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Coverage criteria policies

Targeted Case Management Eligibility- Adult – Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

  • Mental Health-Targeted Case Management (MH -TCM) for adults does not require prior authorization.
  • MH-TCM services require use of network providers.

Coverage

Targeted Case Management Services outlined in this policy are covered per the indications below and your plan documents.

Indications that are covered

Eligible Recipients

Eligible recipients meet one of the following:

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

For purposes of adult mental health targeted case management (MH -TCM), a “person with serious and persistent mental illness” means an adult (age 18 or older) who has a mental illness and meets at least one of the following criteria.

  1. The recipient had two or more episodes of inpatient care for mental illness within the past 24 months
  2. The recipient had continuous psychiatric hospitalization or residential treatment exceeding six months’ duration within the past 12 months
  3. The recipient has been treated by a crisis team two or more times within the past 24 months
  4. The recipient has a diagnosis of schizophrenia, bipolar disorder, major depression or borderline personality disorder; evidences a significant impairment in functioning; and has a written opinion from a mental health professional stating he or she is likely to have future episodes requiring inpatient or residential treatment unless community support program services are provided
  5. The recipient has, in the last three years, been committed by a court as a mentally ill person under Minnesota statutes, or the adult’s commitment as a mentally ill person has been stayed or continued
  6. The recipient was eligible under one of the above criteria, but the specified time period has expired
  7. The recipient was eligible as a child with severe emotional disturbance, and the recipient has a written opinion from a mental health professional, in the last three years, stating that he or she is reasonably likely to have future episodes requiring inpatient or residential treatment of a frequency described in the above criteria, unless ongoing case management or community support services are provided

Covered Services

The AMH -TCM service has four core components:

  1. Assessment
  2. Planning
  3. Referral and linkage
  4. Monitoring and coordination
Indications that are not covered

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

AMH-TCM services are not:

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

Definitions

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

If available, codes are listed below for informational purposes only, and do not guarantee coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

T2023 HE

Face to face contact between case manager and recipient – 1 unit per month of T2023 HE or HE U4

T2023 HE U4

Telephone contact, including telemedicine between case manager and recipient – 1 unit

T1017 HE

Face to face contact between case manager and recipient for HIS/638 and FQHC billing only – 1 per month (Adult MH-TCM provided via videoconferencing technology is permitted and billable as comparable to a qualifying telephone call. MHCP does not cover videoconferencing as a face-to-face contact for AMH-TCM services. Direct face-to-face contact remains an important characteristic of MH-TCM services.)

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. This information is not the same for Medicare. If you have questions or would like help, please call Member Services at 952-883-7979 or 1-800-233-9645.

References:

  1. Section 1905(a)(19) of the Social Security Act - http://www.ssa.gov/OP_Home/ssact/title19/1905.htm
  2. Section 1915(9g) of the Social Security Act - http://www.ssa.gov/OP_Home/ssact/title19/1915.htm
  3. Minnesota Statute, section 245.462 - https://www.revisor.mn.gov/statutes/?id=245.462
  4. Minnesota Statute, section 245.4871 - https://www.revisor.mn.gov/statutes/?id=245.4871
  5. Minnesota Statute, section 245.4875 - https://www.revisor.leg.state.mn.us/statutes/?id=245.4875
  6. Minnesota Statute, section 245.4881 - https://www.revisor.leg.state.mn.us/statutes/?id=245.4881
  7. Minnesota Rules, section 9505.0322 - https://www.revisor.mn.gov/rules/?id=9505.0322
  8. Minnesota Statute, section 256B.0625, subd 20 - https://www.revisor.mn.gov/statutes/?id=256B.0625
  9. Minnesota Health Care Programs Provider Manual – Adult Mental Health Targeted Case Management, Revised 08-04-2016

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Policy activity

  • 11/20/2009 - Date of origin
  • 08/03/2017 - Effective date
Review date
  • 05/2017
Revision date
  • 08/01/2017

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