Common use of Documenting Services and Service Definitions Clause in Contracts

Documenting Services and Service Definitions. Each service listed below requires a Progress Note, which must meet medical necessity guidelines and meet Medi-Cal requirements as described by service and activity code. CONTRACTOR may use the COUNTY CARE Form041 or its own progress note form, if it has all the Medi-Cal required elements, to ensure that Medi-Cal required elements are completed. Each note must include the date of service, activity code, location of service, and duration (minutes) of service. Progress Notes shall be computer-generated. Documentation time shall be included as part of the service provided. Documentation must be completed at the time service is provided and should not be excessive. Time used for Progress Note documentation shall be included in “duration of service” time recorded on the Progress Note and monthly invoice. It is recognized that some services will be held in community settings and some billing for travel time is necessary as part of documentation. Travel time shall not exceed face-to-face service delivery time, except in rare instances. Driving time between certified locations is not billable time, however, it is allowable between service locations in the community. health status and diagnosis. Included in the assessment shall be any relevant physical health condition, presenting problems, mental status exam, special risk factors, medication history, allergies and history of adverse reactions to medications, mental health treatment history, pre-natal and perinatal events, developmental history, a five-axis diagnosis, and child or youth strengths. CONTRACTOR may use its’ own assessment form or COUNTY’S Biopsychosocial Assessment form, CARE015. The assessment must be updated at least every year, or every three months for youth meeting the Xxxxx X. lawsuit subclass. CONTRACTOR’S Progress Notes shall include a description of attempted intervention and/or what was accomplished by the client, family (when applicable) and the CONTRACTOR toward treatment goals or necessary interventions at the time service was delivered and a description of any changes in the child or youth’s level of functioning. The notes must reflect any significant new information or changes as they may occur and a follow-up plan. This section also applies to Intensive Home Based Services (IHBS). CONTRACTOR must write a group Progress Note for each child or youth attending a group session, with the goal for each group clearly articulated, and each child or youth’s individualized response to the group interventions documented. The group Progress Note formula must be clearly indicated on every group note, with the correct calculations conducted. CONTRACTOR shall permit any member of the direct service program to document the date and time when a beneficiary has ingested any prescribed or nonprescription medication, denote any side effects the beneficiary has experienced as reported by the beneficiary and/or as observed by direct program staff as consistent with DHCS STRTP Mental Health Regulations, unless amended by DHCS. Documentation shall be in a Medication Administration Record (MAR) by direct program staff, or equivalent. Documentation in the form of a specialty mental health service claim is not considered an equivalent or permissible form of documentation.

Documenting Services and Service Definitions. Each service listed below requires a Progress Note, which must meet medical necessity guidelines and meet Medi-Cal requirements as described by service and activity code. CONTRACTOR may use the COUNTY CARE Form041 or its own progress note form, if it has all the Medi-Cal required elements, to ensure that Medi-Cal required elements are completed. Each note must include the date of service, activity code, location of service, and duration (minutes) of service. Progress Notes shall be computer-generated. Documentation time shall be included as part of the service provided. Documentation must be completed at the time service is provided and should not be excessive. Time used for Progress Note documentation shall be included in “duration of service” time recorded on the Progress Note and monthly invoice. It is recognized that some services will be held in community settings and some billing for travel time is necessary as part of documentation. Travel time shall not exceed face-to-face service delivery time, except in rare instances. Driving time between certified locations is not billable time, however, it is allowable between service locations in the community. Assessment/Evaluation: CONTRACTOR shall provide a clinical analysis of the history and current status of the child or youth’s mental, emotional or behavioral functioning, appraisal of the child or youth’s community functioning in several areas including living situation, daily activities, social support systems, health status and diagnosis. Included in the assessment shall be any relevant physical health condition, presenting problems, mental status exam, special risk factors, medication history, allergies and history of adverse reactions to medications, mental health treatment history, pre-natal and perinatal events, developmental history, a five-axis diagnosis, and child or youth strengths. CONTRACTOR may use its’ own assessment form or COUNTY’S Biopsychosocial Assessment form, CARE015. The assessment must be updated at least every year, or every three months for youth meeting the Xxxxx X. lawsuit subclass. CONTRACTOR’S Progress Notes shall include a description of attempted intervention and/or what was accomplished by the client, family (when applicable) and the CONTRACTOR toward treatment goals or necessary interventions at the time service was delivered and a