Section 65 Behavioral Health Services
Q: What are the covered Behavioral Health Services for which Maine School districts can seek Medicaid reimbursement?
A: Neurobehavioral Status Exam, Neuropsychological Testing, Psychological Testing, and Children’s Behavioral Health Day Treatment.
Q: Prior to the commencement of any of these covered Behavioral Health Services, will schools need to notify DHHS of the initiation of services for Utilization Review Purposes?
Q: What does “medically necessary” mean?
A: Reasonably necessary and remedial services that are provided in an appropriate setting; recognized as standard medical care based on national standards for best practices and safe, effective, quality care; required for the diagnosis, prevention and/or treatment of illness, disability, infirmity, or impairment, and which are necessary to improve, restore, or maintain health and well-being; are MaineCare covered services; performed by enrolled providers within their scope of licensure and/or certification and are provided within the regulations of the Maine Care Benefits Manual .
Q: What is a “Comprehensive Assessment?”
A: An integrated evaluation of a child’s medical and psycho-social needs, including co-occurring mental health and substance abuse needs to determine the need for treatment and/or referral and to establish the appropriate intensity and level of care.
Q: What is an “Individualized Treatment Plan” (ITP)?
A: A plan of rehabilitative care based on a Comprehensive Assessment developed by a clinician.
Q: Who is considered a “Clinician?”
A: A person appropriately licensed, practicing within scope of practice, in the following areas: LCPC, LCPC-conditional, LCSW, LMSW-conditional clinical, LMFT, LMFT-conditional, LADC, CADC, physician, psychiatrist, APRN-PMH-NP, APRN-PMH-CNS, psychological examiner, physician’s assistant, RN, or licensed clinical psychologist.
Q: Does a Comprehensive Assessment need to be conducted to develop all ITPs?
Q: Must covered services provided by a school be ordered in an ITP?
A: Yes, except for Neurobehavioral Status Exam, Neuropsychological Testing, and Psychological Testing. We do believe, however, that these Exams and Testing should be ordered in the child’s IEP.
Q: How often does a Comprehensive Assessment need to be updated?
A: When there is a change in level of care, when major life events occur, and annually.
Q: What must be documented in the Comprehensive Assessment?
- The integration of co-occurring mental health and substance abuse issues within 30 days of the day the child begins services;
- Must include a direct encounter with the child and if appropriate, family members, parents, friends, and guardian;
- Must be updated at a minimum when there is a change in level of care, when a major life event occurs, and annually;
- Child’s current status, history, strengths, and needs in the following domains: personal, family, social, emotional, psychiatric, psychological, medical, drug and alcohol (including screening for co-occurring services), legal, housing, financial, vocational, educational, leisure/recreation, potential need for crisis intervention, physical/sexual and emotional abuse;
- May also contain documentation of developmental history and sources of support that may assist the child;
- For a child with substance abuse, the documentation must also contain age of onset of alcohol and drug use, duration, patterns and consequences of use, family usage, types and response to previous treatment.
- Must be summarized and include a diagnosis using DSM axes or the DC 0-3. The assessment must include the signature, credentials, and date by the clinician conducting the assessment. If the child has a substance abuse diagnosis, the assessment must contain ASAM level of care criteria. If the assessment is for a child receiving integrated treatment for co-occurring disorders, it must contain both the DSM and ASAM criteria;
- If a provisional diagnosis is made by a MHRT or CADC providing the direct service, the diagnosis will be reviewed within 5 working days by the supervising licensed clinician and documented in the record.
Q: What are “co-occurring” mental health and substance abuse disorders?
A: Any combination of a mental health and substance abuse diagnosis.
Q: What is the “DSM?”
A: Diagnostic and Statistical Manual of Mental Health Disorders, published by the American Psychiatric Association. It is used to classify mental health diagnoses and provide standard categories for definition of mental health disorders grouped in five axes.
Q: What is the “DC 0-3?”
A: The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, which formulates categories for the classification of mental health and developmental disorders manifested early in life. It is published by “Zero To Three: National Center for Infants, Toddlers and Families.”
Q: What must be documented in an ITP?
