This rule establishes standards of delivery for behavioral health services provided through contracted Behavioral Health Entities (BHEs) under New Mexico's Interagency Behavioral Health Purchasing Collaborative. It sets broad operational requirements covering quality management, utilization management, credentialing, performance measures, reporting, and coordination of care across the full range of behavioral health services. BHEs and their subcontracted providers must comply with these standards regardless of funding source, and must ensure services are individually centered, evidence-based, and coordinated across physical health, emergency, and other service systems.
View official sourceTITLE 7 HEALTH CHAPTER 21 BEHAVIORAL HEALTH PART 2 STANDARDS OF DELIVERY FOR BEHAVIORAL HEALTH SERVICES 7.21.2.1 ISSUING AGENCY: Human Services Department [7.21.2.1 NMAC - N, 9-1-11] 7.21.2.2 SCOPE: This rule applies to the general public. [7.21.2.2 NMAC - N, 9-1-11] 7.21.2.3 STATUTORY AUTHORITY: Subsection F of Section 9-7-6.4 NMSA 1978 requires the interagency behavioral health purchasing collaborative (the collaborative) to adopt rules through the human services department. The collaborative is created by statute and comprised of the secretaries of aging and long-term services; Indian affairs; human services; health; corrections; children, youth and families; finance and administration; workforce solutions; public education; and transportation; the directors of the administrative office of the courts; the New Mexico mortgage finance authority; the governor’s commission on disability; the developmental disabilities planning council; the vocational rehabilitation division of the public education department; the New Mexico health policy commission; and the governor’s health policy coordinator, or their designees. [7.21.2.3 NMAC - N, 9-1-11] 7.21.2.4 DURATION: Permanent [7.21.2.4 NMAC - N, 9-1-11] 7.21.2.5 EFFECTIVE DATE : September 1 , 2011, unless a later date is cited at the end of a section. [7.21.2.5 NMAC - N, 9-1-11] 7.21.2.6 OBJECTIVE: The objective of this rule is to provide policies for the standard of delivery for behavioral health services through contracted behavioral health entities. [7.21.2.6 NMAC - N, 9-1-11] 7.21.2.7 DEFINITIONS: [RESERVED] [See 7.21.1.7 NMAC.] 7.21.2.8 MISSION STATEMENT: The mission of the interagency behavioral health collaborative (the collaborative) is to ensure quality behavioral health services are provided to medicaid and non-medicaid consumers; providers are reimbursed timely and accurately; data is collected, and services promote prevention, recovery, resilience, and efficient use of available resources. This mission serves the collaborative vision to establish a behavioral health service delivery system in which consumers and family members are assisted in participating fully in the life of their communities; support of recovery and development of resiliency are expected; behavioral health is promoted; and the adverse effects of substance abuse and mental illness are prevented or reduced. [7.21.2.8 NMAC - N, 9-1-11] 7.21.2.9 QUALITY MANAGEMENT: The collaborative recognizes that strong programs of quality improvement and assurance help ensure that better care is delivered in a cost-effective manner with better outcomes for consumers and families. Under the terms of the interagency behavioral health collaborative contracts, quality assurance and management programs are incorporated into behavioral health care delivery and administrative systems. [7.21 .2. 9 NMAC - N, 9-1-11] 7.21.2.10 BROAD STANDARDS: A. Commitment to persons served: The BHE and provider shall provide or ensure that: (1) service delivery is individually centered and family-centered, and furthers an individual’s capacity for recovery and resiliency; (2) all services are designed to enhance, promote and expand the recovery, resiliency, independence, self-sufficiency, self-esteem and quality of life of the persons served; (3) individuals served are involved in the individual planning, decision-making, implementation and evaluation of services provided; (4) agents under an advance directive, family members, guardians or treatment guardians, caregivers, or other persons critical to the consumer’s life and well-being are involved in the individual planning, decision-making, implementation and evaluation of services provided, subject to requirements or principles of confidentiality and individual choice; (5) the system offers a full range of appropriate behavioral health services for multi-diagnosed clients, including facilitating access to and coordinating care with appropriate medical care providers; (6) services are based on evidence of effectiveness; (7) services consider the individual consumer’s and family’s preferences; (8) services and providers comply with Title VI of the Civil Rights Act of 1964; Title IX of the Education Amendments of 1972 (regarding education programs and activities); the