor or treatment therapist who is face to face with a single member. The service may include simultaneous direction of a technician, guardian, and/or caregiver who is face to face with a member.
In general, providers may request up to one hour of protocol modification for each five hours of direct behavioral treatment. Providers may submit prior authorization amendment requests to seek additional units if the member's unique circumstances warrant direction of staff in excess of one hour per five hours of direct behavioral treatment.
Care collaboration (or case sharing) is treatment by two providers of different disciplines during overlapping episodes of care but does not include co-treatment. Behavioral treatment providers may share a case with the following types of providers:
- Case management
- Day treatment
- Home health services
- Intensive in-home mental health and substance abuse services
- Outpatient mental health
- Personal care
- Psychosocial rehabilitation (for example, CCS, CRS, and CSP)
Behavioral treatment providers are required to document their communication with these other providers regarding the member's needs, POC, and scheduling. This will ensure coordination of services and continuity of care and will prevent duplication of services provided to a member.
Co-treatment is simultaneous treatment by two providers of different disciplines during a single member encounter. Co-treatment may be authorized when the treatment approach is medically necessary to optimize the member's benefit from behavioral treatment. Behavioral treatment providers may provide co-treatment with the following types of providers:
- Outpatient mental health
Behavioral treatment providers are required to specify on the initial PA request or on a PA amendment request the plan for co-treatment with another provider. Co-treatment occurs when the member is present with both providers for a joint intervention, but it does not include professional collaboration or consultation. Co-treatment requests should address the specific and unique contribution of each provider.
If co-treatment is approved, two providers of different disciplines can be reimbursed by ForwardHealth for the same time period. For example, if a member is treated by an SLP provider and a behavioral treatment provider from 1:00 p.m. to 2:00 p.m., both providers could receive ForwardHealth reimbursement for one hour of treatment time. However, if co-treatment is not approved, neither the SLP provider nor the behavioral treatment provider would receive reimbursement for one hour. Instead, each provider could receive reimbursement for 30 minutes of treatment time.
Comprehensive Behavioral Treatment
Comprehensive behavioral treatment may be provided by licensed supervisors, treatment therapists, or treatment technicians.
The behavioral treatment benefit covers high-intensity, early-intervention comprehensive behavioral treatment typically lasting for a year or more. The aim of comprehensive treatment is for the member to acquire a broad base of skills (e.g., communication, social-emotional development, adaptive functioning) with an emphasis on "closing the developmental gap" between the member and same-age peers in the primary deficit areas associated with autism. The broad scope of goals and focus on early developmental impacts are the defining features of this treatment. Comprehensive treatment must be administered face-to-face with the member. Only face-to-face services are reimbursable.
PA requirements for comprehensive behavioral treatment are available.
ForwardHealth reimburses comprehensive behavioral treatment services under federal EPSDT authority. EPSDT authority limits services to ForwardHealth members under 21 years of age. PA requests and claim submissions for comprehensive behavioral treatment for members 21 years of age or older will be denied by ForwardHealth.
Hours of Treatment
ForwardHealth authorizes comprehensive treatment for no fewer than 20 hours per week at the outset of treatment. Fewer than 20 hours of comprehensive treatment may be approved as part of a planned reduction in hours following a course of high-intensity treatment.
Location of Treatment
Treatment may occur in the member's home, the provider's office, or in the community.
Concurrent Behavioral Treatment and Behavioral Health Services
ForwardHealth will allow for the concurrent delivery of behavioral treatment services with behavioral health services when both services are identified as medically necessary, per Wis. Admin. Code § DHS 101.03(96m).
ForwardHealth recognizes that coordinated services between behavioral treatment and behavioral health providers may be clinically appropriate.
Definition of Covered Services
A covered service is a service, item, or supply for which reimbursement is available when all program requirements are met. Wis. Admin. Code § DHS 101.03(35) and ch. DHS 107 contain more information about covered services.
Behavioral treatment providers are required to maintain documentation in accordance with Wis. Admin. Code ch. DHS 106 and other applicable laws and rules. According to Wis. Admin. Code § DHS 106.02(9)(f), covered services are not reimbursable under Wisconsin Medicaid unless the documentation and medical record keeping requirements are met. Providers are required to be able to produce documentation upon request from the Wisconsin DHS or federal auditors. Documentation is evaluated by DHS during the audit process.
Expectations and Documentation Requirements for Collaborating Providers
Whether or not PA is required for a service, each provider must separately document their collaboration with the other provider in the member's medical record. The documentation must include services the member is receiving from the other provider and the current schedule of services or the frequency of services from both providers. This will ensure better coordination and continuity of care and will prevent duplication of services.
ForwardHealth requires providers to coordinate with each other at least once every six months, or more often if indicated by the member's condition.
