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Adult Mental Health Targeted Case Management (AMH-TCM)

Revised: 08-04-2016

  • Overview
  • Eligible Providers
  • Clinical Supervision
  • Eligible Recipients
  • Covered Services
  • Additional Services Requirements
  • Noncovered Services
  • Documentation
  • Billing
  • Legal References
  • Overview

    Adult Mental Health Targeted Case Management (AMH-TCM) services help adults with serious and persistent mental illness (SPMI) gain access to medical, social, educational, vocational and other necessary services connected to the person’s mental health needs. AMH-TCM services include developing a functional assessment (FA) and individual community support plan (ICSP), referring and linking the person to mental health and other services, ensuring coordination of services, and monitoring the delivery of services.

    Eligible Providers

    AMH-TCM agencies run by or under contract with a county or tribe are eligible to provide Minnesota Health Care Programs (MHCP) MH-TCM services.

    Eligible providers are case managers or case manager associates (CMA) employed by an AMH-TCM agency and meet qualifications in Minnesota Statute.

    Case managers (CM) with less than 2,000 hours of supervised service to adults with mental illness, new case management associates (CMA) and new immigrant case managers (CM working with immigrant population) must complete 40 hours of training approved by the commissioner of DHS. These case managers and associates must successfully complete the Department of Human Service’s (DHS) AMH-TCM web-based curriculum as part of the approved training. Certificates of completion must be maintained, and it is recommended they be stored in the CM’s personnel record or similar file.

    Clinical Supervision

    “Clinical supervision” means the oversight of treatment plan development, plan implementation and mental health service delivery, including that provided by the CM and CMA. Clinical supervision ensures the appropriateness of assessment and the mental health services, and provides a mechanism for CMs and CMAs to receive direction and guidance on the provision of services.

    Reimbursement from Minnesota Health Care Programs (MHCP) requires that the professional be licensed at the independent clinical level or as a tribal-credentialed mental health professional and be able to enroll in the MHCP provider system as a licensed mental health professional. Clinical supervision must be provided by a full or part-time employee or a contracted and licensed mental health professional(s).

    All CMs and CMAs except licensed mental health professionals, must receive ongoing clinical supervision at least monthly. See Minnesota statute and rule for when additional clinical supervision applies. Clinical supervision may be provided on an individual basis with the CM or CMA in small groups or be a combination of individual and group supervision. Clinical supervision may be completed via videoconferencing.

    Eligible Recipients

    Eligible recipients meet one of the following:

  • 1. Is a person with a serious and persistent mental illness (SPMI), and is determined eligible by the county mental health or tribal authority.
  • 2. Is determined by a county or tribe to appear to be eligible for case management but due to the person’s initial refusal to participate in the diagnostic assessment process, the eligibility determination can’t be completed. In these circumstances, eligibility is limited to four months from the day the person first received case management services.
  • 3. Is an adolescent who has received children’s MH-TCM services within 90 days of turning 18 years old, and upon turning 18 seeks adult MH-TCM services. Transition aged youth maintain eligibility for AMH – TCM for up to 36 months and based upon the most recent diagnostic assessment when the youth transitioned to adulthood.
  • Covered Services

    The AMH-TCM service has four core components:

  • • Assessment
  • • Planning
  • • Referral and linkage
  • • Monitoring and coordination
  • Adult Mental Health Targeted Case Management:

    Core Service Components and Process

    “Gaining access to needed medical, social, educational, vocational and other necessary services”

    DHS image

    The AMH-TCM components often overlap and may be provided concurrently. The person receiving services and the CM are constantly:

  • • Assessing the person’s needs and goals and impact of mental illness, and utilizing the person’s strengths and progress
  • • Clarifying goal-related plans and steps and updating the ICSP and thinking of new resources
  • • Referring and linking to resources, supports and services
  • • Coordinating with partners and natural supports identified by the person as being important to his or her recovery process
  • • Monitoring the effectiveness of the resources, supports and services being utilized
  • • Reviewing the need for AMH-TCM services
  • • Discussing the progress made toward goals and recovery
  • Assessment

    An AMH-TCM assessment has five parts:

  • • Review the diagnostic assessment
  • • Assess with the person receiving AMH – TCM for strengths, resources, supports, needs, functioning, health problems and conditions, safety, vulnerability and injury risk. Assessment should include family members, significant others and providers identified by the person as being important to their recovery process
  • • Screen for substance use and abuse
  • • Review documentation and updating documentation of the person’s status, cultural considerations and functional description in all the FA domains specified in Minnesota statute
  • • Complete LOCUS assessment to determine resources and resource intensity needs
  • It is important that the FA, defined in Minnesota statute, include the person’s health care coverage, access to preventative and routine health care, individual participation in recommended health care treatment, and health and wellness issues important to the person.

