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AMENDMENT#14 TO
BEACON FACILITY AGREEMENT
This fourteenth amendment ("Amendment") amends the Beacon Facility Agreement ("Agreement") entered into by Beacon
Health Options, Inc. ("Beacon") and County of Grant dba Grant Integrated Services ("Facility"). Unless otherwise defined herein,
all capitalized terms used in this Amendment shall have the same meaning as set forth in the Agreement.
WHEREAS, the Agreement permits amendments to the Agreement by Beacon and Facility; and
WHEREAS, Beacon and Facility desire to amend the Agreement to make certain changes to it.
NOW, THEREFORE, in consideration of the promises and mutual covenants contained herein and other good and valuable
consideration, the receipt and sufficiency of which is hereby acknowledged, the Agreement is hereby amended as follows,
effective July 1, 2021:
1. Exhibit A Facility Location(s) & Practitioners, Services & Payment is removed in its entirety and replaced with Exhibit
A,A14 Facility Location(s) & Practitioners, Services & Payment.
2. ExhibitA-1.A8 NWRF Rate Schedule is removed in its entirety and replaced with ExhibitA-1,A14 NWRF Mobile Crisis
and Designated Crisis Responder Rate Schedule,
3. Exhibit A -2.A4 NWSA Rate Schedule is removed in its entirety and replaced with Exhibit A -2.A8 NWSA Outpatient
Substance Use Disorder Rate Schedule.
4. Exhibit A -3,M11 NWSR Rate Schedule is removed in its entirety and replaced with Exhibit A -3.A14 NWSR Inpatient
Residential Mental Health Rate Schedule
5. Exhibit B -2.M13 Maximum Contract Amounts is removed in its entirety and replaced with Exhibit B -2.A14 Maximum
Contract Amounts.
6. Exhibit B -4.A10 Crisis Program Provisions (Mobile Crisis and Designated Crisis Responder) is removed in its entirety
and replaced with Exhibit B -4.A14 Crisis Program Provisions (Mobile Crisis and Designated Crisis Responder).
7. Exhibit B -7.M11 Mental Health Program Provisions is removed in its entirety and replaced with Exhibit B -7.A14 Mental
Health Program Provisions
8. Exhibit B -8.A10 Washington State Health Care Authority Specific Provisions is removed in its entirety and replaced
with Exhibit B -8.A14 Washington State Health Care Authority Specific Provisions.
9. Exhibit B -10,A10 Mental Health Block Grant Program Provisions is removed in its entirety and replaced with Exhibit B -
10.A14 Mental Health Block Grant Program Provisions.
10. Addendum to B-11 A.8 Mobile Outreach Team is removed in its entirety and replaced with Addendum to B -10A.14
Mobile Outreach Team.
11. Exhibit B -11.A10 Substance Use Disorder Program Provisions is removed in its entirety and replaced with Exhibit B -
11.A14 Substance Use Disorder Program Provisions.
12. Exhibit B -20.A8 ESSB 5883 Start Up Funds is removed in its entirety and replaced with Exhibit B -20.A14 ESSB 5883
Start Up Funds.
13. Exhibit B -25.A14 Reporting Provisions is added in its entirety.
14. This Amendment shall be effective upon the date set forth by Beacon following signature by both Beacon and Facility.
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page 1 of 64
15. Except as amended herein, all other terms and conditions of the Agreement shall remain in full force and effect without
modification.
16. Scope of work pursuant with contract terms between Beacon and Health Care Authority as dictated in contract
amendment dated July 1, 2021.
Facility: County of Grand dba Grant Integrated Services
Address: 840 E. Plum, Moses Lake, WA 98837
NPI: 1689677833, 1982792537
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page 2 of 64
DocuSign Envelope ID: 43F2D078-08F5-46CF-B862-68A66889CA16
Intending to be legally bound, the parties have caused their authorized representatives to execute this -AQ-reement
effective as of the date set forth bv Beacon below.
County of Grant dba Grant Integrated Services:
Cindy Carter, BC C'. Chair
Print Name & Title
Federal Tax Identification Number: 91-6001319
Address for Notice:
County of Grant dba Grant Integrated Services
PO Box 1057
Moses Lake, WA, 98837-0160
Beacon Health Options, Inc.:
-Docuftned by:
39 E 3
1—gria ure
11/10/2021
Date
Janet RVP
Print Name & Title
Address for Notice:
Beacon Health Options, Inc.
P.O. Box 989
Latham, NY 12110-6402
Attn: National Provider Network Operations
Please do NOT write below this line. For Beacon office use ONLY.
111-111� 11 11111 11gill III 1111j.1111MI-1 RONNIE g,
I EFFECTIVE DATE: Jul 2021
Negotiated by: Karen Black
Print Name
Contract Development Manager
11/10/2021
Date Received by Beacon
I Please check if included: Ej
BHO-F-COM-MA-MCD/I 1/2015
(AG — VO STD FACILITY)
Amend 14 — PI D 301052
Page 3 of 64
Facility LocationExhibit A.A14
Location(s) &Practitioners, Services & Payment
I: Facility Location(s) & Practitioners.
(1) The list of those Facility locations and Practitioners who are or will be renderingavailable Cove
Individuals under this Agreement i red Services to Eligible
g s set out in the most recently approved credentialing documentation.
II: Facility Services.
(1) All Behavioral Health Services: (a) available from Facility and/or Practitionersursuant to their respective p espective licensure or
certification; (b) for which Facility and/or Practitioners have been credentialed pursuant to Beacon' '
credentialing policies and procedures; and p s credentialing/re-
p (c) for which there is a corresponding rate schedule herein.
III: Rate Schedules & Payment.
(1) The parties agree that:
(a) Payment amounts for Covered Services shall be in accordance with the Rate s Schedule orated herein b reference;
()attached hereto and
incor y
p
(b) The date of receipt of a claim is the date Beacon, or Payor, receives the claim as indicated
the claim;
by its date stamp on
(c) The date of payment is the date of the check or other form of payment;
(d) The per diem payment rates listed in attached Rate Schedules are inclusive includingwithout out limitation, facility,
supplies, materials, drugs, equipment, x-ray, laboratory (technical, facility) and other diagnostic fees,semi-privateroom and board (where applicable), operating room (where applicable),
nurses and other Facility employees and
permitted contracted entities and individuals; and
(e) Inpatient days commence at 12:00 midnight however no pament is due for date of dis
charae.
ffi Crisis stabilization services are considered in atient services with the len th of stav calculated per
the Health Care
Authorit 'sWCALInpatient Hos ital billin uide. When admit and discharge are on same da one'
b_e=
erdiem unit will
(2) No payment in addition to the applicable per diem rate for Covered Services above will be ma '
de for. (a) any outpatient
services rendered in the emergency room of Facility prior to an inpatient admission; oran outpatient
services rendered prior � (b) Y observation
p o to an inpatient admission.
BHO-F-COM-MA-MCD/11/2015 Amend 14 —
(AG — VO STD FACILITY) PID 301052
Page 4 of 64
Exhibit A -1.A14
NWRF Mobile Crisis and Designated Crisis Responder Rate Schedule
This Exhibit contain the Service Codes and billing rates that are allowed under the NWRF fund code. Following the Rate
Schedule is a table listing modifiers and their descriptions as well as a keyto abbreviations that may
Schedule.
y be used In this Rate
Definitions
1. Payment Type;
a. Fee for Service (FFS): Claims submitted for health care payments, also known as the Fee for Service (FFS)
payment type, must be cleanly submitted within current Washington State Health Care Authoritytime) filing
requirements in the format outlined in this Rate Schedule.
Y g
b. Prepaid: Encounters submitted for health care reporting purposes, also known as the Prepaid
must be clean) submitted to Beacon mon p payment type,
Y monthly in the format outlined in this Rate Schedule. Payment for
services provided will be made according to the Payment Method identified in Exhibit B-2 Maximum Contract
Amounts.
NWRF Rate Schedule.A14: Mobile Crisis and Designated Crisis Responder (DCR
Service
Code
Allowed
Add On
Codes
Interactive Service r N
Complexity �,
Add On Description o 0
M
0
�
CD
o
Rate
per
Allowed21
B. ,
10
a '�.
Place of Service (POS) Payment
Code NWRF
Unit
filling Unit
(2
Type
99075
N/A
N/A Medical Hg ET
Testimony
$0.01
UN (1 per
N0
03, 04, 06, 09, 11, 12, 13,
14, 15, 16, 18, 20, 21, 22,
encounter)
23 31 32 51 53, 55,Prepaid
56) *57, 62, 71, 72 99
99075
N/A
N/A Medical H9 ET
Testimony
GT
0.01
UN (1 per
N0
03, 04, 06, 09, 11, 12, 13,
14, 15, 16, 18, 20, 21) 221
Prepaid
encounter)
23 31, 32 51 53, 55,
561 *57, 62, 71, 72 99
Self-help/peer
UN (1=15
03, 04, 06, 09, 11, 12, 13,
H0038
N/A
N/A services, per ET HK
$0.01
minutes; 1
No
14, 15, 16, 18, 20, 21, 22)
Prepaid
15 minutes
or more)
23, 31, 32, 51, 53, 55,
561 *57, 62, 71, 72 99
Self-help/peer
UN (1=15
03, 04, 06, 09, 11, 12, 13,
H0038
N/A
N/A services, per ET
$0.01
minutes; 1
No
14, 15, 16, 18, 20, 21, 22,
Prepaid
15 minutes
or more)
23, 31, 32, 51, 53, 55,
56, *57, 62, 71, 72 99
Self-help/peer
UN (1=15
03, 04, 06, 09, 11, 12, 13,
H0038
N/A
N/A services, per ET GT
$0.01
minutes; 1
No
14, 15, 16, 18, 20, 21, 22,
Prepaid
15 minutes
or more)
23, 31, 32, 51, 53, 55,
56, *57, 62, 71, 72 99
H0046
N/A
N/A Mental health ET
$0.01
UN (1=<15
minutes; 1
03, 04, 06, 09, 11, 12, 13,
14, 15, 16, 18, 20, 21, 22,
services, NOS
per
No
23, 31 32 51, 53, 55Prepaid
,
encounter)
561 *57, 62, 71, 72 99
H0046
N/A
N/A Mental health ET HK
$0.01
UN (1=<15
minutes; 1
03, 04, 06, 09, 11, 12, 13,
14, 15, 16, 18, 20, 21, 22)
services, NOS
per
N0
23 31 32 51 53, 55Prepaid
,
encounter
561 *57, 62, 71, 72 99
H0046
N/A
N/A Mental health ET GT
$0.01
UN (1=<15
minutes; 1
03, 04, 06, 09, 11, 12, 13,
14, 15, 16, 18, 20, 21, 221
services, NOS
per
N0
23 31 32 51 53, 55Prepaid
,
encounter)
561 *57, 62, 71, 72 99
BHO-F-COM-MA-MCD/11/2015 Amend 14 - P
(AG - VO STD FACILITY) ID 301052
Page 5 of 64
Allowed Interactive
Service Complexity
Cod On
Code de(s) Add On
Service
Descri tion
p
N M
�,
o .� .�
�.