The following shows care collaboration requirements for a collaborating behavioral health provider under two possible scenarios:
- If a behavioral health provider intends to provide a service that requires PA, the behavioral health provider must include the mode and frequency of the coordination between themselves and the collaborating behavioral treatment provider in the PA request and the member's medical record.
- If a behavioral health provider is providing a service that does not require PA, the behavioral health provider must document coordination between themselves and the collaborating behavioral treatment provider in the member's medical record.
Services That Require PA
Collaborating providers must include the following information in their PA request:
- The concurrent services received by the member
- The mode and frequency of the care collaboration between providers (for example, phone calls, meetings, the member's weekly schedule)
Note: ForwardHealth may request additional information, if needed, to establish the medical necessity of the service.
In the event a provider experiences challenges obtaining the required documentation from their collaborating provider, ForwardHealth recommends that the provider submit the PA request, detailing the barriers to obtaining the required documentation. ForwardHealth will consider the current barriers and may allow flexibility to authorize services as appropriate.
Family Adaptive Behavior Treatment Guidance
The aim of family adaptive behavior treatment guidance is to teach parents and/or caregivers to properly use treatment
procedures designed to teach new skills and reduce challenging behaviors. Covered activities include face-to-face instruction
to parents and/or caregivers, with or without the member present, with a focus on identifying problem behaviors and deficits
following the POC, to reduce maladaptive behaviors and/or skill deficits.
ForwardHealth covers both team meetings and family treatment guidance under family adaptive behavior treatment guidance as
these are considered related, but distinct, services. Team meetings and family treatment guidance require PA.
Family Treatment Guidance
ForwardHealth covers treatment guidance provided to the member's family and caregivers. This service must include specific
ForwardHealth covers family treatment guidance under CPT procedure code
97156 (Family adaptive behavior guidance, administered by physician or other qualified health care professional [with
or without the patient present], face-to-face with guardian[s]/caregiver[s], each 15 minutes). Procedure code 97156 is used
with modifier TG (Comprehensive level of service) or TF (Focused level of service), as appropriate. Family treatment guidance
may satisfy the ForwardHealth direct patient observation requirements for licensed supervisors if clinical notes reflect that
the member was present and the provider engages inactivities directly involving the member, such as demonstration protocols or
coaching family members in the implementation of a protocol.
In order for family treatment guidance to be reimbursable, providers are required to document all of the following:
- Information collected from the family
- Information shared with the family
- Length of the meeting, including time in and out
- Measurable family goals addressed
- Name of the licensed supervisor and family members or caregivers that were present
- Update of family goals resulting from the family treatment guidance session
- Renderer's signature
Regardless of the number of participants, family treatment guidance is reimbursed up to two hours per DOS. The licensed
supervisor is required to be indicated as the rendering provider on the claim.
ForwardHealth covers team meeting services with PA. In team meeting services, licensed supervisors or treatment therapists
meet with a member's parent(s) or caregiver(s) and the behavioral treatment team to discuss the member's progress and to help
the team and caregivers learn how to:
- Identify behavioral problems.
- Implement treatment strategies to minimize destructive behavior.
- Participate in the treatment of the member.
ForwardHealth covers team meeting services under CPT code 97156. Procedure code 97156 is used with modifier AM (Physician,
team member service) in addition to modifier TG or TF, as appropriate. As indicated in the code description, the service is
delivered "with or without the member present."
In order for team meeting services to be reimbursable, providers are required to document all of the following:
- Goals resulting from the meeting
- Learning objectives that were targeted
- Length of the meeting
- Names of the parents, caregivers, and team members who were present
- Comprehensive In addition to the parents or caregivers, a licensed supervisor or treatment therapist and other
treatment team member(s) must be present in order for the meeting to qualify as a team meeting
- Focused In addition to the parents or caregivers, a licensed supervisor and other treatment team member(s) must be
present in order for the meeting to qualify as a team meeting
- Outcome of the learning objectives
- Renderer's signature
Team meetings are reimbursed up to one hour per week, as long as PA is received from ForwardHealth. Team meeting services
must be requested as a separate line item on the PA request. Regardless of the number of participants, the team meeting is
reimbursed once per member per DOS. Either the licensed supervisor or treatment therapist who must be documented as
present and leading the meeting is required to be indicated as the rendering provider on the claim. Team meeting
services may satisfy the ForwardHealth direct patient observation requirements for licensed supervisors if clinical notes
reflect that the member was present and provider engaged in activities directly involving the member, such as demonstration
protocols or coaching team members in the implementation of a protocol.
PA requirements for team meeting services are available.
Further claim submission information is also available.
requirements must be met for team meeting services to be reimbursable by ForwardHealth.
Focused Behavioral Treatment
Focused treatment may be provided by licensed supervisors, treatment therapists, or treatment technicians.