description of any changes in the child or youth’s level of functioning. The notes must reflect any significant new information or changes as they may occur and a follow-up plan. This section also applies to Intensive Home Based Services (IHBS). CONTRACTOR must write a group Progress Note for each child or youth attending a group session, with the goal for each group clearly articulated, and each child or youth’s individualized response to the group interventions documented. The group Progress Note formula must be clearly indicated on every group note, with the correct calculations conducted. CONTRACTOR shall permit any member of the direct service program to document the date and time when a beneficiary has ingested any prescribed or nonprescription medication, denote any side effects the beneficiary has experienced as reported by the beneficiary and/or as observed by direct program staff as consistent with DHCS STRTP Mental Health Regulations, unless amended by DHCS. Documentation shall be in a Medication Administration Record (MAR) by direct program staff, or equivalent. Documentation in the form of a specialty mental health service claim is not considered an equivalent or permissible form of documentation. CONTRACTOR shall permit COUNTY nurse direct access to prescribing physicians, including psychiatrists, for communication relating to prescribing, medication monitoring support, refills, and court orders.

Documenting Services and Service Definitions. Each service listed below requires a Progress Noteprogress note, which must meet medical necessity guidelines and meet Medi-Cal requirements as described by service and activity code. CONTRACTOR may shall use the COUNTY CARE Form041 or its own progress note form, if it has all the Medi-Cal required elements, Form 041 to ensure that Medi-Cal required elements are completed. Each note must include the date Date of serviceService, activity codeActivity Code, location Location of serviceService, and duration Duration (minutes) of serviceService. Progress Notes notes shall be computer-computer generated. Documentation time shall be included as part of the service provided. Documentation must be completed at the time service is provided and should normally not be excessiveexceed 10 minutes for every hour of service provided. Time used for Progress Note documentation shall be included in “duration of service” time recorded on the CONTRACTOR’S Event Monitoring Slip, Progress Note and monthly invoice. It is recognized that some services will be held in community settings and some billing for travel time is necessary as part of documentation. Travel time shall not exceed face-to-face to face service delivery time, except time in rare instancesany instance. Driving time between certified locations is not billable time. CONTRACTOR shall submit a copy of original documentation for each service provided with its monthly invoices. Documentation may include but not be limited to assessment, howevermedical necessity form, it is allowable between service locations in the communityClient Services Plan, and outpatient services treatment authorization request form. health status and diagnosis. Included in the assessment shall be any relevant physical health condition, presenting problems, mental strategies employed during treatment, current status exam, special risk factors, medication history, allergies of psychiatric symptoms or change in status that represents a critical need for this service and history of adverse reactions to medications, mental health treatment history, pre-natal and perinatal events, developmental history, a five-axis diagnosismeets medical necessity guidelines, and child or youth strengthswhat additional treatment is necessary. CONTRACTOR may use its’ own assessment form or COUNTY’S Biopsychosocial Assessment form, CARE015. The assessment must be updated at least every year, or every three months for youth meeting the Xxxxx X. lawsuit subclass. CONTRACTOR’S Progress Notes All progress notes shall include contain a description of attempted intervention and/or what was accomplished by the client, family (when applicable) and the CONTRACTOR toward treatment goals or necessary interventions at the time service was delivered and a description of any changes in the child or youthclient’s level of functioning. The notes must reflect any significant new information or changes as they may occur and a follow-up plan. This section also applies to Intensive Home Based Services (IHBS). CONTRACTOR A group progress note must write a group Progress Note be written for each child or youth client attending a the group session, with the goal for each group clearly articulated, and each child or youththe client’s individualized response to the group interventions documented. The group Progress Note progress note formula must be clearly indicated on every group note, with the correct calculations conducted. Additionally, CONTRACTOR shall permit any member list all clients attending the group session on the Event Monitoring Form each time a group session is held, identifying the clients, the group service by activity code, date of the direct service program to document the date and time when a beneficiary has ingested any prescribed or nonprescription medicationlength of group in minute increments, denote any side effects the beneficiary has experienced as reported by the beneficiary and/or as observed by direct program staff as consistent with DHCS STRTP Mental Health Regulations, unless amended by DHCS. Documentation shall be in a Medication Administration Record (MAR) by direct program staff, or equivalent. Documentation in the form of a specialty mental health service claim is not considered an equivalent or permissible form of documentationincluding documentation time.

