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Adult Mental Health Targeted Case Management (AMH-TCM) and Children’s Mental Health Targeted Case Management (CMH-TCM)

Revised: 08-24-2018

  • 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) and children’s mental health targeted case management (CMH-TCM) services help adults with serious and persistent mental illness (SPMI) and children with severe emotional disturbance (SED) gain access to medical, social, educational, vocational and other necessary services connected to the person’s mental health needs. Targeted case management (TCM) services include developing a functional assessment (FA) and individual community support plan (ICSP) for an adult and an individual family community support plan (IFCSP), referring and linking the person to mental health and other services, ensuring coordination of services, and monitoring the delivery of services.

    Eligible Providers

    Agencies that provide targeted case management must be an enrolled Minnesota Health Care Programs (MHCP) provider.

    Eligible service providers are case managers (CM) or case manager associates (CMA) employed by MH-TCM agencies and meet the qualifications as stated in Minnesota Statutes.

    The following case managers must complete 40 hours of training approved by the Behavioral Health Division under the authority of the commissioner:

  • • CMs with less than 2,000 hours of supervised service to adults with mental illness or children with severe emotional disturbance
  • • New CMAs
  • • New immigrant case managers (CMs working with immigrant population)
  • CMs and CMAs must successfully complete the Department of Human Service’s (DHS) MH-TCM curriculum as part of the approved training; see TrainLink for more information. 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 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. A full or part-time employee or a contracted and licensed mental health professional(s) must provide clinical supervision.

    All CMs and CMAs, except licensed mental health professionals, must receive ongoing clinical supervision at least monthly. See Minnesota statutes 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 of CMs and CMAs may be completed via videoconferencing.

    Eligible Recipients

    Adult Mental Health
    Eligible recipients must meet one of the following:

  • • Is a person with a serious and persistent mental illness (SPMI), as determined by a diagnostic assessment.
  • • 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.
  • • 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 MH – TCM for up to 36 months and based upon the most recent diagnostic assessment when the youth transitioned to adulthood.
  • Children’s Mental Health
    Children eligible to receive children’s MH-TCM services must have a severe emotional disturbance (SED) and meet one of the following criteria:

  • • The child has been admitted within the last three years or is at risk of being admitted to inpatient treatment or residential treatment for an emotional disturbance.
  • • The child is a Minnesota resident and is receiving inpatient treatment or residential treatment for an emotional disturbance through the interstate compact.
  • • The child has one of the following as determined by a mental health professional:
  • • Psychosis or clinical depression
  • • Risk of harming self or others as a result of an emotional disturbance
  • • Psychopathological symptoms as a result of being a victim of physical or sexual abuse or of psychic trauma within the past year
  • • The child, as a result of emotional disturbance, has significantly impaired home, school or community functioning that has lasted at least one year or that, in the written opinion of a mental health professional, presents substantial risk of lasting at least one year.
  • Covered Services

    MH-TCM services have four core components:

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

    Core Service Components and Process

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

    DHS image

    Components of targeted case management (CM) often overlap and may be provided concurrently. The person receiving services and 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 or IFCSP 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 MH-TCM services
  • • Discussing the progress made toward goals and recovery
  • Assessment

    Adult Mental Health
    An adult MH-TCM assessment must include:

  • • Review of the diagnostic assessment
  • • Assess with the person receiving MH – 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 statutes
  • • Complete LOCUS assessment to determine resources and resource intensity needs
  • It is important that the FA, defined in Minnesota statutes, 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.

    Children’s Mental Health
    A children’s MH-TCM assessment includes the following:

  • • Review and assess the diagnostic assessment, CASII, and SDQ as provided by the mental health professional.
  • • Complete the functional assessment (FA) by assessing, with the child and family receiving CMH – 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.
  • • Review documentation and updating documentation of the person’s status, cultural considerations and functional description in all the FA domains specified in Minnesota statutes.
  • It is important that the FA, defined in Minnesota statutes, 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 IFCSP. 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.

    Planning

    A case manager (CM) must develop an ICSP or IFCSP 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 or IFCSP within 30 days of the first meeting with the person and at least every 180 days after the development of the service plan. The CM must develop the service plan with the person, other service providers and significant members of the person’s support network.

    Referral and Linkage

    Referral and linkage to MH-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 or IFCSP so that the person is not exposed to discontinuous or conflicting interventions and services
  • • Determine achievement of the goals and objectives in the ICSP or IFCSP to see if goals are being achieved according to the ICSP or IFCSP’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 or IFCSP 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

    Adult Mental Health
    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 adult MH-TCM services provided by lead agencies (counties, tribes and managed care organizations).

    Children’s Mental Health
    The average caseload size of a full-time equivalent children’s MH-TCM CM must not exceed 15 clients 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 children’s MH-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. In fee-for-service, MH-TCM (non-tribe-run provider agency) reimbursement is a monthly rate paid if at least one of the following occurs:

  • • Adult and children’s MH-TCM: One case management core service component (assessment, planning, referral, linkage, monitoring and coordination) is provided consistent with the ICSP or IFCSP in at least one face-to-face contact with the person during the month
  • • Adult MH-TCM only: 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
  • Children’s MH-TCM is required to have face-to-face contact with the child served. Telephone contact substitutions are not allowed.

    For adult MH-TCM, interactive video may be used instead of a face-to-face contact if the client resides in a hospital, nursing facility, residential mental health facility or an intermediate care facility for persons with developmental disabilities. The use of interactive video may substitute for no more than 50 percent of the required face-to-face contacts.

    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.