    The case manager must complete the FA within 30 days of the first meeting with the person and at least every 180 days after the development of the ICSP. The FA must be developed with input from the person and with the person’s service providers and significant members of the person’s support network.


    A CM must develop an ICSP with the person and include the following:

  • • Goals and the specific services
  • • Activities for accomplishing each goal
  • • Schedule for each activity
  • • Frequency of face-to-face contact with CM
  • The CM must complete an ICSP within 30 days of the first meeting with the person and at least every 180 days after the development of the ICSP. The CM must develop the ICSP with the person, other service providers and significant members of the person’s support network.

    Referral and Linkage

    Referral and linkage to AMH-TCM services involve resource acquisition to help the person obtain planned goals.

    A primary focus of referral and linkage is to break down the walls separating people from the community to replace segregation with true community integration. CMs must be familiar with the community and key contact persons within particular agencies (housing, education, vocational, financial, health care services and other providers) to assist the person.

    Referral and linkage involves interactions with the person to:

  • • Connect with informal natural supports
  • • Link with the local community, resources and service providers
  • • Refer to available health treatment and rehabilitation services
  • Monitoring and Coordination

    A significant portion of the CM’s monitoring and coordination activities are done over the phone with other providers, resources and service representatives. Monitoring and coordination serves four global purposes:

  • • Ensure service coordination by reviewing programs and services for accountability and verify that everyone is addressing the same purposes stated in the ICSP so that the person is not exposed to discontinuous or conflicting interventions and services
  • • Determine achievement of the goals and objectives in the ICSP to see if goals are being achieved according to the ICSP’s projected timeline(s) and continue to fit the person’s needs
  • • Determine service and support outcomes through ongoing observations which can trigger reconsideration of the plan and it’s recommended interventions when the ICSP is not accomplishing its desired effects
  • • Identify emergence of new needs by staying in touch with the person to identify problems, modify plans, ensure the person has resources to complete goals, and track emerging needs
  • Additional Services Requirements

    Limit on size of case manager’s caseload

    The average caseload size of a full-time equivalent CM must not exceed 30 persons on a caseload to one full time equivalency case manager. This standard applies to the average caseload size of case managers across the provider agency. This applies to AMH-TCM services provided by lead agencies (counties, tribes and managed care organizations).

    Face-to-face contact between client and case manager

    Monthly face-to-face contact between the client and the CM is the standard. Face-to-face contact of less than monthly is NOT an acceptable standard for the large majority of people receiving case management services. Although administrative rule allows for flexibility, this flexibility is to be applied in limited circumstances. For example, prior to terminating AMH-TCM services, the person receiving services and case manager might plan for less than monthly face-to-face contact to assess the person’s readiness for closure.

    Face-to-face contact of less than once per month must be supported by an evaluation of the person’s functioning and preferences, and planned in the ICSP.

    In fee-for-service, AMH-TCM (non-tribe-run provider agency) reimbursement is a monthly rate paid if at least one of the following occurs:

  • • One case management core service component (assessment, planning, referral, linkage, monitoring and coordination) is provided consistent with the ICSP in at least one face-to-face contact with the person during the month
  • • A telephone contact with the person within which at least one case management core service component is provided consistent with the ICSP, plus at least one qualifying face-to-face contact within the preceding two months
  • However, reimbursement for qualifying services should not be interpreted as the service standard for face-to-face contact frequency. Monthly face-to-face contact is the standard.

    Tribe-run provider agency reimbursement is the “daily Indian Health Services encounter rate” for that tribe for each face-to-face contact with the member during which a qualifying AMH-TCM service is provided consistent with the ICSP (within other “encounter rate” rules).

    Arrangement of standardized assessment by a physician for recipients on psychotropic medications

    The CM must arrange for a standardized assessment, by a physician of the person’s choice, of side effects related to the administration of the person’s psychotropic medications.

    Noncovered Services

    MHCP does not cover videoconferencing as a face-to-face contact for AMH-TCM services.