Documenting Services and Service Definitions. Each service listed below requires a Progress Noteprogress note, which must meet medical necessity guidelines and meet Medi-Cal requirements as described by service and activity code. The CONTRACTOR may use the COUNTY CARE Form041 Form 041 or its own progress note form, if it has all the Medi-Cal required elements, to ensure that Medi-Cal required elements are completed. Each note must include the date Date of serviceService, activity codeActivity Code, location Location of serviceService, and duration Duration (minutes) of serviceService. Progress Notes notes shall be computer-computer generated. Documentation time shall be included as part of the service provided. Documentation must be completed at the time service is provided and should not be excessive. Time used for Progress Note documentation shall be included in “duration of service” time recorded on the CONTRACTOR’S Event Monitoring Slip, Progress Note and monthly invoice. It is recognized that some services will be held in community settings and some billing for travel time is necessary as part of documentation. Travel time shall not exceed face-to-face service delivery time, time except in rare instances. Driving time between certified locations is not billable time, however, it is allowable between service locations in the community. health status and diagnosis. Included in the assessment shall be any relevant physical health condition, presenting problems, mental status exam, special risk factors, medication history, allergies and history of adverse reactions to medications, mental health treatment history, pre-natal and perinatal events, developmental history, a five-axis ICD10 diagnosis, and child or youth client strengths. The CONTRACTOR may use its’ its own assessment form or COUNTY’S the COUNTY Biopsychosocial Assessment form, CARE015CARE 015. The assessment must be updated at least every year, or every three months for youth meeting the Xxxxx X. lawsuit subclass. CONTRACTOR’S Progress Notes All progress notes shall include contain a description of attempted intervention and/or what was accomplished by the client, family (when applicable) and the CONTRACTOR toward treatment goals or necessary interventions at the time service was delivered and a description of any changes in the child or youthclient’s level of functioning. The notes must reflect any significant new information or changes as they may occur and a follow-up plan. This section also applies to Intensive Home Based Services (IHBS). CONTRACTOR A group progress note must write a group Progress Note be written for each child or youth client attending a the group session, with the goal for each group clearly articulated, and each child or youththe client’s individualized response to the group interventions documented. The group Progress Note progress note formula must be clearly indicated on every group note, with the correct calculations conducted. Additionally, the CONTRACTOR shall permit any member list all clients attending the group session on the Event Monitoring Form each time a group session is held, identifying the clients, the group service by activity code, date of the direct service program to document the date and time when a beneficiary has ingested any prescribed or nonprescription medicationlength of group in minute increments, denote any side effects the beneficiary has experienced as reported by the beneficiary and/or as observed by direct program staff as consistent with DHCS STRTP Mental Health Regulations, unless amended by DHCS. Documentation shall be in a Medication Administration Record (MAR) by direct program staff, or equivalent. Documentation in the form of a specialty mental health service claim is not considered an equivalent or permissible form of documentationincluding documentation time.