Age Discrimination Act of 1975; the Rehabilitation Act of 1973; and the Americans with Disabilities Act. B. Collaboration and system of care requirements: The BHE shall be responsible for developing a system of care that offers acceptable access and appropriate, effective care to all individuals and families served. The BHE shall coordinate and collaborate with the collaborative in the implementation of the requirements of this or other rules and the requirements of any contracts between the BHE and the collaborative. The BHE shall work with the BHPC and, upon request, with LCs to seek advice and comment during the planning, implementation, and evaluation of services. The BHE shall consult with the BHPC to identify service gaps and needs, including provider training, coaching and supervision needs and opportunities. C. Reporting requirements: The BHE shall provide to the collaborative such reports as may be required by the BHE contract. The BHE shall verify the accuracy and completeness of data and other information in reports submitted. D. Behavioral health data: For reporting purposes, behavioral health data shall be collected and reported as required by contract for any consumer or family member receiving any behavioral health service provided by a behavioral health practitioner, regardless of setting or location as required by the collaborative, including behavioral health licensed professionals, practicing within the BHE. The BHE shall monitor and ensure the integrity of data. Findings shall be reported to the collaborative as required by the BHE contract. E. Emergency response requirements: The BHE shall participate in disaster behavioral health planning and emergency response with the collaborative and in a manner consistent with the protocol of described in the New Mexico department of health emergency operations plan, psychosocial annex. The BHE shall ensure that its network providers are likewise prepared to be responsive and appropriate to the specific needs of an event calling for emergency response and psychosocial support services. F. Sexual assault: The BHE shall ensure that its providers have the capacity to provide comprehensive, confidential and sensitive services to victims of sexual assault as mandate by the Sexual Crimes and Prosecution and Treatment Act Sections 29-11-1 through 29-11-7, NMSA 1978. G. Advance directives: The BHE shall have and implement policies and procedures for advance directives. The BHE shall require its providers to honor advance directives within its utilization management protocols. H. Forensic evaluations: The BHE shall ensure that network and non-network providers providing forensic evaluations shall assure that such evaluations shall be performed pursuant to court authority and either the Rules of Criminal Procedure for the District Courts, 5-602.B, NMSA 1978, or other legal authority. Each evaluation file shall have a copy of the court order from the state district court. I. Special coordination requirements: The BHE shall ensure effective coordination with other service systems and providers. Such coordination shall include at least the following: (1) physical and behavioral health services; (2) emergency services; (3) pharmacy services; (4) transportation; (5) supportive housing; (6) SCI MCOs; (7) CYFD, including children in CYFD custody; (8) New Mexico corrections department; (9) court-ordered or parole board-ordered treatment; (10) children in tribal custody or under tribal supervision; (11) adolescents transitioning into the adult system; (12) children with IEPs; (13) medicaid eligibility outreach and assistance; (14) medicaid waiver and non-medicaid disability programs; (15) aging and long-term services department programs; (16) HIV/AIDS treatment providers; (17) individuals with special health care needs; (18) supported employment. J. The BHE shall ensure that consumers with both a developmental disability and a mental illness, including consumers with autism spectrum disorders, receive covered services in a manner that meets their unique needs and in accordance with the specific requirements of the BHE contract. K. The BHE shall comply with all applicable standards, procedure manuals, practice guidance, clinical protocols, orders or regulations issued by the collaborative or by collaborative member agencies or departments. L. The BHE shall hold subcontractors to all standards, procedure manuals, practice guidance, clinical protocols, orders or regulations issued by the collaborative or by collaborative member agencies or departments and shall monitor and assure compliance. Subcontracts of the BHE shall allow the BHE to observe or review administrative or clinical practices for contract compliance, quality management and outcomes. [7.21 .2. 