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Coverage criteria policies

Targeted case management eligibility - Child - 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 children 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 MH-TCM Recipients

Recipients eligible to receive MH-TCM services must:

  1. Be eligible for Medical Assistance; and
  2. Have a current diagnostic assessment and a diagnosis of severe emotional disturbance (SED) (see definition below) if a child under 18 years old; and
  3. Be determined, or re-determined every 36 months, eligible for MH-TCM by a county or tribal government, based on a diagnostic assessment; and
  4. Be referred for MH-TCM services (with or without the recipient’s consent) by a:
    1. Physician;
    2. Mental health provider;
    3. Family member;
    4. Social worker employed by or under contract with the county;
    5. Legal representative;
    6. Other interested persons; or
    7. Self (self-referral).

If the recipient has not had a diagnostic assessment within 180 days, obtain a new diagnostic assessment within 10 days of receiving the referral for MH-TCM services.

For purposes of eligibility for child mental health targeted case management (MH-TCM), a “child with severe emotional disturbance” means a child who has an emotional disturbance and who meets one of the following criteria:

  1. the child has been admitted, or is at risk of being admitted, to inpatient treatment or residential treatment for an emotional disturbance within the last three years; or
  2. the child is a Minnesota resident and is receiving inpatient treatment or residential treatment for an emotional disturbance through the interstate Compact; or
  3. the child has one of the following as determined by a mental health professional:
    1. psychosis or clinical depression; or
    2. risk of harming self or others as a result of an emotional disturbance; or
    3. psychopathological symptoms as a result of being a victim of physical or sexual abuse or of psychic trauma within the past year; or
  4. the child, as a result of an 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.

Note: Case managers must assess and reassess the delivery, appropriateness, and effectiveness of services over time

MH-TCM Covered Services

Case management services include conducting a functional assessment, developing an ICSP/IFSCP, assisting the recipient in obtaining needed mental health and other services, ensuring the coordination of services, and monitoring and evaluating the delivery of services.

Case management services can be any of the following activities:

  1. Developing and reviewing the recipient’s ICSP/IFCSP based on the functional and diagnostic assessments, and incorporating the ITP;
  2. Monitoring the discharge planning for a recipient leaving residential treatment facility, regional treatment center, or inpatient hospital;
  3. Assisting a recipient in obtaining health coverage for covered medical services;
  4. Arranging for transportation, lodging, meals, or child care needed for a recipient to access services;
  5. Assessing and evaluating the effectiveness of services received by a recipient;
  6. All planning, assessing, record keeping and documenting associated with the service coordination of a case;
  7. Receiving clinical supervision for an identified recipient with SPMI or SED;
  8. Routine contacting and other monitoring or communicating with the recipient, family members, or other relevant persons about the status of the recipient, the individual service plan or progress in achieving the goals of the service plan;
  9. Developing goals, service plans, written service agreement and routine case supervisory activities;
  10. Participating in case conferences, administrative reviews, recipient staffing and informal conferences;
  11. Completing and regularly reviewing the written functional assessment;
  12. Assisting a recipient in obtaining needed services;
  13. Coordinating with other agencies to obtain services for recipients.
Indications not covered
  1. Therapy and treatment services
  2. Legal advocacy
  3. Performing a diagnostic assessment
  4. Administration, management, or monitoring medications
  5. Child mental health targeted case management services for recipients covered under commercial plans.

Definitions

Mental health targeted case management services are services furnished to assist individuals in gaining access to needed medical, social, educational and other services.

Child mental health targeted case management services means activities that are coordinated with the family community support services and are designed to help the child with severe emotional disturbance and the child's family obtain needed mental health services, social services, educational services, health services, vocational services, recreational services, and related services in the areas of volunteer services, advocacy, transportation, and legal services. The services include assistance in obtaining a comprehensive diagnostic assessment if needed, developing a functional assessment, developing an individual family community support plan, and assisting the child and the child's family in obtaining needed services by coordination with other agencies and assuring continuity of care.

Child with emotional disturbance: A child with an organic disorder of the brain, or a clinically significant disorder of thought, mood, perception, orientation, memory, or behavior that meets both of the following:

  1. Is detailed in a diagnostic code list published by the commissioner
  2. Seriously limits a child’s capacity to function in primary aspects of daily living, such as personal relations, living arrangements, work, school, and recreation

If available, codes for a procedure, device or diagnosis 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 HA

Face to face contact between case manager and recipient under age 18 – 1 unit per month

T1017

HE HA

Face to face contact between case manager and recipient under age 18 for HIS/638 and FQHC billing only – 1 per encounter

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. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

MS 245.462 Definitions
MS 256B.0625, subd. 20 Mental Health Case Management
MS 245.487 to 245.4887 Minnesota Comprehensive Children’s Mental Health Act
Minnesota Rules 9505.0322 Mental Health Case Management Services
Minnesota Rules 9520.0900 to 9520.0926 Case management services for children

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Policy activity

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

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