- The clinician, child and other service providers, parents or guardian must develop an ITP based on the Comprehensive Assessment, within 30 days of the start of services.
- The child’s diagnosis and reason for receiving the service;
- Measurable long-term goals with target dates for achieving the goals;
- Measurable short-term goals with target dates for achieving the goals with objectives that allow for measurement of progress;
- Specific services to be provided with amount, frequency, duration, practice methods of services, and designation of who will provide the service, including documentation of co-occurring services and natural supports, when applicable;
- Measurable discharge criteria;
- Special accommodations needed to address physical or other handicaps to provide the service; and
- The signature, date, and credentials (if applicable) of all who developed the ITP
- Documentation of review of the ITP. The ITP must be reviewed every 90 days, or more frequently if clinically indicated. All who developed the ITP must sign the review documentation. This would mean that the parent or guardian must review and sign the ITP at least every 90 days, along with other members of the ITP development “team.”
Q: Do Schools have to include a “Crisis Safety Plan” in the ITP for Children’s Behavioral Health Day Treatment Services?
A: Historically, we have answered “No” to this question. A Crisis/Safety Plan is required only where indicated by the Covered Service. The only Covered Service that requires a Crisis/Safety Plan is Children’s Home and Community Based Treatment, which is not a Covered Service for which a school can seek Medicaid reimbursement. However, DHHS published a School Based Audit Checklist for Section 65 and Section 28 in October of 2013, indicating that students receiving CBHDT services must have a Crisis Safety Plan.
Q: What documentation must be retained for all covered services?
A: Progress notes that contain the following:
- Description of service provided;
- Provider’s signature and credentials;
- Date of service;
- Duration of service;
- The progress the child is making toward attaining the goals or outcomes identified in the ITP;
- For in-home services, the time the provider arrived and left as well as a “sign off” by an adult responsible for the child on a time slip or other documentation that shows the date, time of arrival, and time of departure of the provider.
- For crisis services, the note must describe the intervention, the nature of the problem, and how the goal of stabilization will be attempted.
- In the case of co-therapists providing group psychotherapy, the provider who bills for services is responsible for maintaining the records and signing the entries for the child. 
- Separate clinical records must be maintained for all children receiving group psychotherapy services. The records must not identify any other child or confidential information of another member. Documentation must also specifically include written information on reports of all medication reviews, medical consultations, psychometric testing and collateral contacts made on behalf of the child, including the name of the person contacted and the relationship to the child. In addition, while not specifically indicated in the policy, trainings held by DHHS state-wide have indicated that some sort of narrative that describes the services being provided is also required.
tempted. services, the note must describe the intervention, the nature of the problem, and how goal of stabilization will be a
Q: Does a school need to maintain a Discharge/Closing Summary?
A: Yes. A closing summary shall be signed, credentialed, dated and included in the clinical record at the time of discharge. This must include a summary of the treatment, which includes any after care or support services recommended. It must also include the outcome in relation to the ITP.
Q: Must schools conduct “Quality Assurance” to assure quality and appropriateness of care in accordance with QA protocols established by DHHS?
A: Yes. Reviews must be in writing, signed and dated by the reviewers and included in the child’s file or in a separate and distinct file parallel to the child’s record.
Q: Do ICD-10 diagnostic codes need to be utilized and documented?
Neurobehavioral Status Exam, Psychological Testing, and Neuropsychological Testing
Q: What are Neurobehavioral Status Exam and Psychological Testing?
A: Clinical assessment of thinking, reasoning and judgment, meeting face-to-face with the child, time interpreting test results and preparing the report of test results, and testing for diagnostic purposes to determine the level of intellectual function, personality characteristics, and psychopathology through the use of standardized test instruments or projective tests. 
Q: What does Psychological Testing include?
A: The administration of the test, the interpretation of the test, and the preparation of the test reports. Reimbursement, however, is limited to testing administered at such intervals indicated by the testing instrument and as clinically indicated. Providers must also maintain documentation that clearly supports the hours billed for administration and associated paperwork.  More specifically, a Psychological Examiner cannot bill for interpretation of the test and preparation of report, but is limited to billing for face-to-face time with the child.
