Covered and Noncovered Services : Covered Services and Requirements

Elements and Documentation Requirements for Strength-Based Assessment and Recovery and Treatment Planning

Strength-Based Assessment

The assessment shall be sufficient to identify the member's need for mental health services. A comprehensive assessment shall be valid; accurately reflect the member's current needs, strengths, and functioning; and be completed before beginning treatment under the treatment plan.

The assessment shall include the following:

• The member's presenting problem.
• Diagnosis established from the current DSM including all five axes or, for children up to age 4, the current DC:0-3.
• The member's symptoms that support the given diagnosis.
• The member's strengths, and current and past psychological, social, and physiological data; information related to school or vocational, medical, and cognitive function; past and present trauma; and substance abuse.
• The member's unique perspective and own words about how they view their recovery, experience, challenges, strengths, needs, recovery goals, priorities, preferences, values, and lifestyle, areas of functional impairment, and family and community support.
• Barriers and strengths to the member's progress and independent functioning.
• Necessary consultation to clarify the diagnosis and treatment.
• Treatments and services concurrently received by the member through other providers if the member is determined to have one or more co-occurring disorders. If substance abuse services are being provided by the same agency, the assessment shall include a copy of the most current approved placement criteria summary.

Documentation

Document the assessment of the member, basing it on the member's strengths. Include current as well as historical psychological, social, and physiological data. Include mental status, developmental and cognitive functioning, school, vocational, cultural, social, spiritual, medical, past and current traumas, substance use/dependence and outcome of treatment, and past mental health treatment and outcome. Include the member's view of the issues; for a child, give the parent/primary caregiver's view. An assessment dated within three months of the request may be attached.

Recovery/Treatment Plan

The recovery and treatment plan shall be based upon the diagnosis and symptoms of the member and include:

• A mental health diagnosis and medications for mental health issues used by the member
• The member's strengths and how they will be used to develop the methods and expected measurable outcomes that will be accomplished
• The method to reduce or eliminate the symptoms causing the member's problems or inability to function in day-to-day living
• The method to increase the member's ability to function as independently as possible
• For a child or adolescent, a consideration of the child's or adolescent's development needs as well as the demands of the illness
• The schedules, frequency, and nature of services recommended to support the achievement of the member's recovery goals, irrespective of the availability of services and funding

Clinical review of the treatment plan shall address all of the following:

• The degree to which the goals of treatment have been met.
• Any significant changes suggested or required in the treatment plan.
• Whether any additional assessment or evaluation is recommended as a result of information received or observations made during the course of treatment.
• The member's assessment of functional improvement toward meeting treatment goals and suggestions for modification.

Documentation

The goals of treatment and specific objectives to meet those goals shall be documented in the member's recovery and treatment plan that is based on the strength-based assessment. In the recovery and treatment plan, the signs of improved functioning that will be used to measure progress toward specific objectives at identified intervals, agreed upon by the provider and member, shall be documented. A mental health diagnosis and medications for mental health issues used by the member shall be documented in the recovery and treatment plan.