�, Rate
o p
Allowed
�' -
a .a
place of Service POS )
Payment
Y
Code
NWRF
M Unit
Billing Unit
Type
H2011 N/A N/A
Crisis
intervention
ET
$0.01
UN (1=15
minutes; 1
No
03, 04, 06, 09, 11, 12, 131
14, 15, 16, 18, 20, 21, 22,
services, per
15 minutes
or more)
23, 31, 32, 51, 53, 55,
Prepaid
Crisis
56, *57, 62, 71, 72 99
H2011 N/A N/A
intervention
ET GT
$0.01
UN (1=15
minutes; 1
No
03, 04, 06, 09, 11, 12, 13,
14, 15, 16, 18, 20, 21, 22,
services, per
15 minutes
or more)
23, 31, 32, 51, 53, 55,
Prepaid
Crisis
56, *57, 62, 71, 72 99
H2011 N/A N/A
intervention
ET HK
$0.01
UN (1=15
minutes; 1
No
03, 04, 06, 09, 11, 12, 13,
14, 15, 16, 18, 20, 21, 221
services, per
15 minutes
or more)
23, 31, 32, 51, 53, 55,
Prepaid
Crisis
56, *57, 62, 71, 72 99
H2011 N/A N/A
intervention
ET XE
$0.01
UN (1=15
minutes; 1
No
03, 04, 06, 09, 11, 12, 13,
14, 15, 16, 18, 20, 21, 22,
services, per
15 minutes
or more)
23, 31, 32, 51, 53, 55,
Prepaid
Crisis
1 561 *57, 62, 71, 72 99
H2011 N/A N/A
intervention
ET GT XE
$0.01
UN (1=15
minutes; 1
No
03, 04, 06, 09, 11, 12, 13,
14, 15, 16, 18, 20, 21, 22,
services, per
15 minutes
or more)
23, 31, 32, 51, 53, 55,
Prepaid
Crisis
56, *57, 62, 71, 72 99
H2011 N/A N/A
intervention
ET HK XE
$0.01
UN (1=15
minutes; 1
No
03, 04, 06, 09, 11, 12, 13,
14, 15, 16, 18, 20, 21, 22,
services, per
15 minutes
or more)
23, 31, 32, 51, 53, 55,
Prepaid
Crisis
56, *57, 62, 71, 72 99
H2011 N/A N/A
intervention
HW
$0.01
UN (1=15
minutes; 1
No
03, 04, 06, 09, 11, 12, 13,
14, 15, 16, 18, 20, 21, 22)
svc, 15
minutes
or more)
23, 31, 32, 51, 53, 55,
Prepaid
Crisis
561 *57, 62, 71, 72, 99
H2011 N/A N/A
intervention
svc, 15
HW HK
$0.01
UN (1=15
minutes; 1
No
03, 04, 06, 09, 11, 12, 13,
14, 15, 16, 18, 20, 21, 22,
minutes
or more)
23, 31, 32, 51, 53, 55,
Prepaid
Crisis
56, *57, 62, 71, 72, 99
H2011 N/A N/A
intervention
svc, 15
HW XE
$0.01
UN (1=15
minutes; 1
No
03, 04, 06, 09, 11, 12, 13,
14, 15, 16, 18, 20, 21, 22,
minutes
or more)
23, 31, 32, 51, 53, 55,
Prepaid
Crisis
56, *57, 62, 71, 72, 99
H2011 N/A N/A
intervention
svc, 15
HW HK XE
$0.01
UN (1=15
minutes; 1
No
03, 04, 06, 09, 11, 12, 13)
14, 15, 16, 18, 20, 21, 22,
minutes
or more}
3, 31, 32, 51, 53, 55,
Prepaid
repaid
Sign Lang/Oral
56, *57, 62, 71, 72, 99
Interpreter
T1013 N/A N/A
Services (Note:
submit
UN (1=15
03, 09, 11 12 1315 19
'
encounters for
$0.01
minutes; 1
No
22, 32 33 34 53 *57
Prepaid
reporting and
or more)
62, 71, 72
invoice for
reimbursement
Sign Lang/Oral
Interpreter
T1013 N/A N/A
Services (Note:
submit
GT
UN1=15
(
03 09 , 11, 12, 13,15, 19,
encounters for
$0.01
minutes; 1
No
22, 32, 33, 34, 53) *571
Prepaid
reporting and
or more)
62, 71, 72
invoice for
reimbursement
T1016 N/A NIA
Case
management,
ET
$0.01
UN (1-_ 15
minutes; 1
No,
03, 04, 06, 09, 11, 121 13,
14 15 16 18 20 21 2
, , , , 221
each 15
minutes
or )
more
23, 31, 32, 51, 53, 55,
Prepaid
1
561 *57, 62, 71, 72 99
BHO_F-COM-MA-MCD/11/2015 Amend 14 - PID
(AG VO STD FACILITY) 301052
Page 6 of 64
Service
Allowed
Interactive
Complexity
CAddIOn
Service
r
L
Code
Add On
Court-ordered
Description
Pre nant/ arentin women's program
HH
Code(s)0
HK
HT
NWRF
M
Type
yp
HZ
Funded by Criminal Justice Treatment Account
Case
Individuals Usinq Intravenous Drugs IUID
T1016
N/A
N/A
management,
ET
HK
UD
WA -PACT
each 15
minutes; 1
No
14, 15, 16, 18, 20, 21, 22,
Prepaid
minutes
53
N
0
M
0
o
ate
per
Allowed
Billing Unit
< �-
¢ Cr
°'
Place of Service(POS)Payment
Court-ordered
HD
Pre nant/ arentin women's program
HH
Unit
HK
HT
Services provided involve multiple staff for safety purposes
Multi -disci lina team
HW
Type
yp
HZ
Funded by Criminal Justice Treatment Account
U5
Individuals Usinq Intravenous Drugs IUID
U6
UN (1=15
U9
03, 04, 06, 09, 11, 12, 13,
UB
HK
UD
WA -PACT
$0.01
minutes; 1
No
14, 15, 16, 18, 20, 21, 22,
Prepaid
Reduced services
53
Discontinued procedure
or more)
23, 31, 32, 51, 53, 55,
56, *57, 62, 71, 72 99
Modifier
Description
ET
Crisis fund onl
GT
Telemedicine via interactive audio and video telecommunication
H9
Court-ordered
HD
Pre nant/ arentin women's program
HH
Integrated Mental Health/Substance Abuse Program
HK
HT
Services provided involve multiple staff for safety purposes
Multi -disci lina team
HW
Funded by state mental health agency or ITA
HZ
Funded by Criminal Justice Treatment Account
U5
Individuals Usinq Intravenous Drugs IUID
U6
Brief Intervention
U9
Rehabilitation Case Management Intake
UB
Request for Services
UD
WA -PACT
XE
Separate encounter, distinct service
25
Significant and separately identifiable E&M
52
Reduced services
53
Discontinued procedure
BHO-F-COM-MA-MCD/1 1/2015
(AG - VO STD FACILITY)
Amend 14 - PID 301052
Page 7 of 64
Exhibit A -2.A14
NWSA Outpatient Substance Use Disorder Rate Schedule
This Exhibit contain the Service Codes and billing rates that are allowed under the NWSA fund code. Following the Rate
Schedule is a table listing modifiers and their descriptions as well as a key to abbreviations that may be used '
Schedule. Y ed In this Rate
Please see Exhibit B-11 Substance Use Disorder Provisions for services without an associated Service Code that can be
submitted via cost reimbursement invoice with prior approval from the Beacon Account PartnershipDirectorf
Service Area (RSA). or your Regional
Definitions
1. Payment Type:
a. Fee for Service (FFS): Claims submitted for health care payments, also known as the Fee for Service (FFS)
payment type, must be cleanly submitted within current Washington State Health Care Authoritytime) filing
requirements in the format outlined in this Rate Schedule.
Y g
b. Prepaid: Encounters submitted for health care reporting purposes, also known as the Prepaid a
must be clean) submitted to Beacon p payment type,
Y monthly in the format outlined in this Rate Schedule. Payment for
services provided will be made according to the Payment Method identified in Exhibit B-2 Maximum Contract
Amounts.