Documenting Services and Service Definitions. Each service listed below requires a Progress Noteprogress note, which must meet medical necessity guidelines and meet Medi-Cal requirements as described by service and activity code. CONTRACTOR may shall use the COUNTY CARE Form041 or its own progress note form, if it has all the Medi-Cal required elements, Form 041 to ensure that Medi-Cal required elements are completed. Each note must include the date of service, activity code, location of service, and duration (minutes) of service. Progress Notes notes shall be computer-computer generated. Documentation time shall be included as part of the service provided. Documentation must be completed at the time service is provided and should normally not be excessiveexceed 10 minutes for every hour of service provided. Time used for Progress Note progress note documentation shall be included in “duration of service” time recorded on the CONTRACTOR’S Event Monitoring Slip, Progress Note and monthly invoice. : It is recognized that some services will be held in community settings and some billing for travel time is necessary as part of documentation. Travel time shall not exceed face-to-face service delivery time, except time in rare instancesany instance. Driving time between certified locations is not billable time, however, it is allowable between service locations in the community. health status and diagnosis. Included in the assessment shall be any relevant physical health condition, presenting problems, mental status exam, special risk factors, medication history, allergies and history of adverse reactions to medications, mental health treatment history, pre-natal and perinatal events, developmental history, a five-axis diagnosis, and child or youth strengths. 1.3.3.1. CONTRACTOR shall submit a copy of original progress note documenting each service provided with submission of Mental Health Crisis Evaluations and include itemized services on invoices. • Crisis Intervention: CONTRACTOR may use its’ own include the following services under Crisis intervention: The time for interviewing the individual, obtaining collateral information during the initial evaluation/assessment form or COUNTY’S Biopsychosocial Assessment formperiod and consultation with psychiatrist. Reviewing an individual record prior to conducting the initial evaluation to determine obtain specific information pertaining to the presenting situation while observing the client, CARE015MUST be carefully documented to ensure appropriate billing practices. The assessment Documentation must be updated at least every year, or every three months for youth meeting include all contacts and include enough information to justify the Xxxxx X. lawsuit subclasstime. CONTRACTOR’S Progress Notes • Assessment/Evaluation: CONTRACTOR may include the following services under Assessment/Evaluation: Reassessment of initial crisis evaluation. All progress notes shall include contain a description of attempted intervention and/or what was accomplished by the client, family (when applicable) and the CONTRACTOR toward treatment goals or and/or necessary interventions at the time service was delivered and a description of any changes in the child or youthclient’s level of functioning. The notes must reflect any significant new information or changes as they may occur and a follow-up plan. This section also applies to Intensive Home Based Services • Targeted Case Management: CONTRACTOR may include the following activities under the Targeted Case Management Services: Detailed conversations with hospitals regarding initial referral packets and obtaining additional information as requested for hospitals. One progress note may be written for all Case Management/Brokerage contact made on behalf of an individual by a staff member during the course of their shift and shall contain date of service, activity code, location of service, duration (IHBS). CONTRACTOR must write minutes) of service and a group Progress Note for each child or youth attending a group session, with description of what was accomplished by the goal for each group clearly articulated, and each child or youth’s individualized response to the group interventions documentedclient and/or staff. The group Progress Note formula note must be clearly indicated on every group notereflect any new significant information or changes as they may occur and cannot exceed the total amount of time in providing case management services for the individual. • Collateral: CONTRACTOR may bill for time spent obtaining additional collateral information that occurs after the initial crisis evaluation, with if this is not captured in the correct calculations conducted. CONTRACTOR shall permit any member of the direct service program to document the date and time when a beneficiary has ingested any prescribed or nonprescription medication, denote any side effects the beneficiary has experienced as reported by the beneficiary and/or as observed by direct program staff as consistent with DHCS STRTP Mental Health RegulationsCrisis Evaluation services. • Plan Development: CONTRACTOR may bill for discharge planning post crisis intervention for non-psychiatric hospital admissions. This does not include the development of a safety plan as that should be included within the crisis intervention assessment determination. • Mental Health Rehabilitation Services: CONTRACTOR crisis staff may provide rehabilitation services after determining an individual did not meet criteria for involuntary psychiatric hospitalization for the time spent assisting the client with skill development to improve, unless amended by DHCS. Documentation shall be in a Medication Administration Record (MAR) by direct program staffmaintain, or equivalent. Documentation in the form of a specialty mental health service claim is not considered restore an equivalent or permissible form of documentationindividual’s functioning skills, daily living skills, social and recreational skills, grooming and personal hygiene skills, meal preparations and support services.