    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

    MH-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 MH-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 MH-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/IFCSP 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 or IFCSP
  • Client file

    The client file must include:

  • • 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 or SED
  • • Information supporting the client’s eligibility for AMH-TCM or CMH-TCM
  • MH-TCM recipient files must include additional documentation:

  • • Releases of information
  • • Diagnostic assessments
  • • FAs
  • • Mandated screenings and level of care documentation
  • • ICSP or IFCSP
  • • 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 or IFCSP is the roadmap of MH-TCM services. It is governed by federal and state regulations. The intent of this plan is 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.

    Adult Mental Health ICSP
    The individual community support plan (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:
  • • The goals of each service
  • • The activities or tasks of the person, CM and others for accomplishing each goal
  • • A schedule for each activity or task
  • • 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 MH-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)
  • Children’s Mental Health IFCSP
    The individual family community support plan (IFCSP) is a written plan of action developed by a case manager in conjunction with the family and child and based on diagnostic and functional assessments. The IFCSP identifies specific services needed by the child and the child’s family, to do the following:

  • • Treat the symptoms and dysfunctions determined in the diagnostic assessment
  • • Relieve conditions leading to emotional disturbance and improve the personal well-being of the child
  • • Improve family functioning
  • • Enhance daily living skills
  • • Improve functioning in education and recreation settings
  • • Improve interpersonal and family relationships
  • • Enhance vocational development
  • • Assist in obtaining transportation, housing, health services and employment
  • • State goals and expected outcomes of each service and criteria for evaluating the effectiveness and appropriateness of the services
  • • Activities for accomplishing each goal
  • • Schedule for each activity
  • • Frequency of face-to-face contacts by the case manager, as appropriate to recipients need and the implementation of the IFCSP
  • Note for clarification: There is contradictory language in statute and administrative rule concerning the minimum frequency which FAs and ICSP or IFCSPs must be completed. The administrative rule for MH-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 or IFCSP must occur at least every 180 calendar days as statute supersedes rule.

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

  • • Which of the MH-TCM four core service components (assessment, planning, referral and linkage, monitoring and coordination) was being provided?
  • • What ICSP or IFCSP 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. Document each service component.

    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 MH-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 (adult MH-TCM only)
  • • Complete or cosign all ICSPs or IFCSPs
  • • “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.

    Billing

    MHCP allows payment for MH-TCM follows:

  • • Submit claims for MH-TCM 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
  • • Counties and county-contracted vendors, bill one claim per month
  • • Tribes and FQHCs, bill one claim per encounter. Enter the date of service
  • To obtain the monthly MH-TCM reimbursement or tribal encounter rate reimbursement, providers must document at least one of the four reimbursable core component services as having been provided consistent with the ICSP or IFCSP 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 the case manager assessed, planned, referred and linked, or monitored and coordinated with the person. More detail is necessary but it is important to frame the billable services using at least one of these four service components, and directly link the service provided to at least one of the goals identified in the ICSP or IFCSP.

    Follow these billing guidelines:

  • AMH-TCM and ACT: MHCP will reimburse MH-TCM and ACT provided concurrently only during the month of admission to or discharge from ACT services. To receive MH-TCM reimbursement for the month of admission, the county, tribe, or county vendor must add modifier 99 to the line item and enter the ACT admission date in the “comments” field.
  • AMH-TCM and RSC: Relocation service coordination (RSC) is a case management service available to recipients in a facility (inpatient hospital). RSC and MH-TCM cannot be provided in the same month to the same recipient. Counties may elect to provide only one of these services.
  • AMH-TCM and Telehealth: Providers must complete and submit the Provider Assurance Statement for Telemedicine (DHS-6806) to MHCP Provider Eligibility and Compliance prior to submitting claims for telehealth. Submit claims for TCM telehealth services in MN-ITS using the place of service (POS) 02 “Telemedicine.”
  • MH-TCM and IMD: MHCP reimbursement for MH-TCM may be available for individuals covered by major program IM.
  • MH-TCM and Diagnostic Assessment: Presumptive Eligibility - MH-TCM is available to recipients before a diagnostic assessment is completed when all of the following conditions are met:
  • • The recipient is referred for and accepts case management services
  • • At the time of referral, the recipient refuses to obtain a diagnostic assessment for reasons related to his or her mental illness or a child's parent refuses to obtain a diagnostic assessment for the child
  • The case manager determines the recipient is eligible for MH-TCM services
  • • The recipient obtains a new or updated diagnostic assessment, resulting in SED or SPMI, within four months of the first day MH-TCM services began
  • Adult and Children’s Mental Health Targeted Case Management Benefits

    Procedure Code

    Modifier

    Brief Description

    Service Limitations and Notes

    T2023

    HE HA

    Face-to-face contact between case manager and recipient under age 18 years

    1 session per month

    HE

    Face-to-face or ITV contact between case manager and recipient age 18 years or older

    HE U4

    Telephone contact (recipient age 18 years or older)

    T1017
    For Indian Health Service/638 and FQHC billing only

    HE HA

    Face-to-face encounter (child under 18)

    1 encounter per day

    HE

    Face-to-face encounter (adult 18 and over)

    Legal References

    MN Statutes 245.461 to 245.468 Minnesota Comprehensive Adult Mental Health Act
    MN Statutes 245.462 subd. 4
    Adult Case Manager Qualifications
    MN Stats. 245.4871, subd. 4
    Children’s Case Manager Qualifications
    MN Statutes 245.462
    Definitions
    MN Statutes 256B.0625
    , subd. 20 Mental Health Case Management
    MN Statutes 256G
    Minnesota Unitary Residence and Financial Responsibility Act
    MN Statutes 245.487 to 245.4887
    MS 245.487 to 245.4887 Minnesota Comprehensive Children’s Mental Health 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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    © 2018 Minnesota Department of Human Services Updated: 8/24/18 7:40 AM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 8/24/18 7:40 AM