NWSA Rate Schedule -A14: Outpatient Substance Use Disorder (SUD
Service
Code
Allowed
Add On
Interactive
Complexity
Add On
Service Description
NWSA
N
�
�,
d
Rate per
Allowed Billing
.2
Place of Service
ice
Payment
Code(s)
Code
M
Unit
Unit
a
(POS)
Type
BH Intervention w/ grp
96164
96165
N/A
(2 or more) face to face,
GT
$27.20
UN (1=30
No
03, 09, 11, 12, 13 15
19, 22, 32 33 34, 53
FFS
first 30 minutes
minutes)
* 57, 62, 71, 72
BH Intervention w/ grp
96164
96165
N/A
(2 or more) face to face,
HD
GT
$27.20
UN (1=30
No
03, 09, 11, 12, 13, 15
19, 22, 32, 33 34 53
FFS
first 30 minutes
minutes)
* 57, 62, 71, 72
BH Intervention w/ grp
96164
96165
N/A
(2 or more) face to face,
HD
U5
GT
$27.20
UN (1=30
No
03, 09, 11, 12, 13, 15,
19, 22, 32 33 34 53
FFS
first 30 minutes
minutes)
* 57, 62, 71, 72
BH Intervention w/ grp
96164
96165
N/A
(2 or more) face to face,
HD
U5
$27.20
UN (1=30
No
03, 09, 11, 12, 13
19, 22, 11 33 34, 15 53
FFS
first 30 minutes
minutes)
*57, 62, 71, 72
BH Intervention w/ grp
96164
96165
NIA
(2 or more) face to face,
HD
$27.20
UN (1=30
No
03, 09, 11, 12, 13, 15 ,
19, 22, 32, 33, 34, 53,
FFS
first 30 minutes
minutes)
*57, 62, 71, 72
BH Intervention w/ grp
96164
96165
N/A
(2 or more) face to face,
U5
GT
$27.20
UN (1=30
No
03, 09, 11, 12, 13,15
19, 22, 32, 33, 34, 53,
FFS
first 30 minutes
minutes )
57, 62, 71, 72
BH Intervention w/ grp
96164
96165
N/A
(2 or more) face to face,
U5
$27.20
UN (1=30
No
03, 09, 11, 12, 13, 15
19, 22, 32 33 34 53)
FFS
- -
first 30 minutes
minutes)
* 57, 62, 71, 72
BH Intervention w/ grp
96164
96165
N/A
(2 or more) face to face,UN
$27.20
(1=30
No
03, 09, 11, 12, 13, 15
19, 22, 32, 33, 34, 53,
FFS
first 30 minutes
minutes)
*57, 62, 71, 72
BH Intervention w/
96167
96168
N/A
family & patient face to
GTUN
$55.82
(1=30
No
03, 09, 11, 12, 13, 15
19, 22, 32, 333 34, 53,
FFS
- I
- I
face, first 30 minutes
minutes)
*57, 62, 71, 72
BHO-F-COM-MA-MCD/11/2015 Amend 14 - PID
(AG - VO STD FACILITY) 301052
Page 8 of 64
Service
Allowed
Add On
Interactive
Complexity
Service Description
N
(POS)
Type
Rate per
Code
Code(s)
Add On
Code
NWSA
0
0
0
0
Unit
57, 62, 71, 72
UN (1=30
BH Intervention w/
03, 09, 11, 12, 13, 15,
minutes)
No
19, 22, 32, 33, 34, 53,
96167
96168
N/A
family & patient face to
HD
UN (1=30
03, 09, 11, 12, 13, 15,
$55.82
minutes)
No
19, 22, 32, 33, 34, 53,
face, first 30 minutes
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13, 15,
BH Intervention w/
No
19, 22, 32, 33, 34, 53,
FFS
96167
96168
N/A
family & patient face to
HD
U5
GT
$55.82
No
19, 22, 32, 33, 34, 53,
FFS
face, first 30 minutes
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13, 15,
BH Intervention w/
No
19, 22, 32, 33, 34, 53,
FFS
96167
96168
N/A
family & patient face to
HD
U5
$55.82
No
19, 22, 32, 33, 34, 53,
FFS
face, first 30 minutes
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13, 15,
BH Intervention w/
No
19, 22, 32, 33, 34, 53,
FFS
96167
96168
N/A
family & patient face to
HD
GT
$55.82
No
19, 22, 32, 33, 34, 53,
FFS
face, first 30 minutes
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13,15)
BH Intervention w/
No
19, 22, 32, 33, 34, 53,
FFS
96167
96168
N/A
family & patient face to U5
GT
$55.82
minutes)
No
face, first 30 minutes
FFS
57, 62, 71, 72
BH Intervention w/
03, 09, 11, 12, 13, 15,
96167
96168 N/A
family & patient face to U5
FFS
$55.82
57, 62, 71, 72
face, first 30 minutes
03, 09, 11, 12, 13,151
minutes)
No
BH Intervention w/
FFS
96167
96168 N/A
family & patient face to
03, 09, 11, 12, 13, 15,
$55.82
minutes)
No
face, first 30 minutes
FFS
57, 62, 71, 72
BH Intervention w/
03, 09, 11, 12, 13, 15,
96170
96171 N/A
family, no patient, face GT
FFS
$55.82
57, 62, 71, 72
to face, first 30 minutes
N/
Same as Primary CTP
FFS
more)
A
BH Intervention w/
UN (1=15
minutes; 1 or
N/
96170
96171 N/A
family, no patient, face HD
GT
/ Rev Code
$55.82
UN (1=15
minutes; 1 or
N/
to face, first 30 minutes
FFS
more)
A
/ Rev Code
BH Intervention w/
No
03, 09, 11, 12, 13, 15,
FFS
96170
96171 N/A
family, no patient, face HD
$55.82
to face, first 30 minutes
BH Intervention w/
96170
96171 N/A
family, no patient, face HD
U5
GT
$55.82
to face, first 30 minutes
BH Intervention w/
96170
96171 N/A
family, no patient, face HD
U5
$55.82
to face, first 30 minutes
BH Intervention w/
96170
96171 N/A
family, no patient, face U5
GT
$55.82
to face, first 30 minutes
BH Intervention w/
96170
96171 N/A
family, no patient, face U5
$55.82
to face, first 30 minutes
BH Intervention w/
96170
96171 N/A
family, no patient, face
$55.82
to face, first 30 minutes
Behay. Hlth Intrvtn. w/
Add on
N/A N/A
grp (2 or more), face -to -
96165
face; each additional 15
$13.60
minutes
Behay. Hlth Intrvtn, w/
Add on
N/A N/A
fam. & pt. face to face,
$27.91
96168
each additional 15
minutes
Behay.Hlth. Intrvtn. w/
Add on
N/A N/A
fam; no pt, face to face,
96171
each additional 15
$27.91
minutes
H0001
N/A N/A
Alcohol/drug 52
$2.32
assessment
BHO-F-COM-MA-MCD/11/2015
(AG - VO STD FACILITY)
Allowed Billing
Unit
a
Place of Service
Payment
(POS)
Type
UN (1=30
03, 09, 11, 12, 13, 15,
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13, 15,
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13, 15,
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13, 15,
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13, 15,
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13, 15,
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13, 15,
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13, 15,
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13,151
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13,15)
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13, 15,
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13, 15,
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13,151
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13, 15,
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=30
03, 09, 11, 12, 13, 15,
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
57, 62, 71, 72
UN (1=15
minutes; 1 or
N/
Same as Primary CTP
FFS
more)
A
/ Rev Code
UN (1=15
minutes; 1 or
N/
Same as Primary CTP
FFS
more)
A
/ Rev Code
UN (1=15
minutes; 1 or
N/
Same as Primary CTP
FFS
more)
A
/ Rev Code
Minutes (1 or
No
03, 09, 11, 12, 13, 15,
FFS
more)
19, 22, 53, 57, 71, 72
Amend 14 - PID 301052
Page 9 of 64
Service
Allowed
Add On
Interactive
Complexity
Service Description
Code
Code(s)
Add On
NWSA
$2.32
Minutes (1 or
more
Code
03, 09, 11, 12, 13,15)
19, 22, 53, 57, 71, 72
H0001
N/A
N/A
Alcohol/drug
HD
U5
52
53
assessment
H0001
N/A
N/A
Alcohol/drug
HD
U5
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
assessment
H0001
N/A
N/A
Alcohol/drug
$2.32
Minutes (1 or
more
assessment
H0001
N/A
N/A
Alcohol/drug
53
GT
assessment
H0001
N/A
N/A
Alcohol/drug
52
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
N/A
assessment
H0001
N/A
N/A
Alcohol/drug
$2.32
Minutes (1 or
more
No
assessment
H0001
N/A
N/A
Alcohol/drug
U5
$2.32
Minutes (1 or
more)
assessment
H0001
N/A
N/A
Alcohol/drug
H0004
N/A
N/A
assessment
H0001
N/A
N/A
Alcohol/drug
more)
therapy, per 15 minutes
53, *57, 62, 71, 72
assessment
H0001
N/A
N/A
Alcohol/drug
*02, 03, 09, 11, 12, 13,
assessment
H0001
N/A
N/A
Alcohol/drug
H0023
N/A
N/A
assessment
GT
Presumptive Drug
UN (1=15
Outreach Service
*02, 03, 09, 11, 12, 13,
Class Screening
H0003
N/A
N/A
(analysis completed
GT
XE
onsite' by provider and
more)
Outreach Service
53, *57, 62, 71, 72
k;ll^r4 kil NMA... .�.. .
M
r- NCD
W-
53
HD
HD U5
Rate per
Unit
Allowed Billing
Unit
o:
Place of Service
(POS)
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
$2.32
Minutes (1 or
more)
No
$2.32
Minutes (1 or
more
No
03, 09, 11, 12, 13,15)
19, 22, 53, 57, 71, 72
$2.32
Minutes (1 or
more)
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
HD
U5
52
53
$2.32
$2.32
Minutes (1 or
more)
Minutes (1 or
more
No
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
HD
U5
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
BH counseling and
HD
HD
52
$2.32
Minutes (1 or
more
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
N/A
N/A
HD
53
GT
$2.32
$2.32
Minutes (1 or
more)
Minutes (1 or
more)
No
No
03, 09, 11, 12, 13,151
19, 22, 53, 57, 71, 72
U5
52
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
N/A
BH counseling and
U5
53
$32.03
$2.32
Minutes (1 or
more
No
03, 09, 11, 12, 13, 15)
19, 22, 53, 57, 71, 72
H0004
U5
N/A
BH counseling and
U5
$2.32
Minutes (1 or
more)
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
therapy, per 15 minutes
*02, 03, 09, 11, 12, 13,
H0004
N/A
N/A
$2.32
Minutes (1 or
more)
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
H0004
N/A
N/A
BH counseling and
GT
*02, 03, 09, 11, 12, 13,
$32.03
therapy, per 15 minutes
No
15, 19, 22, 32, 33, 34,
H0004
N/A
N/A
BH counseling and
HD
U5
therapy, per 15 minutes
*02, 03, 09, 11, 12, 13,
H0004
N/A
N/A
BH counseling and
HD
U5
therapy, per 15 minutes