ForwardHealth covers time-limited, lower-intensity treatment that focuses on specific behaviors or deficits. The aim of focused behavioral treatment is to reduce challenging behaviors of the member, develop replacement behaviors, and develop discrete skills that enhance personal independence. A narrow scope of goals and a 12-month timeline for goal mastery are the defining features of focused treatment, in contrast to the broad scope of goals with comprehensive treatment. Focused treatment must be administered face-to-face with the member. Only face-to-face services are reimbursable.
ForwardHealth covers the following two levels of focused behavioral treatment:
- Focused treatment for members whose significant maladaptive behavior (e.g., aggression, self-injury, property destruction) or complex conditions (e.g., comorbid mental health diagnoses) require skilled direct treatment by licensed supervisors and/or treatment therapists.
- Focused treatment to address specific behaviors or skill deficits for members with ongoing behavioral needs for whom early intervention is no longer appropriate. Focused treatment to address skill building or management of low-level behaviors can be safely and effectively addressed by treatment technicians. ForwardHealth covers symptoms or behaviors associated with a diagnosed condition that impairs or limits the member's functional community living but does not cover skill acquisition unrelated to functional community living.
These two levels of focused behavioral treatment are distinguished for the purpose of PA and claims via modifiers.
ForwardHealth adjudicates PA requests based on individual needs and circumstances of members. Treatment plans may be reviewed for appropriateness of the member's full schedule of cognitive and social demands.
Location of Treatment
Treatment may occur in the member's home, the provider's office, or in the community.
Requirements for Technicians Delivering Focused Behavioral Treatment
Behavioral treatment technicians may deliver focused behavioral treatment under the following conditions:
- PA requests must be submitted by a behavioral treatment licensed supervisor.
- The licensed supervisor must attest that treatment technicians can safely and effectively implement the POC. ForwardHealth will review all information in the client's file to evaluate whether technicians are appropriate providers. Services will be authorized based on ForwardHealth's determination of the appropriate provider level.
- A licensed supervisor or treatment therapist must provide regular face-to-face observation with simultaneous direction of behavioral treatment technicians during delivery of direct treatment. ForwardHealth requires a minimum of one hour of direct case supervision per 10 hours of direct treatment provided by treatment technicians.
- The reimbursement rate for behavioral treatment technicians is the same for both focused and comprehensive behavioral treatment.
Enrollment for Technicians
Behavioral treatment technicians should enroll under the behavioral treatment technician provider specialty. Only one enrollment per technician is required, even if the technician will render both comprehensive and focused behavioral treatment.
Wisconsin Medicaid reimburses only for services that are medically necessary as defined under Wis. Admin. Code § DHS 101.03(96m). Wisconsin Medicaid may deny or recoup payment if a service fails to meet Medicaid medical necessity requirements.
Member Payment for Covered Services
Under state and federal laws, a Medicaid-enrolled provider may not collect payment from a member, or authorized person acting on behalf of the member, for covered services even if the services are covered but do not meet program requirements. Denial of a claim by ForwardHealth does not necessarily render a member liable. However, a covered service for which PA was denied is treated as a noncovered service. (If a member chooses to receive an originally requested service instead of the service approved on a modified PA request, it is also treated as a noncovered service.) If a member requests a covered service for which PA was denied (or modified), the provider may collect payment from the member if certain conditions are met.
If a provider collects payment from a member, or an authorized person acting on behalf of the member, for a covered service, the provider may be subject to program sanctions including termination of Medicaid enrollment.
For a covered service to meet program requirements, the service must be provided by a qualified Medicaid-enrolled provider to an enrolled member. In addition, the service must meet all applicable program requirements, including, but not limited to, medical necessity, PA, claims submission, prescription, and documentation requirements.
Services That Do Not Meet Program Requirements
As stated in Wis. Admin. Code § DHS 107.02(2), BadgerCare Plus and Wisconsin Medicaid may deny or recoup payment for covered services that fail to meet program requirements.
Examples of covered services that do not meet program requirements include the following:
- Services for which records or other documentation were not prepared or maintained
- Services for which the provider fails to meet any or all of the requirements of Wis. Admin. Code § DHS 106.03, including, but not limited to, the requirements regarding timely submission of claims
- Services that fail to comply with requirements or state and federal statutes, rules, and regulations
- Services that the Wisconsin DHS, the PRO review process, or BadgerCare Plus determines to be inappropriate, in excess of accepted standards of reasonableness or less costly alternative services, or of excessive frequency or duration
- Services provided by a provider who fails or refuses to meet and maintain any of the enrollment requirements under Wis. Admin. Code ch. DHS 105
- Services provided by a provider who fails or refuses to provide access to records
- Services provided inconsistent with an intermediate sanction or sanctions imposed by DHS