    AMH-TCM services are not:

  • • Treatment, therapy or rehabilitation services
  • • Other types of case management (for example: CAC, CADI, TBI, DD)
  • • Legal advocacy
  • • A diagnostic assessment
  • • Eligibility determination for AMH-TCM
  • • Medication administration
  • • Services that are integral components of another service or direct delivery of an underlying medical, educational, social or other service
  • • Transportation services
  • Documentation

    Minnesota must comply with federal regulations in order to receive Federal Financial Participation (FFP) and documentation is necessary to demonstrate compliance.

    Documentation must support the qualifying AMH-TCM services provided to an eligible recipient by a qualified provider.

    All MHCP service records must contain the following information when applicable:

  • • The record must be legible to the individual providing care
  • • The person’s name must be on each page of the record
  • • Each entry in the health service record must contain:
  • • The date on which the entry is made
  • • The date or dates on which the health service is provided
  • • The length of time spent with the person, if the amount paid for the service depends on time spent
  • • The signature and title of the person who delivered the service
  • • The progress or response to the intervention and the changes in ICSP or presentation
  • • When applicable, the co-signature of the vendor or supervisor as required
  • • Documentation of clinical supervision
  • • The record must state:
  • • Case history and health condition as determined by the vendor’s examination or assessment
  • • The results of diagnostic tests and examinations
  • • The diagnosis resulting from the examination
  • • The record must contain reports of consultations that are ordered for the person
  • • The record must contain the ICSP
  • Client file

    The client file includes information such as:

  • • Name
  • • Address
  • • Phone
  • • Email
  • • Identification numbers
  • • Natural support contacts
  • • Other mental health provider contacts
  • • Health conditions and health care coverage and providers
  • • Other significant contacts (landlord, employer, etc.)
  • • Emergency contacts
  • • Current medications
  • • Intake date
  • • Relapse prevention plans
  • • Referral materials
  • • Client rights materials
  • • Determination of SPMI
  • • Information supporting the client’s eligibility for MH-TCM
  • AMH-TCM recipient files must include additional documentation:

  • • Releases of information
  • • Diagnostic assessments
  • • FAs
  • • Mandated screenings and level of care documentation
  • • ICSPs
  • • Progress notes
  • • Entries of any assessment, planning, referral, linkage, monitoring and coordination activities with collateral contacts (such as family members, significant others, other providers of services, representatives of other community resources and the person’s natural supports). Documentation must appear in the person’s record when the client’s case, plan or situation is reviewed by the agency team or with the clinical supervisor.
  • The ICSP is the roadmap of AMH-TCM services. It is governed by federal and state regulations. At its heart, the ICSP is a straight-forward plan to help the person utilize his or her current strengths and resources, and gain access to additional services and resources to accomplish his or her goals.

    The ICSP documentation should include:

  • • A recovery vision and include the person’s voice.
  • • The development of the ICSP consistent with statute and rule.
  • • To the extent possible, the person and his or her family, advocates, service providers and significant others must be involved in all phases of development and implementation of the ICSP.
  • • The ICSP must state:
  • (1) The goals of each service
  • (2) The activities or tasks of the person, CM and others for accomplishing each goal
  • (3) A schedule for each activity or task
  • (4) The frequency of face-to-face contacts by the CM based upon assessed need and the implementation of the ICSP
  • • The ICSP should reflect the prioritization of goals, risk, vulnerability and needs identified in the assessment process.
  • • The ICSP should identify the natural supports, services, programs and resources that the person is gaining access to, who and how that access will be gained, and planned monitoring and coordination to assure the progress and value of supports, services, programs and resources.
  • • A written ICSP needs to be completed within 30 days of beginning AMH-TCM services, and a new FA completed at least every 180 days thereafter. ICSP and FA updates may be completed more often and if the person requests this.
  • • The ICSP needs to be written by a mental health professional or signed by the clinical supervisor of the CM.
  • • The person’s name, date of completion of the ICSP and signatures of the person, case manager and clinical supervisor (optional are signatures of others who participate in the development and implementation of the ICSP).
  • Note for clarification: There is contradictory language in statute and administrative rule concerning the minimum frequency which FAs and ICSPs must be completed. The administrative rule for AMH-TCM services notes that the FA and ICSP need to be reviewed and, if necessary, revised at least once every 90 calendar days after the development of the initial plan. Minnesota statute indicates “at least every 180 days”. Documentation of the revision of the FA and ICSP must occur at least every 180 calendar days as statute supersedes rule.