10 NMAC - N, 9-1-11] 7.21.2.11 STANDARDS FOR QUALITY MANAGEMENT AND IMPROVEMENT: A. Program structure and operations: Quality management is an integrated approach that links knowledge, structure and processes together throughout a BHE’s system to assess and improve quality. The BHE’s quality management (QM) and improvement (QI) structures and processes shall be planned, systematic, clearly defined, and in full compliance with the BHE contract. The BHE shall comply with the provisions of 8.305.8.12 NMAC, regardless of the funding source of services. The BHE shall ensure that the QM/QI program is applied to the entire range of covered services and all major demographic population groups in accordance with the BHE contract. The BHE shall have an annual QM/QI work plan, prior approved by the collaborative, and as specified in its BHE contact with the collaborative. B. Continuous quality improvement/total quality management: The BHE shall base its administrative operations and service delivery on principles of continuous quality improvement/total quality management (QM/QI). Such an approach shall include at least the following: (1) recognize that opportunities for improvement are unlimited; (2) ensure that the QM/QI process shall be data driven; (3) require the continual measurement of clinical and non-clinical effectiveness and programmatic improvements of clinical and non-clinical processes driven by such measurements; (4) require the re-measurement of effectiveness and continuing development and implementation of improvements as appropriate; and (5) rely on consumer and stakeholder input. C. Prevention and coordination of care: The BHE shall institute QM/QI policies and procedures that emphasize and promote prevention and coordination across multiple providers and systems. D. Consumer/family satisfaction: The BHE shall work with the collaborative in conducting the annual adult and child/family consumer satisfaction survey based on the national mental health statistics improvement project or successor projects. If the BHE conducts any other or separate satisfaction survey, such survey, including the survey instrument and methodology, shall be prior approved by the collaborative. The BHE shall comply with requirements of 8.305.8.11 and such other requirements as the BHE contract may require. E. Clinical practice guidelines: The BHE shall disseminate recommended practice guidelines, practice parameters, consensus statements and specific criteria for the provision of services for acute and chronic behavioral health care conditions. (1) The BHE shall select the clinical issues to be addressed with clinical guidelines based on the needs of consumers. (2) The clinical practice guidelines shall be evidence-based. (3) The BHE shall comply with the provisions of 8.305.8.12 NMAC regardless of the funding source for services. The BHE shall fully comply with all specifications of the BHE contract regarding clinical practice guidelines and evidence-based practices. [7.21 .2. 11 NMAC - N, 9-1-11] 7.21.2.12 PERFORMANCE MEASURES: A. BHE shall be accountable as specified in its contract for the achievement of any performance measure targets identified by the collaborative. The BHE shall measure and track performance measures, report on such measures at intervals defined by the collaborative, and incorporate performance measures as part of its QM/QI program. Performance measures include those required by the federal government or specified by the collaborative. B. Effectiveness of the QI program: The BHE shall evaluate the overall effectiveness of its QI program and demonstrate improvements in the quality of clinical care and non-clinical service to consumers. The BHE shall conduct data-driven evaluations of clinical practices to improve quality of care. The BHE shall demonstrate how it has influenced or changed provider practice patterns. [7.21 .2. 12 NMAC - N, 9-1-11] 7.21.2.13 STANDARDS FOR UTILIZATION MANAGEMENT: The collaborative requires appropriate utilization management (UM) standards to be implemented as well as activities to be performed so that excellent services are provided in a coordinated fashion with neither over nor under-utilization. The BHE shall manage the use of resources, maximize the effectiveness of care by evaluating clinical appropriateness, and authorize the type and volume of services through fair, consistent and culturally competent decision-making processes while ensuring equitable access to care and a successful link between care and outcomes. The consumer’s service plan or treatment plan priorities, advance directives, and prolonged service authorizations for individuals with chronic conditions shall be considered in the decision-making process. A. Necessity requirement: The BHE shall comply with 8.305.8.13 NMAC regarding standards for utilization management. References to “medical necessity” in 8.305.8.13 NMAC shall be read as “clinical and psychosocial necessity” as defined in these rules. References to “member” in 8.305.8.13 NMAC shall be read as “consumer” and shall include the consumer’s family, legal guardian, and designated representative as