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

Revised: September 17, 2025

· Overview

· Eligible Providers

· Clinical Supervision

· Eligible Members

· 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) are services provided to individuals on medical assistance. The people served must be adults with a serious and persistent mental illness (SPMI) or children with a serious mental illness (SMI). Mental health targeted case managers work with the people they serve to assess and address the profound effects of housing instability, food insecurity, and other social determinants of health. Using a person-centered approach with the person served, the case manager assesses, plans, refers, coordinates and assists the person in gaining access to services including, but not exclusive, to:

· mental health services

· social services

· educational services

· health services

· vocational services

· recreational services

· volunteering, advocacy, transportation, legal, and so on

Eligible Providers

Agencies providing mental health targeted case management must be enrolled with Minnesota Health Care Programs (MHCP). Eligible service providers are case managers or case manager associates (CMAs) employed by MH-TCM agencies. MH-TCM refers to both adult and children’s mental health targeted case management throughout this manual section.

AMH-TCM case managers, CMAs, and immigrant case managers must meet the requirements outlined in Minnesota Statutes, 245.462, subdivision 4.

CMH-TCM case managers, CMAs, and immigrant case managers must meet the requirements outlined in Minnesota Statutes, 245.4871, subdivision 4.

AMH-TCM case managers or CMH-TCM case managers with less than 2,000 hours of supervised experience delivering mental health services to adults with mental illness or children with serious mental illness must:

· Complete the Minnesota Department of Human Services (DHS) 40-hour commissioner-approved Rule 79 training curriculum. Refer to the Mental Health Targeted Case Management Trainings webpage for more information, including registration.

· Receive clinical supervision regarding individual service delivery from a mental health professional (MHP) until the requirement of 2,000 hours of experience is met.

An AMH-TCM case manager or CMH-TCM case manager with at least 2,000 hours of supervised experience in the delivery of services to adults with mental illness or children with serious mental illness must receive regular ongoing supervision and clinical supervision, totaling 38 hours per year. The case manager must meet with the clinical supervisor at least one time per month to discuss individual service delivery. The remaining 26 hours of supervision may be provided by a case manager with two years of experience. Group supervision may not constitute more than one-half of the required supervision hours. Clinical supervision must be documented in the client record.

An adult or children’s MH-TCM who is not licensed, registered, or certified by a health-related licensing board must receive 30 hours of continuing education and training in mental illness and mental health services every two years.

Clinical Supervision

Clinical supervision must be provided by a mental health professional (MHP). MHP qualifications are contained within Minnesota Statutes, 245I.04, subdivision 2.

“Clinical supervision” means the oversight responsibility for individual treatment plans and individual mental health service delivery, including oversight provided by the case manager. Clinical supervision must be provided by a mental health professional.

Clinical supervision must be provided by a full or part-time employee or a contracted and licensed mental health professional. The professional must 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.

Following the clinical supervision meeting, the clinical supervisor must document the meeting and cosign the AMH-TCM individual community support plans (ICSP). It is best practice for the clinical supervisor to sign the CMH-TCM individual family community support plans (IFCSP). The clinical supervisor and case manager will enter the plan and a record of the clinical supervision in the file of the person served.

Eligible Members

Eligible MHCP members must be an adult with a SPMI or a child with SMI as determined by a MHP within a diagnostic assessment (DA).

Initial eligibility is based on a DA that has been completed within the previous 180 days. A DA must be completed every 36 months to determine member’s continued eligibility for case management services.

Presumptive eligibility: All of the following conditions must be met.

· The person served must request case management services

· The adult who has a mental illness, child who has a serious mental illness or parent of the child must refuse to obtain a DA to receive case management services via presumptive eligibility.

· The case manager determines the person is eligible for case management services

· Person receives new or updated DA within four months of the day the person first receives case management services

· Presumptive eligibility is limited to four months from the day the person first received case management services. Billing begins at the date the MHP signs the DA.

Adults and youth eligible to receive MH-TCM services must have a serious and persistent mental illness (SPMI) or a serious mental illness (SMI) to receive targeted case management services. SPMI criteria is outlined in Minnesota Statutes, 245.462, subdivision 20. (SMI) criteria is outlined in Minnesota Statutes, 245.4871, subdivision 6.

Covered Services

Adult and Children’s Mental Health targeted case management (AMH-TCM and CMH-TCM) have four core billable case management activities:

· Assessment – development of a functional assessment (FA)

· Planning – completion of an individual community support plan (ICSP) for an adult or an individual family community support plan (IFCSP) for a child

· Referral and linkage to mental health and other services

· Coordinating and monitoring service delivery

Assessment

AMH-TCM and CMH-TCM case managers complete a Functional Assessment with the person served and their supports. The purpose and intent of a functional assessment (FA) is to clearly describe in a narrative the person’s current status in each of the 11 elements listed under Elements of a narrative assessment, the person’s current functioning within that domain, and making the link to the individual’s mental illness. The case manager shall only describe the person’s current status. It is important the person and their supports have an active voice and are allowed to express their impressions of the current situation as this document is developed. The person should be encouraged to state their vision of the needs and priorities. This document will serve as a resource when completing the ICSP or the IFCSP.