53, *57, 62, 71, 72
*02, 03, 09, 11, 12, 13,
15, 19, 22, 32, 33, 34,
H0004
N/A
N/A
BH counseling and
HD
GT
more)
therapy, per 15 minutes
53, *57, 62, 71, 72
H0004
N/A
N/A
BH counseling and
HD
$32.03
minutes; 1 or
therapy, per 15 minutes
15, 19, 22, 32, 33, 34,
H0004
N/A
N/A
BH counseling and
U5
UN (1=15
therapy, per 15 minutes
*02, 03, 09, 11, 12, 13,
H0004
N/A
N/A
BH counseling and
U5
GT
more)
therapy, per 15 minutes
53, *57, 62, 71, 72
H0004
N/A
N/A
BH counseling and
*02, 03, 09, 11, 12, 13,
$32.03
minutes; 1 or
therapy, per 15 minutes
15, 19, 22, 32, 33, 34,
H0023
N/A
N/A
Behavioral Health
GT
UN (1=15
Outreach Service
*02, 03, 09, 11, 12, 13,
H0023
N/A
N/A
Behavioral Health
GT
XE
more)
Outreach Service
53, *57, 62, 71, 72
H0023
N/A
N/A
Behavioral Health
HW
$32.03
minutes; 1 or
Outreach Service
15, 19, 22, 32, 33, 34,
BHO-F-COM-MA-MCD/11 /2015
(AG - VO STD FACILITY)
$25.20 UN (1 per UA) No 03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
Payment
Type
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
Amend 14 - PID 301052
Page 10 of 64
UN (1=15
*02, 03, 09, 11, 12, 13,
$32.03
minutes; 1 or
No
15, 19, 22, 32, 33, 34,
more)
533 *57, 62, 71, 72
UN (1=15
*02, 03, 09, 11, 12, 13,
$32.03
minutes; 1 or
No
15, 19, 22, 32, 33, 34,
more)
53, *57, 62, 71, 72
*02, 03, 09, 11, 12, 13,
15, 19, 22, 32, 33, 34,
GT
$32.03
UN (1=15
minutes; 1 or
No
more)
53, *57, 62, 71, 72
UN (1=15
*02, 03, 09,11, 12, 13,
$32.03
minutes; 1 or
No
15, 19, 22, 32, 33, 34,
more)
531 *57, 62, 71, 72
UN (1=15
*02, 03, 09, 11, 12, 13,
$32.03
minutes; 1 or
No
15, 19, 22, 32, 33, 341
more)
53, *57, 62, 71, 72
UN (1=15
*02, 03, 09, 11, 12, 13,
$32.03
minutes; 1 or
No
15, 19, 22, 32, 33, 34,
more)
53, *57, 62, 71, 72
UN (1=15
*02, 03, 09, 11, 12, 13,
$32.03
minutes; 1 or
No
15, 19, 22, 32, 33, 34,
more)
53, *57, 62, 71, 72
UN (1=15
-*02.03, 09, 11, 12, 13,
$32.03
minutes; 1 or
No
15, 19, 22, 32, 33, 34,
more)
53, *57, 62, 71, 72
$100.92
UN (1 per
No
03, 09, 11, 12, 13, 15,
19, 22, 32, 33, 34, 53,
encounter)
57, 62, 71, 72, 99
03, 09, 11, 12, 13,151
19, 22, 32, 33, 34, 53,
$100.92
UN (1 per
No
encounter)
57, 62, 71, 72, 99
$100.92
UN (1 per
No
03, 09, 11, 12, 13, 15,
19, 21, 22, 32, 33,341
encounter)
53, 57, 62, 71, 72, 99
Payment
Type
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
Amend 14 - PID 301052
Page 10 of 64
Service
Allowed
d On
Interactive
Complexity
Service Description
Payment
N
M
a
Code
Cod
Code(s)
Add On
NWSA
o
0
0
0
encounter)
53, 57, 62, 71, 72, 99
Code
M
M
M
03, 09, 11, 12, 13, 15,
19, 21, 22, 32, 33, 34,
H0023
N/A
N/A
Behavioral Health
HW
HD
GT
UN (1 per
encounter)
No
03, 09, 11, 12, 13, 15,
19, 21, 22, 32, 33, 34,
FFS
Outreach Service
531 57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health
HW
HD
U5
53, 57, 62, 71, 72, 99
$100.92
Outreach Service
No
03, 09) 11, 12, 13, 15,
19, 21, 22, 32, 33, 34,
FFS
U5
H0023
N/A
N/A
Behavioral Health
Outreach Service
HW
HD
U5
GT
H0023
N/A
N/A
Behavioral Health
HW
U5
FFS
53, 57, 62, 71, 72, 99
UN (1 per 03, 09, 11, 12, 13, 15,
$100.92
encounter) No 19, 21, 22, 32, 33, 34,
Outreach Service
53 57 62 71 72 99
N/A
Behavioral HealthUN
Outreach Service
XE
H0023
N/A
N/A
Behavioral Health
HW
XE
Outreach Service
H0023
N/A
N/A
Behavioral Health
HW
GT
XE
Behavioral Health
Outreach Service
Outreach Service
FFS
H0023
N/A
N/A
Behavioral Health
Outreach Service
HW
U5
GT
XE
H0023
N/A
N/A
Behavioral Health
HW
HD
XE
N/A
Behavior Health
Prevention Education
HD
Outreach Service
UN (1 per 03,11,12,13,15,19--,
$78'75 No 22, 32, 33, 34, 53, *57,
FFS
Rate per
Unit
Allowed Billing
Unit
N/A
Place of Service
Payment
HD
GT
a
(POS)
Type
$100.92
UN (1 per
encounter)
No
03, 09, 11, 12, 13, 15,
19, 21, 22, 32, 33, 34,
FFS
encounter)
53, 57, 62, 71, 72, 99
531 57, 62, 71, 72, 99
$100.92
UN (1 per
encounter)
No
03, 09, 11, 12, 13, 15,
19, 21, 22, 32, 33, 34,
FFS
H0023
N/A
N/A
53, 57, 62, 71, 72, 99
HW
$100.92
UN (1 per
encounter)
No
03, 09, 11, 12, 13, 15,
19, 21, 22, 32, 33, 34,
FFS
531 57, 62, 71, 72, 99
$100.92
UN (1 per
encounter)
No
03, 09, 11, 12, 13, 15,
19, 21, 22, 32, 33, 34,
FFS
53, 57, 62, 71, 72, 99
$100.92
UN (1 per
encounter)
No
03, 09) 11, 12, 13, 15,
19, 21, 22, 32, 33, 34,
FFS
U5
XE
$ 100.92 UN (1 per 03, 09, 11, 12, 13,15,
No 19, 21, 22, 32, 33, 34,
53, 57, 62, 71, 72, 99
$100.92
UN (1 per
encounter)
03, 09, 11, 12, 13, 15,
No 19, 21, 22, 32, 33, 34,
FFS
531 57, 62, 71, 72, 99
$100.92
UN (1 per 03, 09, 11, 12, 13, 15,
encounter) No 19, 21, 22, 32, 33, 34,
FFS
53, 57, 62, 71, 72, 99
UN (1 per 03, 09, 11, 12, 13, 15,
$100.92
encounter) No 19, 21, 22, 32, 33, 34,
FFS
53 57 62 71 72 99
N/A
H0023
NIA
N/A
Behavioral Health
Outreach Service
HW
HD
GT
XE$92 100.UN (1 per 03, 09,11,12,13,15,
No 19, 21, 22, 32, 33, 34,
FFS
encounter)
53, 57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health
Outreach Service
HW
HD
U5
XE 100.92 UN (1 per 03, 09, 11, 12, 13,15,
$ No 19, 21, 22, 32, 33, 34,
FFS
encounter)
531 57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health
Outreach Service
HW
U5
XE
$ 100.92 UN (1 per 03, 09, 11, 12, 13,15,
No 19, 21, 22, 32, 33, 34,
FFS
encounter)
53, 57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral HealthUN
Outreach Service
XE
(1 per 03, 09, 11, 12, 13,15,
$100.92 No 19, 22, 32, 33, 34, 53,
FFS
encounter)
57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health
Outreach Service
UN (1 per 03, 09, 11, 12, 13,15,
$100.92 No 19, 22, 32, 33, 34, 53,
FFS
encounter)
57, 62, 71, 72, 99
H0025
N/A
N/A
Behavior Health
Prevention Education
HD
UN (1 per 03,11,12,13,15,19--,
$78'75 No 22, 32, 33, 34, 53, *57,
FFS
encounter)
6231172
72
H0025
N/A
N/A
Behavior Health
Prevention Education
HD
GT
$78,75 UN (1 per 03,11,12,13,15,19,
No 22, 32, 33, 34, 53, *57,
FFS
encounter)
62, 71, 72
H0025
N/A
N/A
Behavior Health
Prevention Education
HD
U5
$78.75 UN (1 per 03,11,12,13,15,193
No 22, 32, 33, 34, 53, *57,
FFS
encounter)
62, 71, 72
H0025
N/A
N/A
Behavior Health
Prevention Education
HD
U5
GT
$ 78.75 UN (1 per 03,11, 12, 13, 15,19,
No 221 32, 33, 34, 53, *57,
FFS
encounter)
62, 71, 72
H0025
N/A
N/A
Behavior Health
Prevention Education
U5
UN (1 per 03,11,12,13,15,19,
$78'75 No 22, 32, 33, 34, 53, *57,
FFS
encounter)
--62,71,72
H0025
N/A
N/A
Behavior Health
Prevention Education
U5
GT
$ 78 75 UN (1 per 03,11,12,13,15,19,
No 22, 32, 33, 34, 53, *57,
FFS
encounter)
62, 71, 72
H0025
N/A
N/A
Behavior Health
Prevention Education
U5
HD
UN (1 per 03,11, 12, 13,15,19,
$78.75 No 22, 32, 33, 34, 53, *57,
FFS
encounter)
62, 71, 72
H0025
N/A
N/A
Behavior Health
Prevention Education
U5
HD
GT
UN (1 per 03, 11, 12, 13, 15,19,
$78.75 No 22, 32, 33, 34, 53, *57,
FFS
encounter) 2,71 72
H0025
N/A
N/A
Behavior Health
UN (1 per 03, 11, 12, 13, 15,19,
$78'75 *57,
Prevention Education
encounter No 22, 32, 33, 34, 53,
)62, 71, 72
UN (1 per
$157.50 encounter No 03,15, 99
FFS
H0026
N/A
N/A
Alcohol /drug
revention
GT
FFS
BHO_F-COM-MA-MCD/11/2015
(AG
VO STD FACILITY)
Amend 14 - PID 301052
Page 11
of 64
Service
Allowed
Add On
Interactive
Complexity
Service Description
T
„
Code
Code(s)
Add On
NWSA
o
0
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
Code
UN (1 per
encounter
2i
M
H0026
N/A
N/A
Alcohol / drug
HD
U5
svc, NOS
$157.50
prevention
No
03,15, 99
H0026
N/A
N/A
Alcohol / drug
HD
U5
encounter)
$157.50
prevention
No
03, 15, 99
H0026
N/A
N/A
Alcohol / drug
HD
03,15, 99
62, 71, 72
$157.50
prevention
No
03,15, 99
H0026
N/A
N/A
Alcohol / drug
HD
GT
U5
GT
$12.92
prevention
No
11, 12, 15, 53, *57, 99
H0026
N/A
N/A
Alcohol / drug
U5
GT
N/A
Alcohol / drug abuse
U5
prevention
encounter)
03, 04, 06, 09, 11,12,
H0026
N/A
N/A
Alcohol / drug
U5
13, 14, 15, 16, 18, 20,
H0047
N/A
$29.45
prevention
No
21, 22, 23, 31, 32, 51,
H0026
N/A
N/A
Alcohol / drug
svc, NOS
53, 55, 56, *57, 62, 71,
UN (1=15
H0050
prevention
N/A
72 99
H0038
N/A
N/A
Self-help/peer services,
No
03, 11, 12, 13, 15, 19,
22 32 33 34 53
per 15 minutes
per 15 minutes
H0050
N/A
N/A
Alcohol/drug services,
HD
Mental health services,
19, 22, 32, 33, 34, 53,
FFS
H0046
N/A
N/A
NOS, less than 15
UB
H0050
N/A
N/A
minutes
HD
GT
H0047
N/A
N/A
Alcohol / drug abuse
GT
*57, 62, 71, 72
H0050
Svc, NOS
N/A
Alcohol/drug services,
Cn
N/A
Rate per
Allowed Billing
.°
Place of Service
Unit
Unit
a
(POS)
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
$157.50
UN (1 per
encounter
No
03, 15, 99
GT
U5
$157.50
UN (1 per
encounter
No
03,15, 99
svc, NOS
$157.50
UN (1 per
encounter
No
03,15, 99
N/A
Alcohol / drug abuse
$157.50
UN (1 per
encounter
No
03, 15, 99
encounter)
$157.50
UN (1 per
encounter
No
03, 15, 99
H0047
N/A
$157.50
UN (1 per
encounter
No
03,15, 99
62, 71, 72
$157.50
UN (1 per
encounter
No
03,15, 99
FFS
H0047
UN (1=15
N/A
Alcohol / drug abuse
U5
GT
$12.92
minutes; 1 or
No
11, 12, 15, 53, *57, 99
svc, NOS
more
H0047
N/A
N/A
Alcohol / drug abuse
U5
encounter)
03, 04, 06, 09, 11,12,
62, 71, 72
svc, NOS
UN (1=<15