appropriate. All requirements in 8.305.8.13 NMAC regarding providing notice to providers shall include notice to the consumer and consumer’s family, legal guardian, and designated representative as appropriate. B. Use of qualified professionals: The BHE shall ensure the involvement of representative practicing providers, consumers and family members in the development of its UM procedures. The BHE shall evaluate network provider satisfaction with the UM process as part of its annual provider satisfaction survey. C. Decisions: The BHE shall make available UM decision criteria to providers, consumers, their families, and the public. The BHE shall ensure that consumers have an optimal choice of providers consistent with their treatment needs and available providers. D. Records: The BHE shall maintain records (both hard and electronic) that verify its utilization management activities and compliance with UM requirements specified in this rule and the specific contractual requirements of the BHE contract. [7.21 .2. 13 NMAC - N, 9-1-11] 7.21.2.14 STANDARDS FOR CREDENTIALING AND RECREDENTIALING: The BHE shall have and implement policies and procedures that comply with 8.305.8.14 NMAC, as well as any other applicable credentialing or recredentialing requirements from collaborative member departments and agencies, including but not limited to any federal block grant or other collaborative practice protocols, rules or other requirements. A. Practitioner participation: The BHE shall have a process for receiving input from participating providers regarding credentialing and recredentialing of providers. B. Credentialing application: The BHE shall use a collaborative-approved application for network participation. C. Evaluation of practitioner site: The BHE shall perform an initial visit to the offices of potential high volume behavioral health care providers, as determined by the BHE with approval of the collaborative. D. Assessment of organizational providers: For organizational providers, the BHE shall confirm that the provider is in good standing with state and federal regulatory bodies and has been certified by the appropriate state certification agency, when applicable. E. Performance evaluation: The BHE shall ensure that all providers maintain the certification and training necessary to provide the services they offer. The BHE shall utilize QM/QI data in conducting provider recredentialing, recontracting or performance evaluations. F. Practices and programs: The BHE shall ensure that credentialing and recredentialing requirements shall recognize and promote approaches to services such as consumer- and family-run programs, Native American healing practices and programs, traditional curanderismo, and other legally acceptable programs. [7.21 .2. 14 NMAC - N, 9-1-11] 7.21.2.15 RIGHTS AND RESPONSIBILITIES: The BHE and the provider shall have a written policy, approved by the collaborative as required, that states their commitment to treating clients in a manner that respects their rights, respecting and recognizing the consumer’s dignity and need for privacy. This policy shall also address the BHE and the provider’s expectations with regard to clients’ responsibilities. The BHE shall comply with 8.305.12 NMAC and 8.349.2 NMAC regarding grievances and appeals, regardless of funding source. The BHE shall be required to comply with NMAC 8.305.8.15 NMAC, member (consumer) bill of rights, any other collaborative member department or agency’s rights’ statements, and all consumer rights and responsibilities provisions of the BHE contract with the collaborative. A. Consumer handbook: The BHE shall maintain a consumer handbook, prior approved by the collaborative, that includes but is not limited to information about consumer rights and responsibilities. The written information provided to consumers or clients of the BHE or provider shall be comprehensible, readable, easily understood and culturally sensitive. B. Complaints or grievances: (1) Consumers, their families or legal guardians, and designated representatives have a right and shall have the means to voice complaints or file grievances and appeals about the care provided by the BHE or provider in its network. (2) The BHE shall establish and maintain written policies and procedures for the filing of provider grievances and appeals. (3) The BHE and the provider shall have written policies and procedures for the timely resolution of client or provider complaints or grievances. (4) The BHE shall provide information specified in 42 CFR Section 438.10(g)(1) about its grievance system to all providers and subcontractors at the time they enter a contract. (5) The BHE shall provide the collaborative regular reporting of all consumer and provider grievances, appeals, and fair hearings, and such other related data and information as specified in the BHE contract. [7.21 .2. 