The FA must include the person’s:

· Health care coverage

· Access to preventative and routine health care

· Individual participation in recommended physical and mental health care treatment; and

· Important wellness issues

The MH-TCM case manager shall review the DA before completing the FA with the person served. 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 or ICSP.

Elements of a narrative assessment
The AMH and CMH TCM case manager’s FA must be a narrative assessment of the person’s:

· mental health symptoms as presented in the diagnostic assessment;

· mental health needs as presented in the diagnostic assessment;

· use of drugs and alcohol;

· vocational and educational functioning;

· social functioning, including the use of leisure time;

· interpersonal functioning, including relationships with the person’s family;

· self-care and independent living capacity;

· medical and dental health;

· financial assistance needs;

· housing and transportation needs; and

· other needs and problems.

Planning

The AMH-TCM case manager will complete the Individual Community Support Plan (ICSP) with the adult who has a SPMI or their legal representative. The CMH-TCM case manager will complete the Individual Family Community Support Plan (IFCSP) with a child with a SMI or their family or legal guardian. The case manager 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 case manager will write the ICSP or IFCSP based on the DA, the FA, and the interview with the person served and their parents, guardians, or legal representatives. The plan will target the development of resilience, independence or improved functioning within the person’s home and community.

The person served, their supports and the case manager will identify goals and services to address the person’s mental health condition. The plan outlines the necessary services the person needs to:

· treat the symptoms and dysfunctions determined in the diagnostic assessment;

· relieve conditions leading to a mental illness 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; and

· assist in obtaining transportation, housing, health services, and employment.

Referral and linkage to mental health or other services

The MH-TCM case manager will refer and link the person to services that will help the individual in reaching the goals they have identified. Case managers must be familiar with the community and key contacts within particular agencies (for example, housing, education, vocational, financial, health care services and the like). The case manager shall ensure the person has access to providers and informal supports that meet their racial, ethnic and cultural preferences and needs. Services should be as close in proximity to the family home as possible. Referral and linkage connects the person with:

· informal natural supports

· local community, resources and service providers

· available mental health treatment and rehabilitation services

Coordinating and monitoring service delivery

The case manager will meet with the person served regularly to monitor and coordinate the person’s progress in meeting their goals, addressing any concerns they may have about their goals and services, modifying the service plan in a person-centered and equity-based lens. The case manager will:

· Ensure service coordination by reviewing programs and services

· Verify that the services adequately address goals stated in the ICSP or IFCSP

· Indicate service activity and documentation supports the goals and objectives are met within realistic timelines and continue to fit the person’s needs

· Assess and reassess if the services match and are appropriate in supporting the person in meeting the goals

· Reconsideration of the services and plan of interventions when the ICSP or IFCSP is not accomplishing its desired effect

· Identify emerging 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

Interactive Video (ITV)

Interactive video means the delivery of targeted case management services in real time through the use of two-way interactive audio and visual communication, or accessible video-based platforms.

MH-TCM services may be provided through ITV according to Minnesota Statutes, 256B.0625, subdivision 20b. ITV or face-to-face contact meets the minimum face-to-face contact requirements for MH-TCM services with the exception of children in out-of-home placement who require an in-person or face-to-face visit only.

Children and youth in foster care for whom a responsible social service agency has placement and care responsibility, must be seen in person to claim targeted case management. Foster care is defined by Minnesota Statutes, 260C.007, subdivision 18 and 260D.02, subdivision 10.

Providers must have a Targeted Case Management Provider Interactive Video Assurance Statement (DHS-8398) (PDF) on their provider file to provide services via ITV.

Additional Services Requirements

Face-to-Face Contact between Client and Case Manager

AMH-TCM or CMH-TCM case managers must have monthly contact to claim reimbursement. The case manager must ensure at least one case management core service component is provided.

CMH-TCM case managers can only have face-to-face or ITV contact with the eligible child, their parent or the child’s legal representative to receive payment. It is best practice to see the child every month. Children who are in foster care must be seen in person. The frequency of face-to-face or ITV contacts with the child must be appropriate to the client need and the implementation of the individual family community support plan. A monthly face-to-face continues to be required when the youth is in out-of-home placement.

AMH-TCM case managers may meet with the member or member’s legal representative via face-to-face or ITV. The county and contracted AMH-TCM providers may have contact with the member by telephone. Telephone contact may occur for up to two months before ITV or face-to-face contact must be made. It is best practice to see the person every month.