13, 14, 15, 16, 18, 20,
H0047
N/A
$29.45
minutes; 1 per
No
21, 22, 23, 31, 32, 51,
more
encounter)
svc, NOS
53, 55, 56, *57, 62, 71,
UN (1=15
H0050
N/A
N/A
72 99
GT
19, 22, 32, 33, 34, 53,
$29.45
UN (1 per
No
03, 11, 12, 13, 15, 19,
22 32 33 34 53
per 15 minutes
UN (1=15
H0050
N/A
H0047
N/A
N/A
Alcohol / drug abuse
HD
GT
62, 71, 72
svc, NOS
UN (1 per
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
H0047
N/A
N/A
Alcohol / drug abuse
HD
U5
$29.45
UN (1 per
encounter)
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
svc, NOS
H0047
N/A
N/A
Alcohol / drug abuse
HD
U5
GT
encounter)
svc, NOS
$29.45
UN (1 per
H0047
N/A
N/A
Alcohol / drug abuse
HD
62, 71, 72
$29.45
UN (1 per
encounter)
svc, NOS
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
H0047
N/A
N/A
Alcohol / drug abuse
U5
GT
No
03) 11, 12, 13, 15, 19,
22, 32, 33, 340 531 *57,
FFS
svc, NOS
H0047
N/A
N/A
Alcohol / drug abuse
U5
encounter)
62, 71, 72
svc, NOS
UN (1=15
03, 09, 11, 12, 13, 15,
H0047
N/A
N/A
Alcohol / drug abuse
19, 22, 32, 33, 34, 53,
FFS
more
*57, 62, 71, 72
svc, NOS
UN (1=15
H0050
N/A
N/A
Alcohol/drug services,
GT
19, 22, 32, 33, 34, 53,
FFS
more)
per 15 minutes
UN (1=15
H0050
N/A
N/A
Alcohol/drug services,
HD
No
19, 22, 32, 33, 34, 53,
FFS
more)
per 15 minutes
*57, 62, 71, 72
H0050
N/A
N/A
Alcohol/drug services,
HD
GT
19, 22, 32, 33, 34, 53,
FFS
more)
per 15 minutes
*57, 62, 71, 72
H0050
N/A
N/A
Alcohol/drug services,
HD
U5
GT
19, 22, 32, 33, 34, 53,
FFS
per 15 minutes
*57, 62, 71, 72
H0050
N/A
N/A
Alcohol/drug services,
HD
U5
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
FFS
per 15 minutes
more)
*57, 62, 71, 72
H0050
N/A
N/A
Alcohol/drug services,
U5
GT
per 15 minutes
BHO-F-COM-MA-MCD/1 1/2015
(AG - VO STD FACILITY)
Payment
Type
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
FFS
'
encounter)
57,
FFS
62, 71, 72
$29.45
UN (1 per
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
encounter)
62, 71, 72
$29.45
UN (1 per
encounter)
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
62,71 72
$29.45
UN (1 per
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *571
FFS
encounter)
62, 71, 72
$29.45
UN (1 per
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
encounter)
62, 71, 72
$29.45
UN (1 per
encounter)
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
62, 71, 72
$29.45
UN (1 per
encounter)
No
03) 11, 12, 13, 15, 19,
22, 32, 33, 340 531 *57,
FFS
-62,71,72
$29.45
UN (1 per
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
encounter)
62, 71, 72
UN (1=15
03, 09, 11, 12, 13, 15,
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
FFS
more
*57, 62, 71, 72
UN (1=15
03, 09, 11, 12, 13, 15,
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
FFS
more)
*57, 62, 71, 72
UN (1=15
03, 09, 11, 12, 13, 15,
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
FFS
more)
*57, 62, 71, 72
UN (1=15
03, 09, 11, 12, 13, 15,
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
FFS
more)
*57, 62, 71, 72
U N (1=15
--
03, 09, 11, 12, 13, 15,
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
FFS
more)
*57, 62, 71, 72
UN (1=15
03, 09, 11, 12, 13, 15,
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
FFS
more)
*57, 62, 71, 72
Amend 14 - PID 301052
Page 12 of 64
Service
Allowed
Add On
Interactive
Complexity
Service Description
Payment
a
Code
Codes)
Add On
Code
NWSA
M �
0
0
$23.26
H0050
N/A
N/A
Alcohol/drug services,
U5
more)
*57, 62, 71, 72
UN (1=15
per 15 minutes
03, 09, 11, 12, 13, 15,
$23.26
minutes; 1 or
H0050
N/A
N/A
Alcohol/drug services,
more)
*57, 62, 71, 72
UN (1= 15
per 15 minutes
$0.01
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
Prepaid
Sign Lang/Oral
*57, 62, 71, 72
UN (1=15
03, 09, 11, 12, 13,15,
Interpreter Services
$0.01
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
T1013
N/A
N/A
(Note: submit
GT
UN (1=15
encounters for reporting
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
FFS
more
and invoice for
UN (1=15
$14.67
reimbursement
No
03, 09, 11, 12, 13,15,
19, 22, 53, 57, 71, 72
FFS
more
Sign Lang/Oral
UN (1=15
$14.67
minutes; 1 or
Interpreter Services
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
FFS
more
T1013
NIA
NIA
(Note: submit
UN (1=15
$14.67
minutes; 1 or
No
encounters for reporting
FFS
more
and invoice for
$14.67
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
reimbursement
more
T1016
N/A
N/A
Case management,
GT
$14.67
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
FFS
each 15 minutes
more
T1016
NIA
N/A
Case management,
HD
U5
GT
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
FFS
each 15 minutes
T1016
N/A
N/A
Case management,
HD
each 15 minutes
T1016
N/A
N/A
Case management,
HD
GT
each 15 minutes
T1016
N/A
NIA
Case management,
U5
each 15 minutes
T1016
N/A
N/A
Case management,
U5
GT
each 15 minutes
T1016
N/A
N/A
Case management,
each 15 minutes
BHO-F-COM-MA-MCD/11/2015
(AG - VO STD FACILITY)
Rate per
Unit
Allowed Billing
Unit
Place of Service
Payment
a
(POS)
Type
UN (1=15
03, 09, 11, 12, 13,15,
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
FFS
more)
*57, 62, 71, 72
UN (1=15
03, 09, 11, 12, 13, 15,
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
FFS
more)
*57, 62, 71, 72
UN (1= 15
03, 09, 11, 12, 13,15,
$0.01
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
Prepaid
more)
*57, 62, 71, 72
UN (1=15
03, 09, 11, 12, 13,15,
$0.01
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
Prepaid
more)
*57, 62, 71, 72
UN (1=15
$14.67
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
FFS
more
UN (1=15
$14.67
minutes; 1 or
No
03, 09, 11, 12, 13,15,
19, 22, 53, 57, 71, 72
FFS
more
UN (1=15
$14.67
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
FFS
more
UN (1=15
$14.67
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
FFS
more
UN (1=15
$14.67
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
FFS
more
UN (1=15
$14.67
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
FFS
more
UN (1=15
$14.67
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
FFS
more
Amend 14 - PID 301052
Page 13 of 64
Exhibit A -3.A14
NWSR Inpatient Residential Mental Health Rate Schedule
This Exhibit contain the Service Codes and billing rates that are allowed under the NWSR fund
Schedule is a table listingmodifiers code. Following the Rate
and their descriptions as well as a key to abbreviations that may be used in this Rate
Schedule.
Definitions
1. Payment Type:
a. Fee for Service (FFS): Claims submitted for health care payments, also known as the Fee for
Service (FFS)
payment type, must be cleanly submitted within current Washington State Health Care Authoritytime) filing
requirements in the format outlined in this Rate Scheduletimely
.
b. Prepaid: Encounters submitted for health care reporting purposes, also known as the Prepaid
must be clean) submitted to B epaid payment type,
Y Beacon monthly in the format outlined in this Rate Schedule. Payment for
services provided will be made according to the Payment Method identified in Exhibit B-2 Maximum Contract
Amounts.
NWSR Rate Schedule.A14: Inpatient Residential MH
Service
Allowed
Add On
Interactive
Complexity
Service Description
21, 51, 55,
Code
Codes
Add on
Code
NWSR
FFS
56, 57, 99
03, 09, 11,
BH services, short
12, 13,15, 19,
22, 32, 33,
Prepaid
term residential
H0018
N/A
- N/A
(nonhospital program
12, 13,15, 19,
22, 32, 33,
Prepaid
where stay is typically
62171,72
less than 30 days)
BH services, long term
residential
H0019
N/A
N/A
(nonmedical, non-
acute care program
where stay is typically
longer than 30 days)
Sign Lang/Oral
Interpreter Services
T1013
N/A
N/A
(Note: submit encounters
for reporting and invoice
for reimbursement)
Sign Lang/Oral
T1013
NIA
N/A
Interpreter Services
(Note: submit encounters
GT
for reporting and invoice
for reimbursement)
BHO-F-COM-MA-MCD/11/2015
(AG - VO STD FACILITY)
N M
Rate per Allowed
�L
Unit Billing Unit Q
UN (1= a day;
$474.30 1 or more) All-
inclusive per Yes
diem
UN(1=qday;
$357.00 1 or more) All-
inclusive per Yes
diem
UN (1= 15
$0.01 minutes; 1 or No
more)
UN (1= 15
$0.01 minutes; 1 or No
more)
Place of
Service
payment
(POS)
Type
21, 51, 55,
FFS
56, 57, 99
21, 51, 55,
FFS
56, 57, 99
03, 09, 11,
12, 13,15, 19,
22, 32, 33,
Prepaid
34, 53, *57,
62, 71, 72
03,09$ 11,
12, 13,15, 19,
22, 32, 33,
Prepaid
34, 53, *571
62171,72
Amend 14 - PID 301052
Page 14 of 64
Exhibit 13-2.A14
Maximum Contract Amounts
Beacon shall have no obligation to pay for costs or claims in excess of the amounts listed below for the identifiederiods
p ,unless
this Exhibit is amended pursuant to the terms of the Agreement.
I: General Provisions.
(1) Whenever in this Exhibit B-2 the term "Facility" is used to describe an obligation or duty, such obligation or duty Y g y wi II also
be the responsibility of each individual licensed health care practitioner, Facility, and provider employed or owned by or
under contract with Facility, as the context may require.
