Behavioral Health

Behavioral Health Resources

Below are documents you will find helpful when working with on ADHD and depression issues with patients.

ADHD

Depression

Our Partnerships in Care (PiC) Program uses data analytics and clinical reviews to enhance our partnership with you as the provider to maximize treatment successes. This approach is based on our philosophy that quality member care is achieved through purposeful collaboration with providers that serve our members receiving a multitude of behavioral health services.

If you are identified as a provider that could benefit from participation in the Partnership in Care program through a data analysis, we will review members’ clinical documentation then collaborate with you to highlight areas of strengths and opportunities.

Care Coordination

What is Care Coordination?

The intentional exchange of information between two or more participants (including the member) who are involved in the member’s care to facilitate the appropriate delivery of healthcare services.
Care coordination is an essential element in treatment planning, service titration, and the discharge planning processes.

The Benefits of Care Coordination

Collaboration between the internal and external treatment team is emphasized to better serve the member.
The member’s needs are supported, and a holistic system of care is integrated.
It assists in the development of comprehensive treatment planning that leads to more appropriate services titration or referrals.
Care coordination consists of anything that bridges gaps in the member’s recovery.
A holistic approach to healthcare results in the best outcomes.

Who Should Coordinate Care?

Care coordination includes a variety of individuals on the treatment team:
- Behavioral health providers (e.g., Counselors, Social Workers, Substance Use Counselors, Psychiatrist)
- Physical health providers (e.g., PCP, Pharmacist, Neurologist)
- Specialty care services (e.g., Physical Therapists, Occupational Therapists, Speech Therapy)
- Educational and community supports (e.g., Teachers, School Psychologists, Mentors)
- Family members (e.g., parent, guardian, spouse, sibling)

Considerations

Release of information must be signed by the member or their guardian prior to any outreach.
Method of care coordination is based on each member’s needs (e.g., phone, fax, meeting).
Request and review records from previous or current providers to align care and member needs.
Notify member and/or guardian about coordination occurring.

What Could Happen If Coordination of Care Does Not Occur?

Multiple providers may be treating different diagnosis and/or presenting problems.
Multiple treatment plans with competing goals can complicate or impede the treatment process for the member.
Symptoms may become exacerbated.
Duplication of efforts and services provided may occur.

Treatment Plan Development

Important Steps of Treatment Planning

Treatment plan goals should:
- Align with assessment, diagnosis, and presenting symptoms
- Be member driven and individualized
- Serve as a guide towards the client’s recovery and be referenced frequently
Clinical Documentation in a treatment plan should include interventions that are being used, measurable target dates for each goal, and member’s strengths.

Creating a Member-Focused Treatment Plan Using Specific, Measurable, Attainable, Relevant, And Time Frame (SMART) Goals

This method helps goals to be measured and adjusted over time to show incremental progress or regression.
- If progress is not occurring, ask yourself, “What can we do differently?” and reflect changes in the updated treatment plan if the goal needs to be amended to improve attainability.
Goals should have a time frame of no more than 90 days.
- Can the goal be met in 1 month, 2 months, or 3 months?
Goals should be member driven and align with their desired outcome.
- Use direct member quotes for identified goals to use member language and ensure their understanding.
Goals should be strengths based and individualized.
It is recommended that each goal has two interventions: one for the member and one for the provider.

Tools to Aid in SMART Goal Development

Biopsychosocial assessment – triage for member’s needs
Diagnosis and presenting problem – clear supportive symptoms and behaviors that align with diagnosis
In-depth interview with member and support – assess the desired outcome and strengths
Motivational interviewing – consider stage of change the member is in and how they want treatment to help them

Considerations

Baseline behaviors and what is attainable for the member
Barriers to meeting the goal
Developmental age and stage of the member
Goals should be updated after a crisis, hospitalization or change in diagnosis
Ensure that the timeframe and interventions for the goal align
Goal should be tangible and able to answer “yes” or “no” if the goal was met at the treatment review

Titration of Services

What is Titration?

Titration implies stepping the member down in their services in order to match their clinical presentation, progress, baseline, and supports.
- Example: Member A. was receiving therapy 4x/month. Due to member’s progress, increase in supports, and coping skills, Member A. is being titrated to receive therapy 2x/month. Member will be evaluated with current service package and continue titration of services as progress continues.
Services should also be reduced slowly when recovery is occurring to avoid worsening of symptoms, feelings of abandonment by the client, and empower the use of skills learned.

