Western Highlands Network
Friday E-Mail Newsletter
Number 102
11/09/2007
The Friday E-Mail is a weekly update for providers by the Services Management Department of Western Highlands Network. Please distribute to all your staff.
WHO Does WHAT in this SYSTEM?
We are frequently asked to clarify the functions of different mental health, developmental disability and substance abuse workers. Hopefully, this will help to clarify the tasks and MH/DD/SA health professionals assigned to these clinical functions.
PHYSICIANS, LICENSED PSYCHOLOGISTS, FAMILY NURSE PRACTITIONERS, PHYSICIAN ASSISTANTS: This group of professionals can order services for consumers. Any of these staff can sign for Medical Necessity of PCPs, or Service Orders. If you do a Diagnostic Assessment, these clinicians perform the psychiatric portion of the assessment and have to give approval of provider’s plans. The CPT code, 90801, is used for this service. This is the only code for medical providers requiring authorization. Other medical provider codes (for use by Physicians, Family Nurse Practitioners, and Physicians Assistants) can be billed without preauthorization. Both DMA and the LME continue to prefer use of Diagnostic Assessment, and this procedure should be used as Best Practice whenever possible.
LCSWs, LMFTs, LPAs, LPCs, and LCASs: These licensed professionals are responsible for assessment, making diagnoses, performing therapy functions, can be case responsible, and in some cases supervise teams of QPs, APs, PPs in the implementation of the Person Centered Plan. The CPT code, 90801, covers the assessment/diagnostic work performed by these licensed professionals. Other CPT codes which can be billed by these staff are available on the Western Highlands Network website, and include all of the therapy event codes. These staff also supervise teams of MH/DD/SA professionals, and can bill Community Support codes when appropriate.
P-LCSWs, P-LPs, Marriage and Family Therapists in Associate-Licensure status, and board-eligible professional counselors can bill H0001, H0004, H0005, and H0031 until June 30, 2008, and thereafter can only work as Qualified Professionals. They can currently practice as Qualified Professionals, but please note QPs cannot bill for these codes.
QPs: These staff are often responsible for developing the Person Centered Plan. They are case responsible, change plans to reflect changes in the needs of the consumer, and supervise teams of APs and PPs in skill building activities prescribed by the PCP. Often, the assigned Q is responsible for the case management functions of Community Support. Work in the field for QPs includes Community Support, Mobile Crisis Management, MST, ACTT, Day Treatment, PSR, SAIOP, SACOT, and other specialty substance abuse services.
APs: Associate Professionals are MH/DD/SA staff who hold college degrees and work individually with consumers. They are responsible for making notes about their individual work with consumers and work in a variety of environments. Most of their work takes place in the consumer’s domains, whether that is at home, at school or in the community. They carry out the support and skill building activities prescribed by the Person Centered Plan.
PPs: These paraprofessionals do many of the same functions as the APs. They do not have a college degree, but often have many years of experience in MH/DD/SA work. They also carry out the activities prescribed by the Person Centered Plan.
Service Providers within Developmental Disabilities
TCM T1017HI: Targeted Case Managers are responsible for developing the Person Centered Plan (PCP) or the CAP-MR/DD Plan of Care (POC). For Medicaid funded consumers, TCM is requested through Value Options (VO) using the LMEs Medicaid Provider Number. The service is then billed through the LME. For state funded consumers, TCM is requested and billed through the LME. TCM staff work for an agency that is separate from the agency that provides direct care services to the consumer. They are responsible for linking the consumer to both paid supports and natural supports within the community. They are required to monitor services provided by the direct care agency and any entity with which the consumer shares a relationship. Consumers with dual diagnoses access MH/DD/SA services through their TCM staff who are required to assist them in coordinating such services if there is a need. Staff who provide this service typically have the designation of QP. There are many ways to meet the qualifications of a QP. Qualifications for providing this service are outlined in the service definition. The definition for this service is currently under review by the Centers for Medicare and Medicaid Services (CMS). Approval has been expected anytime for the last 18 months!
Provider QPs/APs: These staff members work for the agency that provides direct care services to the consumer. There are many ways to meet the qualifications to be a QP. APs require the supervision of a QP and typically lack the required experience to be considered a QP. These staff members work with the TCM staff and the guardian and/or consumer in developing the PCP or POC. For the POC, they are responsible for developing the methodologies required to achieve the goals of the consumer. For all of their consumers, they are responsible for hiring and supervising the direct care staff. They must ensure that the hired staff meets all the requirements for providing the services specified in the PCP or POC. They must ensure that the services that their agency renders have been authorized as required by the different funding streams. They monitor the consumer’s progress towards meeting goals and notify the TCM staff if a goal is met so the consumer’s PCP or POC may be updated.
Provider PPs: These paraprofessional staff members work for the agency that provides direct care services to the consumer. They are supervised by the Provider QPs/APs. They must meet the requirements for each service that is outlined in the service definitions. Minimum requirement is a high school diploma or equivalency. They provide many of the CAP-MR/DD periodic and daily services (Home and Community Supports, Residential Supports, Day Supports, Personal Care, Respite Care) and are required to document the consumer’s progress towards planned outcomes. PPs provide state funded services such as Developmental Therapy, Personal Assistance, Personal Care, Respite Care, Family Living, Supervised Living, etc.
FOR A COMPLETE LIST OF STAFFING REQUIREMENTS, PLEASE REFER TO THE SERVICE DEFINITIONS PUBLISHED BY NORTH CAROLINA DMA. In addition, you will find links to fees and billing requirements on the Western Highlands website, under Reimbursement and Claims Procedures, under Fee Schedules.
General Perspective:
At the present time in MH/DD/SA care, North Carolina’s system works within a “Rehabilitation” model of care. This perspective centers around illness management, and assumes that most consumer’s presenting for care will work toward lessening dependence on formal or paid supports while enhancing natural and community supports during the course of treatment supports. While there are many challenges in moving from habilitation to rehabilitation, the current model is effective in empowering consumers to take charge of their lives and move forward while managing their illness issues.
NEW PHONE NUMBERS
We have initiated the use of new phone numbers:
PLEASE NOTE - All future calls to WHN by Providers should be to 1-800-671-6560. Please do not use 225-2800 as this is no longer the # for providers. If you are a provider calling Western Highlands from Buncombe County, use the local phone number 225-2785.
Please be patient with us if you call the consumer numbers. We will be unable to transfer calls for other business within the LME. You will be asked to call again, using the provider number.
Western Highlands Network
356 Biltmore Avenue
Asheville, NC 28801
Providers Call: 828-225-2785 or 1-800-671-6560
Fax: (828) 225-2779
E-Mail: ring@westernhighlands.org
Website: www.westernhighlands.org