(2) Facility agrees:
a. All contracted crisis providers under this Exhibit are delegated crisis providers under the following Manageded CareOrganization (MCO) networks: CCCWA CHPW AH, AGPWA, Molina's Medicaid network
and United's
Washington Medicaid Network
II: Definitions.
(1) Claims, also known as Fee for Service (FFS) payment type, means an attempt to cause a health carea er to
p y make a
health care payment for a specified health care service.
(2) Encounters, also known as the Prepaid payment type, means the transmission of information equivalent to a health
q care
claim for a specified health care service for the purpose of health care reporting.
(3) Payment Method:
a. Fee for Service (FFS) means the Facility will submit clean claims within timely filing limits to receivea ment for
i
direct services provided. Claims should be submitted wp Y
with the rate on the Rate Schedules in this contract.
b. Prepaid:
i. Capacity means the Facility will submit monthly invoices to Beacon for 1/6 of each 6-montheriod's
contract maximum and will also submit encountersp
to document all direct services provided. Direct
Services are those details in the current Rate Schedule(s). Encounters must be submitted month) for
the previous month. y
ii. Cost Reimbursement means the Facility will submit monthly invoices to Beacon for actual costs to be
reimbursed up to the contract maximum and will also submit encounters to document all direct services
provided. Direct services are those detailed in the current Rate Schedule(s). Encounters must be
submitted monthly for the previous month.
III: Maximum Contract Amounts.
(1) The following table outlines the maximum amounts funded under this contract for the statederiod. Unspent fun
p p ds from
the first 6 -month period may be spent in the second 6 -month period. Unspent funds do not carry over after June 30 2022
(2) Monitoring Facility spending against the funds allocated in this Amendment is the responsibility of Facility. Beacon
supports this responsibility by providing Facility with periodic Finance Memos that include payments made b Beacon to
Y
Facility and any remaining funds available for that fiscal year.
Y
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page 15 of 64
(3) Invoices for Capacity or Cost Reimbursement payment methods shall be submitted monthly within 30 days of the end of
the month being billed, unless otherwise specified in a subject matter Exhibit. Final invoices must be submitted within 30
days of the end of fiscal year to facilitate a determination on re -allocation of unused funds.
a. Payment may be withheld if contractual obligations, including but not limited to the timely provision of required
reports, are not met.
(4) Behavioral Health Workforce Investment Program:
a. Dollars allocated in the Maximum Contract Amounts table below for BH Workforce Investment Program are
available to the Facility only when all of the following steps have been completed.
i. Proposal outlining how BH Workforce Investment Program will be implemented is received by the due
date outlined in the invitation letter.
ii. Proposed spending is within the allowable expenses and approved by Beacon.
iii. Proposal includes only cost reimbursement expenses.
iv. Facility agrees to provide 2 brief reports
1. Brief mid -year narrative update due January 31, 2022
2. Final report on program outcomes due June 30, 2022
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page 16 of 64
Table 1.A14
Maximum Contract Amounts
July 1, 2021— June 30, 2022
Program
g am or Service
Exhibit
Payment
Funding
Fund
July 2021
—Dec
Jan 2022
— June
Total
Method
Source
Code
2021
2022*
FY21/22
Workforce Investment
(Base Amount
B- 2
Cost
Reimbursement
est
Non-
N/A
$50,000
$50,000
$1003000
Workforce Investment
(Medicaid Incentive
Medicaid
$12,500
$12,500
$253000
State
Mobile Crisis and
Designated Crisis
B-4
Capacity
NWRF
$126189
$1263189
$252,377
Medicaid
$2943440
$294,440
$5883881
Responder Services
IP Residential MH
Step-down
Treatment
B-7
Fee for Service
Transitional
NWSR
$110,350
$110,350
$220,700
Residential
NWMH
$55,965
$55,965
$111,931
Mobile Outreach Team
B-10 and
MHBG
Addendum
Cost
Reimbursement
SABG
NWSA
$213981
$21,981
$43,962
Safe Syringe Program
$5,100
$510010
2
$ 00
Outpatient Substance
Use Disorder Services
8-11
Fee For Service
$143229
$14,229
$283458
Certified Mental Health
Professional with
Cost
Dedicated
Chemical Dependency
Reimbursement
Marijuana
N/A
$10,000
$10,000
$20,000
Certification
Acct (DMA)
fundina
Grand
for this eriod.
Total
$1,401,509
* Contin ent upon Beacon's recei t of si ned HCA Amendment confirming
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page 17 of 64
Exhibit B -4.A14
Crisis Program Provisions (Mobile Crisis and Designated Crisis Responder)
This Exhibit contains additional provisions applicable to Covered Services rendered to Eligible Individuals as defined below
covered under Crisis Program Provisions (as defined below) offered and/or administered by Washington State Health Care
Authority (HCA). In the event of an conflict between provisions g
Y the provisions of the Agreement (including Exhibit B-8), and this Exhibit B-4
and subject to the provisions set out in Exhibit B-4, the provisions of this Exhibit control as related to services rendered to individuals
receiving Crisis Program Services.
General Provisions.
(1) Whenever in this Exhibit B-4 the term "Facility" is used to describe an obligation or duty, such obligation or duty will also
be the responsibility of each individual licensed health care practitioner, Facility, and provider employed Y ed or owned b or
under contract with Facility, as the context may require.
(2) Facility agrees:
a. Facility shall provide crisis intervention services in accordance with 246-341-0900 (Crisis MH Services —
General), 246-341-0905 (Crisis MH Services — Telephone Support Services), 246-341-0910 Crisis MH Services
Outreach Services Outreach), 246-341-0915 (Crisis MH Services — Stabilization Services), 246-341-0920
(Crisis MH Services — Peer Support), 246-341-0810 (Crisis MH Services — Emergency Involuntary Detention
Services), and 246-341-0748OP Services — S D
( U Info Assistance- Info and Crisis Services), and Chapters
71.05 RCW and 71.34 RCW and be licensed by the DOH under WAC 246-341-0900 to -0915; as well as the
Beacon Level of Care Guidelines which are incorporated herein by reference.
b. Crisis System Staffing Requirements
i. Facility shall ensure compliance with applicable staffing requirements of Chapter 246-341 WAC.
ii. Facility shall ensure they have sufficient staff available, including DCRs, to respond to requests for
Crisis Services and ITA services, as applicable.
iii. Facility shall comply with DCR qualification requirements in accordance with Chapters 71.05 and 71.34
RCW and WAC 246-341-0900 to -0915 and shall incorporate the statewide DCR Protocols, listed on
the HCA website, into the practice of DCRs.
iv. DCRs must be designated by the county or other authority authorized in rule. DCR designation shall
be documented in credentialing rosters submitted to Beacon and monthly attestations confirming
whether the DCR designation remains valid.
v. Facility shall ensure that staff are available for consultation 24 hours a day, seven (7) days a week who
have expertise in Behavioral Health conditions pertaining to children and families.
vi. Facility shall have at least one SUDP and one CPC with experience providing Behavioral Health crisis
support available for consultation by phone or on site during regular Business Hours.
vii. Facility shall have established crisis and ITA services policies and procedures, as applicable, that
the requirements:
implement WAC 246-341-0810 and f p
1. No DCR or crisis worker shall be required to respond to a private home or otherp rivate
location to stabilize or treat a person in crisis, or to evaluate a person for potential detention
under the state's ITA, unless a second trained individual accompanies them.
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page 18 of 64
2. The team supervisor, on-call supervisor, or the individual, shall determine the need for a
second individual to accompany them based on a risk assessment for potential violence.
3. The second individual who responds may be a First Responder, a Mental Health Professional,
a SUDP, or a mental health provider who has received training required in RCW 49.19.030.
4. No retaliation shall be taken against an individual who, following consultation with the clinical
team or supervisor, refuses to go to a private home or other private location alone.
5. Have a plan to provide training, mental health staff back up, information sharing, and
communication for crisis staff who respond to private homes or other private locations.
6. Every DCR dispatched on a crisis visit shall have prompt access to information about an
Individual's history of dangerousness or potential dangerousness documented in crisis plans
or commitment records and is available without unduly delaying a crisis response.
7. Facility shall provide a wireless telephone or comparable device to every DCR or crisis worker,
who participates in home visits to provide Crisis Services.
c. Facilities shall provide mobile crisis outreach services in accordance with Chapter 246-341 hereafter referred to
as Mobile Crisis Intervention services consistent with Mobile Crisis Intervention technical specifications as well
as the Beacon Level of Care Guidelines which are incorporated herein by reference.
d. If applicable, Facility shall provide Involuntary Treatment Act Services (ITA) in a manner that includes all services
and administrative functions required for the evaluation for involuntary detention or involuntary treatment of
individuals in accordance with WAC 246-341-0810 Chapters 71.05 RCW, 71.34 RCW, and 71.24.300 RCW.
Crisis Services become Involuntary Treatment Act Services when a Designated Crisis Responder (DCR)
determines an individual must be evaluated for involuntary treatment. The decision making authority of the DCR
must be independent of Beacon's administration. Services include investigation and evaluation activities,
management of the court case findings and legal proceedings in order to ensure the due process rights of the
Individuals who are detained for involuntary treatment. ITA services continue until the end of the involuntary
commitment.
e. Facility shall respond in a full and timely manner to law enforcement inquiries regarding an Individual's eligibility
to possess a firearm under RCW 9.41.040(2)(a)(ii).
f. Facility shall coordinate interventions with other community resources, including regional Managed Care
Organization (MCO) when applicable, to provide an array of stabilization and recovery services and avoid
unnecessary hospitalizations. For Individuals who are American Indian/Alaska Native (AVAN), assist in connecting
the Individual to services available from a Tribal government or Indian Health Care Provider (IHCP).
g. All contracted crisis providers under this Exhibit are delegated crisis providers under the following Managed Care
Organization (MCO) networks: CCCWA, CHPW AH, AGPWA, Molina's Medicaid network and United's
Washington Medicaid Network.
II: Definitions.
(1) Co -responder: Teams consisting of law enforcement officer(s) and behavioral health professional(s) to engage with
individuals experiencing behavioral health crises that does not rise to the level of need for incarceration.
(2) Crisis Hotline: This is the 24/7 regional crisis line that is available to all individuals in the region and serves as the front
door to the crisis system.
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page 19 of 64
(3) Crisis Program: The program is the provision of those crisis services further described within this Exhibit B-4 which are
reimbursable pursuant to the contract between Beacon and the Washington State Health Care Authority.
Y
(4) Crisis Services (Behavioral Health): Crisis Services (Behavioral Health) means providing evaluation and short term
treatment and other services to individuals with an emergent mental health condition or are intoxicated or incapacitated
due to substance use and when there is an immediate threat to the individuals health or safety.