Why is Titrating Services Important?

Promotes independence and working towards effective independent functioning
- Discharge should be discussed with the members openly at the start and throughout treatment. A key goal of therapy is to work towards effective independent functioning.
- This process includes helping members identify their natural support systems and assisting with coordination of care to support their step-down plan and access community-based resources.
- Studies demonstrate that it is not necessary to be in therapy for years in order to achieve improvement in symptoms.
Helps to ensure individualized treatment
- Treatment type and duration should always be matched appropriately to the nature and severity of the member’s presenting problems.
- Length of treatment also varies with the type of treatment provided.
Discourages unhealthy attachments
- Titration helps discourage unhealthy attachments to treatment providers because it promotes independence and monitors the member’s progress. It ensures that a member isn’t stuck in one level of care or becomes too dependent on a provider or services.

Barriers to Titration Services

Sunshine Health recognizes that barriers may be present for providers and members.
If symptoms worsen, services can be titrated up to increase frequency and duration of services, if the documentation supports the medical necessity of that service and authorization is obtained.

Discharge Readiness

Discharge Planning Process

Discharge planning is not a one-time event. It requires collaboration with the entire treatment team including providers, member, family, and additional supports.
Discharge planning should begin on the first day of treatment and continue to be assessed and frequently discussed with the member.
The discharge plan should be written clearly and agreed to by the member.
Titrating services, which is the continuous appraisal of current needs, will also help identify when discharge is appropriate.
Discharge should occur when: All the treatment goals and needs have been addressed, OR member has reached their baseline, OR the member has reached the maximum benefit of services for that level of care.

Step-down Planning Process

Members should begin their step-down plan when they have shown improvement and are meeting their goals and objectives.
Members should also have been compliant with treatment recommendations and are no longer severely functionally impaired.
To prepare for transition, encourage the use of the skills learned in treatment:
- Self-care reminders
- Coping skills
- Medication regiments
- Accessing and utilizing support systems
Recommend potential referrals to connect the member to natural supports prior to discharge to allow practice using services such as:
- AA/NA and sponsors
- Senior centers or respite
- Employment programs
- Spiritual or religious supports
- Community mentors or peer support specialists
- Sports/hobby groups
- Online supports (e.g., apps, online groups)
Discharge plans and instructions on how to return for care if needed should be provided to the member and openly discussed. They should be informed that they can resume services if needed.

Consider Family Readiness

Refer family to parent education/training, if needed.
Equip the family with tools and steps to take if the need for treatment arises again.
Ensure the family’s inclusion on discharge planning.

BH News

The Measurement Year (MY) 2025 changes to the behavioral health measures include:

Antidepressant Medication Management (Retired)
Follow-Up Care for Children Prescribed ADHD Medication
Follow-Up After Hospitalization for Mental Illness
Follow-Up After Emergency Department Visit for Mental Illness
Social Need Screening and Intervention

Antidepressant Medication Management (AMM)

Commercial, Medicaid, Medicare, and Marketplace Ages 18+

The AMM measure has been fully retired, reflecting NCQA's shift towards other aspects of mental health.

Follow-Up Care for Children Prescribed ADHD Medication (ADD-E)

Medicaid Ages 6-12

The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 300-day (10-month) period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported.

Initiation Phase. The percentage of members 6–12 years of age with a prescription dispensed for ADHD medication, who had one follow-up visit with a practitioner with prescribing authority during the 30-day Initiation Phase.
Continuation and Maintenance (C&M) Phase. The percentage of members 6–12 years of age with a prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.

Key Changes to ADD-E:

Added ADHD medications: dexmethylphenidate-serdexmethylphenidate and viloxazine (potential to increase the denominator).
Clarified the age criteria (members 6 years of age as of the start of the intake period to 12 years of age as of the end of the intake period)

Follow-Up After Hospitalization for Mental Illness (FUH)

Commercial, Medicaid, Medicare, and Marketplace Ages 6+

The percentage of discharges received between January 1 - December 1, for members 6 years of age and older who were hospitalized for a principal diagnosis of mental illness, or any diagnosis of intentional self-harm and had a mental health follow up service. Two rates are reported:

The percentage of discharges for which the member received follow-up within 30 days after discharge.
The percentage of discharges for which the member received follow-up within 7 days after discharge.