15 NMAC - N, 9-1-11] 7.21.2.16 STANDARDS FOR CLINICAL RECORDS: A. Standards and policies: The BHE shall require clinical records to be maintained in a format and manner that is timely, legible, current, and organized, and that permits effective and confidential consumer care and quality review. The BHE shall fully comply with all medical records, data, and confidentiality requirements of the BHE contract and any relevant state and federal law. B. Confidentiality: The BHE shall have and implement clinical record confidentiality policies and procedures that implement the requirements of state and federal law and policy, this rule, and the BHE contract. These policies and procedures shall be consistent with confidentiality requirements in 45 CFR parts 160 and 164 for all medical records and any other health and enrollment information that identifies a particular consumer. Medical record contents shall be consistent with the utilization control required in 42 CFR Part 456, 42 CFR 431.305(b) and 45 CFR 164.530(c). C. Evaluation and treatment or service records: (1) To promote effective service delivery and quality review, treatment or service records shall be maintained in a manner that is current, comprehensive, detailed, organized, and legible. (2) The BHE and the provider shall ensure that consumers and family members participate in treatment or service planning, development, and implementation and maximize consumer and family recovery and resiliency. The BHE shall ensure that consumers and family members, where appropriate, are presented with opportunities to proactively engage and participate in the behavioral health service delivery system, with a focus on the family as a potential change agent where consistent with the consumer’s preferences and wishes. [7.21 .2. 16 NMAC - N, 9-1-11] 7.21.2.17 STANDARDS FOR ACCESS: A. Ensure access: The BHE shall ensure the accessibility and availability of behavioral health providers for each medically, clinically or psychosocially necessary service. The BHE shall comply with 8.305.8.18 NMAC, regardless of the funding source and shall comply with such geo-access standards as the collaborative may require. The BHE shall maintain and update its service access plan, which shall describe the BHE’s system for consumer access to services. B. Array of services: The BHE shall ensure that in each region of the state there is an array of covered services that allow consumers to be served within the least restrictive setting and in close proximity to their places of residence, with preference given to in-state providers. C. Appointment standards: The BHE shall ensure that appointment standards detailed in the BHE contract are met by the provider and shall report to the collaborative on the compliance of providers in meeting appointment standards. D. Access to transportation services: The BHE shall assist consumers in accessing existing transportation benefits and resources to provide transportation to covered services, including transportation to address a behavioral health issue during non-business hours and transportation related to an emergency. The BHE shall coordinate behavioral health transportation services with the consumer’s respective MCO, where applicable. E. Cultural competency: The BHE and provider shall provide effective services to people of all cultures, races, ethnic backgrounds, religions in a manner that respects the worth of the individual and protects the dignity of each individual regardless of the circumstances under which services are sought. (1) The BHE shall develop, implement, evaluate, and update a cultural competency plan for itself and for all network providers to ensure that consumers and their families, including individuals with disabilities, receive covered services that are culturally and linguistically appropriate to meet their needs. (2) The BHE shall ensure that providers have access to specific clinical standards, service approaches, techniques and marketing programs that match an individual’s culture to increase the quality and appropriateness of behavioral health care and outcomes. The BHE shall ensure compliance with 8.305.1.7 NMAC, regardless of funding source. [7.21 .2 .17 NMAC - N, 9-1-11] 7.21.2.18 DELEGATION: Delegation is a process whereby the BHE gives another entity the authority to perform certain functions on its behalf. The BHE shall be fully accountable for the quality of clinical care and services provided to consumers through its delivery system. The BHE may not delegate the accountability for the quality of services provided. The BHE will be responsible for the QM/QI program and not delegate this responsibility to subcontractors. The BHE shall not assign, transfer or delegate key management functions such as utilization review/utilization management or care coordination without the explicit written approval of the collaborative. The BHE shall ensure its full compliance with all delegation requirements of the BHE contract. [7.21 .2 .18 NMAC - N, 9-1-11] HISTORY OF 7.21.2 NMAC: [RESERVED]