Q: What does Neuropsychological Testing include (e.g. Halstead-Reitan Neuropsychological Battery Wechsler Memory Scales and Wisconsin Card Sorting)?
A: When performed by a Psychologist or Physician, Neuropsychological Testing services includes both face-to-face time administering tests to the child and time interpreting these test results and preparing the report. In addition to the administration, scoring, interpretation and report writing, this covered service also allows reimbursement for additional time necessary to integrate other sources of clinical data, including previously completed and reported technician and computer administered tests. When provided by a Psychological Examiner, Neuropsychological Testing services include interpretation and report preparation. The test is administered by a Psychological Examiner (i.e. technician) and includes any reportable amount of time the technician spent with the child to assist the child with completing the assessment.
Q: Do a Neurobehavioral Status Exam, Neuropsychological Testing, and Psychological Testing require prior authorization, a Comprehensive Assessment, or Treatment Plan?
A: No. If the services are provided in a school, however, the need for the evaluation must be documented in the child’s prior written notice and maintained in the child’s file. It should also be noted that when a school district submits a claim for Neurobehavioral Status Exam, Neuropsychological Testing, or Psychological Testing, a TM modifier is attached to the procedure code, denoting that the service was delivered pursuant to an IEP. As such, the documentation of the need of the Exam or Testing should be ordered in the child’s IEP.
Q: What are some limits on Psychological Testing?
A: Reimbursement for testing is limited to no more than 4 hours for each test except for the following tests:
- For each Halstead-Reitan Battery or any other comparable neuropsychological battery is limited to 7 hours, including testing and assessment. This test is limited to when there is a question of a neuropsychological and cognitive deficit.
- Testing for intellectual level is limited to 2 hours per test.
- Each self-administered test is limited to 30 minutes.
Q: What tests are “self-administered?”
- Achenbach Child Behavior Checklist
- Adult Adolescent Parenting Inventory
- Child Abuse Potential Survey
- Connor’s Rating Scales
- Parenting Stress Index
- Piers-Harris Self Concept Scale
- Reynolds Children’s Depression Scale
- Rotter Incomplete Sentences Blank
- Shipley Institutes of Living Scale
- Fundamental Interpersonal Relations Orientation Scale-Behavior (FIROB)
Q: Who can deliver a Neurobehavioral Status Exam?
A: A Physician and Licensed Clinical Psychologist. A LCPC or Psychological Examiner cannot bill MaineCare for Neurobehavioral Status Exams.
Q: Who can deliver Neuropsychological Testing?
A: Licensed Clinical Psychologist, Physician, Psychological Examiner, Psychiatrist and NTA/Psychometrician.
Children’s Behavioral Health Day Treatment
Q: What is Children’s Behavioral Health Day Treatment?
A: Structured therapeutic services designed to improve a child’s functioning in daily living and community living. The services may include a mixture of individual, group, and activities therapy and include therapeutic treatment oriented toward developing a child’s emotional and physical capability in the area of interpersonal functioning. The services may include behavioral strategies and interventions. 
Q: Must the child’s “family” be involved in treatment planning and provision?
Q: How is “family” defined?
A: Primary caregiver in the child’s life and may include a biological or adoptive parent, foster parent, legal guardian or designee, sibling, stepparent, stepbrother or stepsister, brother-in-law, sister-in-law, grandparent, spouse of grandparent or grandchild, a person who provides kinship care, or any person sharing a common abode as part of a single family unit.
Q: What is “kinship care?”
A: The full-time care, nurturing, and protection of a child by relative, members of their tribes or clans, godparents, stepparents, or any adult who has a kinship bond with a child.
Q: Who is “qualified” to determine medical necessity, develop the ITP and refer a child for Children’s Behavioral Health Day Treatment Services?
A: Licensed Clinical Psychologists, LCSWs, LMSWs-condition clinical, LCPCs, or LMFTs.
Q: Who is qualified to provide Children’s Behavioral Health Day Treatment Services?
A: Psychiatrists, Licensed Clinical Psychologists, LCSWs, LMSWs-conditional clinical, LCPCs, LMFTs, and BHPs. BHPs must also have completed 90 documented college credit hours or Continuing Education Units.