Key Changes to FUH:

Modified the denominator criteria to allow intentional self-harm diagnoses to take any position on the acute inpatient discharge claim (potential to increase the denominator).
Added new diagnoses including phobia, anxiety, intentional self-harm X-chapter codes, and the R45.851 suicidal ideation code to the denominator in the event/diagnosis (potential to increase the denominator).
Added more provider type visits (i.e., PCP) with any diagnosis of a mental health disorder to meet the mental health follow-up numerator (potential to increase the numerator).
Added peer support and residential treatment services to the numerator (potential to increase the numerator).

Follow-Up After Emergency Department Visit for Mental Illness (FUM)

Commercial, Medicaid, Medicare Ages 6+

The percentage of emergency department (ED) visits between January 1 – December 1, for members 6 years of age and older with a principal diagnosis of mental illness, or any diagnosis of intentional self-harm, and had a mental health follow-up service. Two rates are reported:

The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).

Key Changes to FUM:

Modified the denominator criteria to allow intentional self-harm diagnoses to take any position on the claim (potential to increase the denominator).
Added new diagnoses including phobia, anxiety, intentional self-harm X-chapter codes, and the R45.851 suicidal ideation code to the denominator in the event/diagnosis (potential to increase the denominator).
Modified the numerator criteria to allow a mental health diagnosis to take any position on the claim (potential to increase the numerator).
Added peer support and residential treatment services to the numerator (potential to increase the numerator).
Added visits in a behavioral healthcare setting and psychiatric collaborative care management services to the numerator(potential to increase the numerator).
Deleted the mental health diagnosis requirement for partial hospitalization/ intensive outpatient visits, community mental health center visits and electroconvulsive therapy (potential to increase the numerator).

Social Need Screening and Intervention (SNS-E)

Commercial, Medicaid, Medicare, and Marketplace

The percentage of members who were screened, using prespecified instruments, at least once during the measurement period for unmet food, housing, and transportation needs, and received a corresponding intervention if they screened positive.

Food Screening. The percentage of members who were screened for food insecurity.
Food Intervention. The percentage of members who received a corresponding intervention within 1 month of screening positive for food insecurity.
Housing Screening. The percentage of members who were screened for housing instability, homelessness, or housing inadequacy.
Housing Intervention. The percentage of members who received a corresponding intervention within 1 month of screening positive for housing instability, homelessness, or housing inadequacy.
Transportation Screening. The percentage of members who were screened for transportation insecurity.
Transportation Intervention. The percentage of members who received a corresponding intervention within 1 month of screening positive for transportation insecurity.

Key Changes to SNS-E:

Updated the description of the intervention categories to include any of the following categories: adjustment, assistance, coordination, counseling, education, evaluation of eligibility, evaluation/assessment, provision, or referral (potential to increase the numerator).

The Measurement Year (MY) 2025 changes to the behavioral health follow-up measures include updates to the Follow-Up After Hospitalization for Mental Illness and Follow-Up After Emergency Department Visit for Mental Illness to expand criteria for diagnoses considered and types of mental health follow-up care that qualify. Efforts have been made to align the follow-up measures, allowing for a more consistent approach to evaluating follow-up care across different care settings.

Follow-Up After Hospitalization for Mental Illness (FUH)

Commercial, Medicaid, Medicare, and Marketplace Ages 6+

The percentage of discharges for which the member received follow-up within 30 days after discharge.
The percentage of discharges for which the member received follow-up within 7 days after discharge.

Key Changes to FUH:

Modified the denominator criteria to allow intentional self-harm diagnoses to take any position on the acute inpatient discharge claim (potential to increase the denominator).
Added new diagnoses including phobia, anxiety, intentional self-harm X-chapter codes, and the R45.851 suicidal ideation code to the denominator in the event/diagnosis (potential to increase the denominator).
Added more provider type visits (i.e., PCP) with any diagnosis of a mental health disorder to meet the mental health follow-up numerator (potential to increase the numerator).
Added peer support and residential treatment services to the numerator (potential to increase the numerator).

Follow-Up After Emergency Department Visit for Mental Illness (FUM)
Commercial, Medicaid, Medicare Ages 6+

The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).