(5) Cultural Humility: The continuous application in professional practice of self -reflection and self -critique, learning from
g
patients, and partnership building, with an awareness of the limited ability to understand the patient's worldview, culture(s)
and communities. '
(6) Culturally Appropriate Care: Health care services provided with Cultural Humility and an understanding of the patient's
culture and community, and informed by Historical Trauma and the resulting cycle of Adverse Childhood Experiences
(ACEs).
(7) Designated Crisis Responder (DCR): Means a person designated by the County or other authority authorized in rule to
perform the civil commitment duties described in Chapter 71.05 RCW. ,
(8) Eligible Individuals: For purposes of this Exhibit B-4, medically necessary Crisis Services will be available to all individuals
who present with a need for Crisis Services in the Regional Service Area regardless of insurance status, ability pay,
aY,
county of residence, or level of income.
(9) Involuntary Treatment Act (ITA): Allows for individuals to be committed by court order to a hospital or facility for a limited
period of time. Involuntary civil commitments are meant to provide for the evaluation and treatment of individuals with a
behavioral health disorder and who may be either gravely disabled or pose a danger to themselves or others and who
refuse or are unable to enter treatment on their own. An initial commitment may last up to one hundred twenty (120)hours,
but if necessa individual ' ' � �
necessary, s can be committed for additional periods of fourteen (14), ninety (90), and one hundred eighty
(180) calendar days of inpatient involuntary treatment or outpatient involuntary treatment (RCW 71.05.180, 71.05.230 and
71.05.290).
(10) Involuntary Treatment Act Services: Includes all services and administrative functions required for the evaluation for
involuntary detention or involuntary treatment of individuals civilly committed under the ITA in accordance with Chapters
71.05 and 71.34 RCW and RCW 71.24.300. p
(11) Less Restrictive Alternative (LRA) Treatment: Means a program of individualized treatment in a less restrictive setting
than inpatient treatment that include the services described in RCW 71.05.585
.
(12) Mobile Crisis Intervention (MCI): MCI provides a short-term service that is a mobile, on-site, face-to-face therapeutic
response to an individual experiencing a behavioral health crisis for the purpose of identifying, assessing, treating, and
stabilizing the situation and reducingimmediate risk of danger g
g to the individual or others. Hours of operation vary by
region. The service includes: A crisis assessment and engagement in a crisis planning process, up to 7 days of crisis
intervention and stabilization services including: on-site face-to-face therapeutic response, psychiatric consultation and
urgent psychopharmacology intervention, as needed, and referrals and linkages to all medically necessary behavioral
health services and supports, including access to appropriate services along the behavioral health continuum of care.
(13) Mobile Crisis Intervention Program Technical Specifications: This a set of documents that describes in detail contracted
program expectations for adult mobile crisis intervention (AMCI) and youth mobile crisis intervention It is a
supplement (YMCI). to the W �
Washington Provider Service Instruction Manual. It is available on Beacon's website
(14) Peer Support Services: means behavioral health services provided by Certified Peer Counselors. This servicep rovides
scheduled activities that promote socialization, recovery, self -advocacy, development of natural supports, and
pp
maintenance of community living skills. Individuals actively participate in decision-making and the operation of the
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page 20 of 64
programmatic supports.
(15) Withdrawal Management (previously known as detoxification); Care and treatment in a residential or hospital setting of
p g
persons intoxicated or incapacitated by alcohol or other drugs during the period in which the person is recovering from
the transitory effects of intoxication or withdrawal. Acute detoxification provides medical care and physician supervision;
subacute detoxification is non-medical.
III. Services. Facility agrees to:
(1) Interpreter services for Individuals in crisis over -the -telephone.
a. Facility will submit encounter codes for interpretation provided over -the -phone to Individuals in crisis.
b. Reimbursable Services must meet the following criteria:
i. The Individuals must be Medicaid eligible on the date the service took place;
ii. The Individual received a Medicaid covered service by a servicing provider that has a Core Provider
Agreement with HCA;
iii. The Interpretation requests must be for urgent same day events, necessary to assist Individuals
determined to be in crisis;
iv. Services must be provided by a qualified interpreter as described by Section 1557 of the Affordable
Care Act; and
v. The encounter must be submitted to Beacon within forty-five (45) calendar days of the date of service.
c. Do not submit encounter codes for administrative activities including but not limited to: scheduling or reminder
calls, scheduled events, and appointments scheduled more than 24 -hours in advance.
(2) Deliver crisis response and intervention services, referral and linkage services to all individuals located in the designated
Regional Service Area/County in accordance with CFR 42, WAC 246-341, current DCR protocols set out by the Division
of Behavioral Health and Recovery (DBHR) (or its successor), and any other documents incorporated by reference.
(3) The Facility will implement the requirements of 2007-2008 Substitute House Bill 1456, including the provision of secondary
personnel when deemed necessary by acting Crisis Supervisor, provision by Facility of a wireless telephone or
comparable device for the purpose of emergency communication, and annual training on safety and violence prevention
topics described in RCW 49.19.030 for all who work directly with clients. This act is known as the Marty Smith law.
(4) Crisis Services shall be delivered as follows:
a. Stabilize Individuals as quickly as possible and assist them in returning to a level of functioning that no longer
qualifies them for Crisis Services.
b. Provide solution -focused, person -centered, and Recovery -oriented interventions designed to avoid unnecessary
hospitalization, incarceration, institutionalization, or out of home placement.
c. Coordinate closely with regional MCOs, community court system, First Responders, criminal justices stem,
inpatient/residential service providers, Tribal governments, ICHPs, and outpatient behavioral health providers to
include processes to improve access to timely and appropriate treatment for Individuals with current and orp rior
criminal justice involvement.
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(AG — VO STD FACILITY) Page 21 of 64
d. Engage the Individual in the development and implementation of crisis prevention plans to reduce unnecessary
crisis system utilization and maintain the Individual's stability.
Y
e. Develop and implement strategies to assess and improve the crisis system over time.
(5) Core MCI services the Facility shall provide include:
a. Coordination with co -responders within the region.
b. A comprehensive crisis assessment, including a mental status exam, crisis precipitants, behavioral health and
physical health history, medication history and compliance, safety/risk issues with the individual and / or
caregiver(s) / natural supports, and functioning at home, work, and community.
c. Providing support, information, understanding and consultation to caregiver(s) / natural supports who are likely
y
experiencing (normal, but often overwhelming) stress, concern, and exhaustion so that they are best equipped
to participate in the intervention, make decisions support their loved one.
.
d. Discussing and activating caregiver / natural support strengths and resources to identifyhow such strengths and
resources impact their ability to care for individual's g
p y the individual's behavioral health needs.
e. Assessing the individual's behavior and the responses of caregivers)/natural support and others to the
individual's behavior
f. Identifying current providers, including state agency involvement.
g. Attempt to obtain Release of Information (ROIs) and document stakeholder coordination in the clinical record.
h. Ensure that all calls, services, and outcomes are documented in compliance with record content and
documentation requirements in accordance with WAC 246-341-0900 to -0915.
i. Identifying natural supports and community resources that can assist in stabilizing the situation and offer ongoing
support to the individual and caregiver(s). g g
j. Identification and inclusion of professional and natural supports (e.g., therapist, neighbors, relatives) ) who can
assist in stabilizing the situation and offer ongoing support.
k. Psychiatric consultation and urgent psychopharmacology intervention (if current prescribing provider cannot be
reached immediately or if no current provider exists), as needed, from an on-call psychiatrist or Psychiatric Nurse
p
Mental Health Clinical Specialist.
Y
I. Confirm whether the Individual has a Crisis Alert on file and get access to any risk management / safety plans,
g Y
if available. If the Individual does not already have one, develop risk management / safety plan.
m. Provide crisis intervention, including solution -focused crisis counseling and brief interventions that address
behavior and safety.
n. Referrals and linkages to all medically necessary behavioral health services and supports, includingaccess to
appropriate services alongthe behavioral health c
continuum of care.
o. For individuals who are receiving Program for Assertive Community Treatment (PACT)ro ram� � � or similar program, ' MCI
staff shall coordinate with the individual's care coordinator throughout the delivery of the Mobile Crisis service.
p. The MCI team shall coordinate with the individual's primary care provider, any other care ram management program,
g p g ,
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page 22 of 64
or other behavioral health providers providing services to the individual throughout the delivery of the Mobile
Crisis service.
q. MCI is not intended for the purposes of accessing respite, out -of -home placement, or outpatient treatment or to
supplant existing front-line responses for adults receiving services from a primary providere.. rima
PACT (g primary care,
residential, etc.).
r. MCI teams will respond in the following timeframes:
i. Triage calls within 15 minutes of initial request
ii. Strive to respond in person within 90 minutes or less, but within no more than the HCA's requirement
of 2 hours.
(6) Following completion of a Mobile Crisis Intervention, if the MCI clinician determines that DCR intervention
may be
medically necessary, the clinician will manage referrals and coordination of care.
a. MCI and DCR programs must coordinate and communicate daily to ensure effective community response
onse
management.
b. MCIs shall be utilized whenever possible to provide the initial response in order to maximize the efficient of
limited DCR resources by helpingto ensure DCRs respond to Y
p cases specific to RCW 71.05 .
(7) If the Facility provides DCR services, core services include:
a. Deliver Involuntary Treatment Act Services including all services and administrative functions required for the
evaluation for involuntarydetention or involuntary q
ry treatment of individuals in accordance with WAC 246-341-
0810, Chapter 71.05 RCW, 71.34 RCW and 71.24.300 RCW. The decision-making authority of the DCR shall
be independent of Beacon Health Options, Inc.
i. The Facility will have a process in place to determine if an individual is impaired due to thep resence of
substances in his/her system.
ii. The Facility will perform functions necessary for facilitation of voluntary psychiatric inpatient care and
least restrictive alternative care, including all necessary documentation and administrative functions.
iii. The Facility will monitor all individuals placed on Least Restrictive Alternatives (LRAs) and Conditional
Release (CR) in accordance with RCW 71.05.320, RCW 71.05.340, and RCW 71.05.585 respectively.,
and submit monthly updates to Beacon.
iv. The Facility shall report to HCA and Beacon when it is determined an Individual meets detention criteria
under RCW 71.05.150, 71.05.153, 71.34.700 or 71.34.710 and there are no beds available at the
Evaluation and Treatment Facility, Secure Withdrawal Management and Stabilization facility,
psychiatric unit, or under a single bed certification, and the DCR was not able to arrange for a less
restrictive alternative for the Individual.
v. When the DCR determines an Individual meets detention criteria, the investigation has been completed
and when no bed is available the DCR shall submitp
an Unavailable Detention Facilities report to HCA
and Beacon within 24 hours. The report shall include the following:
1. The date and time the investigation was completed;
2. A list of facilities that refused to admit the Individual;
BHO_F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG VO STD FACILITY) Page 23 of 64
3. Information sufficient to identify the Individual, including name and age or date of birth;
4. The identity of the responsible BH -ASO and MCO, if applicable;
5. The county in which the person met detention criteria; and
6. Other reporting elements deemed necessary or supportive by HCA.
w
vi. When a DCR submits a No Bed Report due to the lack of an involuntary treatment bed a face -to -fa
re -assessment is conducted each dab the DCR or Mental H face-to-face
Y Y Health Professional (MHP) employed by
the crisis provider to verify that the person continues to require involuntary treatment. If a bed is still
not available, the DCR sends a new Unavailable Detention Facilities Report (No Bed Report) p ) to HCA
and Beacon and the DCR or MHP works to develop a safety plan to help the person meet their health
and safety needs, which includes the DCR or MPH continuing to search for an involuntary treatment
bed or appropriate less restrictive alternative to meet the individual's current crisis.
b. The Facility will respond in person when requested by community stakeholders androviders unless: s. (
are significant safety issues identified, documented, and reported to Beacon; and / or(2)requesting
provider the re q g
stakeholder or
p der agree that a face-to-face response is not required.