    Contact or Progress Notes
    Contact or progress notes should answer primary questions to ensure good communication, planning and billing support:

  • • Which of the AMH-TCM four core service components (assessment, planning, referral and linkage, monitoring and coordination) was being provided?
  • • What ICSP goals were being addressed?
  • • What was the service provided and what did the CM do?
  • • What was the person’s response to the service?
  • • What is the plan for the next contact?
  • • Any significant observation of the person’s situation or condition should also be included (situation, information or condition that is not necessarily related to planned services, but that is important or out of the ordinary (example: major news, changes in behavior). These will not be present in every contact note.
  • Often during a contact, a case manager will be providing more than one case management service component. Each service component should be documented.

    Communication with the person’s family members, support system, other providers, doctors, resource representatives, and community representatives (employer, landlord), whether initiated by the CM or not, must be documented in the person’s file.

    Documentation is necessary to demonstrate AMH–TCM service provision. When possible, concurrent documentation is recommended to promote transparency and expedite completion of documentation.

    Documenting clinical supervision
    The clinical supervisor must document the following:

  • • Complete or cosign all recipients’ FAs
  • • Complete or cosign all recipients’ level of care assessments LOCUS
  • • Complete or cosign all ICSPs
  • • “Case reviews” by the case manager with clinical supervision summarized, with signatures in the person’s file
  • • Inclusion of signatures for entries in the record regarding case review and supervisory activities
  • Clinical supervision of the CM that is not specific to person receiving services, but rather is for the benefit and professional growth of the CM or CMA must be documented in the CM’s personnel file or related file.


    MHCP allows payment for AMH-TCM as follows:

  • • Submit AMH-TCM services in the 837P format
  • • Do not enter a treating provider NPI on each service line
  • • Use procedure codes and modifiers only per table below
  • • When multiple teams provide services concurrently, each team may submit a claim
  • • MHCP covers AMH-TCM services concurrently with ACT services only for one month at time of transition from AMH-TCM to ACT services, and from ACT services to AMH-TCM
  • • When services are provided concurrently with ACT, also use modifier 99 and enter the ACT admission or discharge date in the Comments field
  • Proc







    Face-to-face contact


    Each Indian Health Service (IHS) face-to-face qualifying encounter

    Daily – within other IHS health services encounter rules



    Face-to-face contact

    County-run agency or

    County/tribe-contracted agency

    1 face-to-face session

    1 session per month of T2023 HE or HE U4 **


    HE U4

    Telephone contact, including telemedicine

    County-run agency or

    County/tribe-contracted agency

    1 telephone or telemedicine videoconference session ***

    1 session per month of T2023 HE or HE U4 *

    * A face-to-face contact is required in at least one month out of a quarter. MH-TCM claims will deny when a face-to-face contact occurs within the preceding two months prior to a change in eligibility status and the first contact under the new eligibility status is a telephone contact. Providers must resubmit the claim with case notes documenting the face-to-face contact using the AUC cover sheet.

    ** The adult rate for MH-TCM is paid for MH-TCM services (children or adult) to recipients over the age of 17 whether provided by an adult or children’s MH-TCM provider agency.

    *** Adult MH-TCM provided via videoconferencing technology is permitted and billable as comparable to a qualifying telephone call. MHCP does not cover videoconferencing as a face-to-face contact for AMH-TCM services. Direct face-to-face contact remains an important characteristic of MH-TCM services.

    Recommendation: To obtain the monthly AMH-TCM reimbursement or tribal encounter rate reimbursement, at least one of the four reimbursable core component services must be documented as having been provided consistent with the ICSP goals and plans, and during a face-to-face contact with the person (or during a qualifying phone contact with the person). Use the core component service terminology: document that you, the case manager, were assessing, planning, referring and linking, or monitoring and coordinating with the person. More detail is necessary but frame your billable services using at least one of these four service components, and directly link the service you provided to at least one of the goals identified in the ICSP.

    Legal References

    MS 245.461 to 245.468 Minnesota Comprehensive Adult Mental Health Act
    MS 245.462 subd. 4
    Case Manager Qualifications
    MS 245.462
    MS 256B.0625
    , subd. 20 Mental Health Case Management
    MS 256G
    Minnesota Unitary Residence and Financial Responsibility Act
    Minnesota Rules 9520.0900 to 9520.0926
    Case Management for Children with SED
    Minnesota Rules 9505.0322
    Mental Health Case Management Services

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