Key Changes to FUM:

Modified the denominator criteria to allow intentional self-harm diagnoses to take any position on the claim (potential to increase the denominator).
Added new diagnoses including phobia, anxiety, intentional self-harm X-chapter codes, and the R45.851 suicidal ideation code to the denominator in the event/diagnosis (potential to increase the denominator).
Modified the numerator criteria to allow a mental health diagnosis to take any position on the claim (potential to increase the numerator).
Added peer support and residential treatment services to the numerator (potential to increase the numerator).
Added visits in a behavioral healthcare setting and psychiatric collaborative care management services to the numerator(potential to increase the numerator).
Deleted the mental health diagnosis requirement for partial hospitalization/ intensive outpatient visits, community mental health center visits and electroconvulsive therapy (potential to increase the numerator).

Follow-Up After Emergency Department Visit for Substance Use (FUA)- No Key Changes
Commercial, Medicaid, Medicare Ages 13+

The percentage of emergency department (ED) visits between January 1 - December 1, among members aged 13 years and older with a principal diagnosis of substance use disorder (SUD), or any diagnosis of drug overdose, for which there was follow-up. Two rates are reported:

The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).

Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)- No Key Changes
Commercial, Medicaid, Medicare Ages 13+

The percentage of acute inpatient hospitalizations, residential treatment, or withdrawal management visits for a diagnosis of substance use disorder between January 1 – December 1, among members 13 years of age and older that result in a follow-up visit or service for substance use disorder. Two rates are reported:

The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 30 days after the visit or discharge.
The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 7 days after the visit or discharge.

Tips for Providers:

Offer in-person, virtual, telehealth and phone visits when applicable.
Include the patient and caregivers in decision making.
Schedule follow-up appointments to meet the 7- and 30-day requirements.
Address social drivers of health, determinants, health equity, and quality care.
Coordinate care between physical and behavioral health providers to address any comorbidity.
Offer psychoeducation, various treatment, medication assistance and recovery options.
Provide timely submission of claims and code related diagnosis and visits correctly.

The Ohio Department of Mental Health and Addiction Services will be releasing a public facing registry of recovery homes in early November. Starting January 1, only homes on this registry may receive referrals from mental health and addiction services providers. Providers should check this registry and ensure that any homes that they regularly refer individuals to are listed on the registry. If they are not, those individuals need to take the needed steps to ensure that they are on the registry by January 1, 2025. Only homes that are appropriately accredited may be on the registry. The two entities that are providing the accreditation are Ohio Recovery Housing which offers a certification and Oxford House which charters recovery homes. For more information or questions contact Ohio Recovery Housing at 614-453-5133 or info@ohiorecoveryhousing.org.

We need providers to bill with the POS 53 to have it count for our HEDIS rates.

FUH= A community mental health center visit with POS code 53 with a principal diagnosis of a mental health disorder.

FUM= A community mental health center visit with POS code 53 with a principal diagnosis of a mental health disorder.

FUA= A community mental health center visit with POS code 53 with any diagnosis of SUD.

Archived News

Prior Authorization Update: Effective immediately, we are no longer requiring a prior authorization for Assertive Community Treatment (ACT) Services CPT code H0040 for the initial 12 months. After 12 months, providers will submit a prior authorization for a medical necessity review.

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Updated Medicaid Behavioral Health Provider Manual Issued For January 1, 2023

ODM has published an updated version of the Medicaid Behavioral Health Provider Manual including several changes that will become effective January 1, 2023. Version 1.25 of the BH provider manual contains the following updates:

Revised Medicaid payment rates for the administration of the Child and Adolescent Needs Survey (CANS). (This change aligns with recent updates to OhioRISE provider guidance.)
Clarification that Mobile Response Stabilization Service (MRSS) may not be billed for time spent administering the CANS assessment. (This change aligns with recent updates to OhioRISE provider guidance)
Discontinuation of prolonged services codes (99354 and 99355) for psychotherapy services beginning January 1, 2023, and after. This follows the new CPT/HCPCS guidance from the American Medical Association (AMA) beginning January 1, 2023.
Discontinuation of CPT code 99343, Evaluation & Management Home Visit, presenting problems moderate to high severity, typically 45 minutes. This change also follows guidance of the AMA.
Codes added for several provider administered pharmaceuticals on Table 2-9

Questions regarding the Medicaid Behavioral Health Provider Manual may be submitted to the ODM Behavioral Health Policy mailbox, BH-Enroll@medicaid.ohio.gov.

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Behavioral Health