Pa. Code 5221.42

Payment

This section establishes payment and billing rules for intensive case management (ICM) services funded through county mental health allocations in Pennsylvania. It specifies conditions for 100% State financial participation, Medical Assistance billing requirements, allowable units of service (billed in 15-minute increments for direct contact), and reimbursable ICM components such as assessment, service planning, community resource linkage, and monitoring. Providers may not deny ICM to eligible adults or children solely due to ineligibility for federally reimbursed services, and non-direct activities such as staff meetings and recordkeeping are not billable.

55 Pa. Code § 5221.42 - Payment 

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(a)
 When conditions
 of this chapter are met and a county plan is approved by the Department,
 intensive case management paid from county mental health allocations is
 eligible for 100% State financial participation.

(b)
 If intensive case management is provided
 to an adult or child eligible for Medical Assistance coverage and the service
 qualifies for Federal financial participation, the provider shall bill the
 Medical Assistance Program in accordance with procedures established by the
 Department under Chapter 1101 (relating to general provisions).

(c)
 The non-Federal portion of the fee shall
 be met using the State portion of program funds as provided for under this
 chapter.

(d)
 No eligible adult or
 child may be denied needed intensive case management merely because the adult
 or child is ineligible for Federally-reimbursed services. In these
 circumstances, 100% State funds may be used to provide payment for the
 necessary service.

(e)
 Provider
 staff meetings, recordkeeping activities and other nondirect services are not
 billable as intensive case management.

(f)
 The unit of service for billing purposes
 shall be 1/4 hour of service or portion thereof in which the intensive case
 manager or intensive case manager supervisor is in face-to-face or telephone
 contact with the consumer, the consumer's family or friends, service providers
 or other essential persons for the purpose of assisting the consumer in meeting
 his needs.
(1)
 Staff time spent in necessary
 travel may be billed as units of services.

(2)
 When one or more intensive case
 management staff persons, acting together, make service contact with or for one
 or more consumers or family members, if the consumer is a child, during a
 1/4-hour period, the maximum number of units that may be billed shall equal the
 number of staff persons involved or the number of cases being served, whichever
 is smaller.

(g)
 A fee-for
 service payment methodology as established in §
 
1150.62
 (relating to payment
 levels) shall be used to reimburse intensive case management.

(h)
 The Department will participate in 100%
 of the approved expenditures for the following components of intensive case
 management provided under this chapter: 
(1)

 Assessment and understanding of the consumer's history and present life
 situation; service planning, based on the consumer's strengths and desires, to
 include activities necessary to enable the consumer to function as an integral
 part of the community.

(2)
 Informal
 support network building.

(3)
 Use
 of community resources, to include assistance to consumers or the consumers'
 parents, if the consumer is a child, in identifying, accessing and learning to
 use community resources.

(4)

 Linking with resources.

(5)

 Monitoring of service delivery.

(6)

 Aggressive and creative attempts to help the consumer gain access to resources
 and required services identified in the treatment plan.

(7)
 Life support and problem resolution, to
 include direct, active efforts to assist the consumer in gaining access to
 needed services and entitlements.

Notes

55

 Pa. Code §
 
5221.42

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