- What are the “prescribed time frames” for obtaining the BHP certification?
A: The BHP training must begin within 30 days of date of hire. The training must be completed and certification obtained within 1 year from the date of hire.
Q: What if a provisional BHP candidate does not complete and obtain her BHP certification within one year of the date of hire?
A: All services beyond one year from the date of hire are not reimbursable. Once the BHP training is completed and the BHP certification is obtained, claims may be submitted pursuant to the effective date of the BHP certification. There are no current continuing education requirements for BHPs once BHP certification is obtained.
Q: What must be documented to support the medically necessary referral of a child for Children’s Behavioral Health Day Treatment Services?
- The child must be referred by Qualified Staff. The child must need treatment that is more intensive and frequent than Outpatient Services but less intense than hospitalization.  It would appear, therefore, that before a school could bill Medicaid for Children’s Behavioral Health Day Treatment Services, the school would need to analyze whether or not the child would be eligible for Section 65 Outpatient Services.
- Within 30 days of the start of services, the child must have received a multi-axial evaluation and must have been diagnosed either with an Axis I or Axis II behavioral health diagnosis based on the most recent DSM or with an Axis I diagnosis based on the DC 0-3; and
- Based on an evaluation using the Battelle, Bayley, Vineland, or other tools approved by DHHS as well as other clinical assessment information obtained from the child and family, have a significant functional impairment (defined as a substantial interference with or limitation of a child’s achievement or maintenance of one or more developmentally appropriate social, behavioral, cognitive, or adaptive skills); or
- Have a completed evaluation establishing that the child has 2 standard deviations below the mean in one domain of development or 1.5 standard deviations below the mean in at least two areas of development on the Battelle, Bayley, Vineland, or other tools approved by DHHS; and
- Receipt of other clinical assessment information obtained from the child and the child’s family.
- A new functional assessment is required, when appropriate, within the clinical standard of care. The regulations do not provide specific guidelines regarding re-evaluations. Other guidance from APS, now KEPRO, however, has indicated that the functional assessment cannot be more than 2 years old.
Q: What are the limits on Medicaid reimbursement for Children’s Behavioral Health Day Treatment Services?
A: 6 hours per day, Monday through Friday, up to 5 days per week.
Q: Must Children’s Behavioral Health Day Treatment Services be delivered in conjunction with an educational program?
A: Yes. The educational program must be approved by the Maine Department of Education as either a Special Purpose Private school or a Regular Education Public School. The services may be provided in conjunction with a residential treatment program.
 §65.02-26, §1.02-4.E.
 §65.09-3.B.1.; §65.09-3
 §65.09-3.B.2.g., §65.09-3.B.1.
 §65.09-3; §65.09-3.B.9.
 §65.09-3.C. In addition, the FAQs for the Sections 65 and 28 Audit Checklist published by DHHS in October of 2013, indicates the service provider must address every requirement in the record even if these items are not applicable.
 §65.13.E. While the policy still indicates ICD-9, practically, claims will not be processed and paid unless an ICD-10 code is submitted with the claim.
 It would appear from the Chapter III procedure codes that only a Licensed Clinical Psychologist or Physician can bill for report writing time. A Psychological Examiner may only bill for “face to face” time with a child. (Procedure code 96102)
 E-mail from Patricia Dushuttle of DHHS to MSB on February 12, 2011
 Appendix I to Section 65, §65.06-7
51 §65.06-13.B., §65.02-11
 Id. Appendix I to Section 65
 Id. §65.02-14
 E-mail from Nicholas Graham of BHSI to MSB on September 26, 2011
 Other tools approved by DHHS are the CALOCUS and the CAFUS, but NOT the BASC- E-mail from Ginger Roberts-Scott of DHHS to MSB on February 18, 2011. The ABAS is a DHHS approved tool pursuant to Suzanne Boras of DHHS in an e-mail to RSU 10 on or about May 23, 2012. The Achenbach System of Empirically Based Assessment for Ages 1-18 is a DHHS approved tool pursuant to Douglas Patrick of DHHS in an e-mail to RSU 10 on or about May 17, 2011.
 Email from Amy Dix to MSB on February 1, 2013.