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 (DA)

· 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

The case record must contain a written description of each encounter of MH-TCM services provided to each individual client. This description must include the following:

· Client name

· Date of service

· Name and relationship of the contacted person to the client (unless the relationship information is included elsewhere in the file)

· Nature and extent of service being provided

· Name and professional title of the person providing the services

· Type of contact (face to face or telephone)

· Location of contact

Contact or progress notes
MH-TCM billing is based on the performance of one of the case management activities (assessment, planning, referral and linkage, monitoring and coordination). The case manager should indicate which activity was completed within the case note. Contact or progress notes should answer the following primary questions to ensure good communication, planning and billing support:

· Which of the four MH-TCM core service components (assessment, planning, referral and linkage, coordinating and monitoring) was being provided?

· What ICSP or IFCSP goals were being addressed?

· What was the service provided and what did the case manager 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: life changes, changes in behavior)]. These will not be present in every contact note.

A case manager will often provide more than one case management service component during a contact. 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 case manager (CM) or not, must be documented in the person’s file.

Documentation is necessary to demonstrate MH-TCM service provision. When possible, use concurrent documentation to promote transparency and expedite the completion of documentation.

Billing

MHCP allows payment for MH-TCM as follows:

· Submit claims for MH-TCM using the MN–ITS 837P format

· Do not enter a treating provider NPI on each service line

· Use procedure codes and modifiers only as shown in the Adult and Children’s Mental Health Targeted Case Management Benefits table

· When multiple teams provide services concurrently, each team may submit a claim

· Counties and county-contracted vendors, bill one claim per month

· Indian Health Service/638 ‒ bill one claim per encounter. Enter the date of service

Providers must document at least one of the four reimbursable core services to obtain the monthly MH-TCM reimbursement or tribal encounter rate reimbursement. The services must be consistent with the ICSP or IFCSP goals and plans. The AMH or CMH case manager must document service delivery during an ITV or face-to-face contact with the person served. The county and contract AMH-TCM providers may have contact with the member by telephone. Encounter rates require in person or both video and audio for payment. 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 Assertive Community Treatment (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 Relocation service coordination (RSC): RSC is a case management service available to members in a facility (inpatient hospital). RSC and MH-TCM cannot be provided in the same month to the same member. Counties may elect to provide only one of these services.

· MH-TCM and IMD: MHCP reimbursement for MH-TCM may be available for individuals covered by major program IM.

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 or ITV contact between case manager, the child, the child’s parent or the child’s legal representative.	1 session per month
	HE	Face-to-face or ITV contact between case manager and member 18 years old or older or the member’s legal representative, if applicable
	HE U4	Telephone contact only. Place of service 10 not required (member 18 years old or older)
T1017 For Indian Health Services/638	HE HA	Face-to-face or ITV encounter between the case manager, the child, the child’s parent or the child’s legal representative (child younger than 18 years old)	1 encounter per day
	HE	Face-to-face or ITV encounter (adult 18 years old and older)

County-contracted vendors that have a DHS-approved rate exception must also include the following modifiers as appropriate to the vendor’s rate exception:

· UA – low intensity (caseload size rate exception for a higher average caseload size)

· TG – high intensity (caseload size rate exception for a lower average caseload size)

· UB – culturally specific rate exception

Interactive Video (ITV)

Providers must have a Targeted Case Management Provider Interactive Video Assurance Statement (DHS-8398) (PDF) on their provider file to bill claims for services provided via ITV. Services provided via ITV have the same service thresholds, reimbursement rates and authorization requirements as services delivered in-person. When services have been delivered via ITV, the appropriate place of service must be provided.

· Place of service 02: ITV contact provided other than the client’s home. The client is not located in their home when receiving MH-TCM service through ITV.

· Place of service 10: ITV contact provided in the client’s home. The client is located in their home when receiving MH-TCM service through ITV.

MHCP does not reimburse for connection charges, or origination, set-up or site fees.

Legal References

Minnesota Statutes, 245I.10, Assessment and Treatment Planning
Minnesota Statutes, 245.461 to 245.468, Minnesota Comprehensive Adult Mental Health Act
Minnesota Statutes, 245.462, Adult Mental Health Act Definitions
Minnesota Statutes, 245.462, subdivision 4, Adult Mental Health Targeted Case Manager Qualifications
Minnesota Statutes, 245.487 to 245.4887, Minnesota Comprehensive Children’s Mental Health Act
Minnesota Statutes, 245.4871, Children’s Mental Health Act Definitions
Minnesota Statutes, 245.4871, subdivision 4, Children’s Mental Health Targeted Case Manager Qualifications
Minnesota Statutes, 256B.0625, subdivision 20, Mental Health Case Management
Minnesota Statutes, 256B.076, Case Management Services
Minnesota Statutes, 256G, Minnesota Unitary Residence and Financial Responsibility Act
Minnesota Statutes, 260C.007, subdivision 18
Minnesota Statutes 260D.02, subdivision 10
Minnesota Rules, 9520.0900 to 9520.0926, Case Management Services
Minnesota Rules, 9505.0322, Mental Health Case Management Services