C. The Facility will have clinicians available 24/7 who have expertise in behavioral health issuesertainin to
children, and families. p g adults,
d. The Facility's community response time will be no longer than 2 hours or as mandated b WAC and
y RCW.
e. The Facility will seek less restrictive alternatives for all individuals served, with effort made to maintain an
individual in his or her community, and voluntary placement when a higher level of care is clinical) indicated.
The Facilitymay provide crisis and commstabilizationY rated.
Y p unity services, in accordance with WAC 246-341-0915, to
stabilize individuals and assist them in returning to a level of functioning. These services may include brief
ief
counseling, skill building, case management, check -ins by phone or in person and other supportive services
Y g others for support
including engagement with family and significant oth pp
.
f. The Facility will coordinate with the outpatient provider system, including the MCO when appropriate, and
participate in treatment planning and treatment team meetings when requested.
g. The Facility may provide targeted, short term interventions including next day immediate access to outpatient
ent
services and/or follow up care. These services may include the following:
i. Face to face therapeutic response
ii. Telephonic psychiatric consultation
iii. Solution focused crisis counseling, including teaching of coping and behavior management skills, parent/family support and psychoeducation
iv. Telephonic support to individual and family
v. Collateral contacts
(8) Facility will execute and maintain inter -agency agreements or memorandum of understandingrovision of a lira ' ' documenting the
p applicable crisis services (Mobile Crisis Intervention, Designated Crisis Responder
partner organizations ) with applicable key
p g s including but not limited to school districts, child welfare, law enforcement, emergency services
g Y ,
BHO_F-COM-MA-MCD/11/2015 Amend 14 — PID 3010
(AG VO STD FACILITY) 52
Page 24 of 64
hospitals, providers, etc.
(9) Partner with Beacon to organize and facilitate community forum(s), on an agreed upon frequency, for theur oses of
p p
obtaining feedback about crisis services, identifying service gaps, and ensuring crisis services are responsive to the
unique needs of communities within the region.
(10) Implement a client satisfaction survey for individuals served through crisis services and report data to Beacon and at
agreed upon community forums. Results from the client satisfaction survey will inform quality improvement initiatives and
program development goals.
IV. Reporting Requirements are detailed in Exhibit B-25
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(AG — VO STD FACILITY) Page 25 of 64
Exhibit B -7.A14
Mental Health Program Provision
This Exhibit contains additional provisions applicable to Covered Services rendered to Eligible Individuals (as defined below)
covered under the Mental Health Program (as defined below) offered and/or administered by Washington State Health Care
Authority (HCA). In the event of any conflict between the provisions of the Agreement (including Exhibit B-8), and this Exhibit B-7
and subject to the provisions set out in Exhibit B-7, the provisions of this Exhibit control as related to services rendered to individuals
receiving Mental Health Program services.
General Provisions.
(1) Whenever in this Exhibit B-7 the term "Facility" is used to describe an obligation or duty, such obligation or duty will also
be the responsibility of each individual licensed health care practitioner, Facility, and provider employed or owned by or
under contract with Facility, as the context may require.
(2) Facility agrees:
a. Facility shall provide mental health services in accordance with the Beacon Level of Care Guidelines, which are
incorporated herein by reference.
b. Follow all rules and regulations of CFDA 93.958 for provision of services for the Block Grants for Community
Mental Health (MHBG) program when funding is used.
c. Provide mental health services as defined in WAC 246-341-0702.
d. Provide residential services as defined in WAC 246-341-0718, licensed under WAC 246-337 and certified for
WACs 246-341-0710, 246-341-0805 (if serving individuals on a least restrictive alternative [LRA] or conditional
release), and 246-341-0712.
e. Provide crisis stabilization services as defined in WAC 246-341-0915.
II: Definitions.
(1) Cultural Humility: The continuous application in professional practice of self -reflection and self -critique, learning from
patients, and partnership building, with an awareness of the limited ability to understand the patient's worldview, culture(s),
and communities.
(2) Culturally Appropriate Care: Health care services provided with Cultural Humility and an understanding of the patient's
culture and community, and informed by Historical Trauma and the resulting cycle of Adverse Childhood Experiences
(ACEs).
(3) Eligible Individuals: For purposes of this Exhibit B-7, Eligible Individual means any non -Medicaid individual eligible to
receive services through the Mental Health Program offered by the Washington State Health Care Authority.
(4) Medically Necessary Services: A requested service which is reasonably calculated to prevent, diagnose, correct, cure,
alleviate, or prevent worsening of conditions in the Individual that endanger life, cause suffering of pain, result in an illness
or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other
equally effective, more conservative or substantially less costly course of treatment available or suitable for the client
Individual requesting the service. "Course of treatment" may include mere observation or, where appropriate, no treatment
at all
(5) Mental Health Program: The program is the provision of those mental health services further described within this Exhibit
B-7 which are reimbursable pursuant to the contract between Beacon and the Washington Health Care Authority,
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page 26 of 64
III. Services. Facility agrees to:
(1) Actively work with Beacon Utilization Management staff to submit invoice billing to the State to be applied to Medicaid
spenddown.
(2) The Facility shall provide medically necessary mental health services to Eligible Individuals, Facility shallp rovide services
at the appropriate level, frequency and duration.
(3) In addition, Facility shall:
a. Operate according to Beacon approved written protocols for service provision;
b. Provide education and support to help the individual and family recognize, understand, and respond to the
individual's needs;
c. Provide linkages to the individual's primary care physician as well as other community services including ongoing
care coordination as needed.
d. Provide strength -based mental health treatment services that match each individual's mental health needs with
an appropriate intensity and array of services in the natural environment (outside a Community Mental Health
Clinic and/or office),
e. Provide only the authorized level of service to an individual. If Facility anticipates based on a clinical assessment
that an individual will require a higher level or type of service than previously authorized, Facility shall timely
request a change of authorization type in accordance with Beacon policies and procedures.
(4) If Facility is providing crisis triage and stabilization services, they must receive training in crisis triage and management
for Individuals of all ages and behavioral health conditions, including SMI, SUDs, and co-occurring disorders.
(5) If Facility is providing Outpatient Mental Health Services, they must be provided by staff with appropriate credentials as
defined by WAC 246-341-0515.
(6) If Facility is providing Residential Supervised Living Services, as authorized by Beacon, the following shall be included:
a. Must provide 24 hours per day, 7 days per week supervision of all residents by licensed staff
b. Must provide a multi -disciplinary licensed staff (i.e. social worker, counselors, nurses etc.)
c. Must have written admission and discharge criteria
d. Must provide a full range of social and recreational therapies
e. Must provide individualized treatment plans
f. Must provide a structured program at least 5 days per week or as clinically indicated to support successful
discharge and reduce risk for recidivism as documented in the treatment plan.
g. Must require and/or encourage family involvement in treatment
h. Must provide emergency psychiatric/medical services on-site or by contract
i. Must receive oversight from a Medical or Clinical Program Director
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page 27 of 64
j. Must conduct criminal background check on all staff
k. Must have a documented patient visit with a prescriber within 72 hours of admission and at least 1 time every 30
days thereafter or as clinically indicated and documented in the treatment plan
1. Services require authorization by Beacon Care Managers
(7) If Facility is providing Residential Treatment Services, as authorized by Beacon, the following shall be included:
a. Must provide 24 hours per day, 7 days per week supervision of all residents by licensed staff
b. Must provide a multi -disciplinary licensed staff (i.e. social worker, counselors, nurses etc.)
c. Must have written admission and discharge criteria
d. Must provide a full range of social and recreational therapies
e. Must provide individualized treatment plans
f. Must provide a full range of treatment programming 7 days per week, with structured programming provided a
minimum of 6 hours per day
g. Must require and/or encourage family involvement in treatment
h. Must provide emergency psychiatric/medical services on-site or by contract
i. Must receive oversight from a Medical or Clinical Program Director
j. Must conduct criminal background check on all staff
k. Must have a documented patient visit with a prescriber at least 1 time per week
I. Services require authorization by Beacon Care Managers
(8) If Facility is providing Intensive Outpatient (IOP) services the following shall be included:
a. Must have a written program narrative
b. Must provide individualized treatment plans
c. Must have written procedures for handling medical/psychiatric emergencies
d. Must provide or make available any structured recovery support groups
e. Must have the supervision of a licensed clinician
f. Must have written admission and discharge criteria
g. Must have a written schedule of program activities
h. Must provide services at least 3 hours per day, 3 to 5 days per week
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(9) If Facility is providing Partial Hospitalization services, as authorized by Beacon, the following shall be included;
a. Must be under the supervision of a physician.
b. Must have written admission and discharge criteria.
c. Must provide physician medication management.
d. Staffing must include psychiatry, nursing, psychology, and social work.
e. Must provide individualized treatment plans.
f. Must provide a full program schedule to include individual and group therapy.
g. Must operate at least 5 days per week and at least a minimum of 4-6 hours per day.
h. Must receive oversight from a Medical or licensed Program Director.
i. Must have a documented patient visit with a prescriber at least 1 time per week
j. Services require authorization by Beacon Care Managers
(10) If the Facility is providing Crisis Stabilization Services (facility based), as authorized by Beacon, the following shall be
included;
a. Medication Management
b. Psychoeducation
c. Skills Teaching
d. Supportive Counseling
e. Coordination with outside services
f. Discharge Planning
g. Room and Board
h. Must be provided 24 hours per day/7 days per week.
i. May be provided prior to an intake evaluation.
j. Shall not exceed 14 days
k. Services require authorization by Beacon Care Managers.
(11) Facility staff must develop a discharge plan for all Eligible Individuals. For individuals not authorized for continuation of
crisis stabilization services, the Facility shall also provide a referral to a Community Mental Health Agency for outpatient
services
9 Y p
IV. Reporting Requirements are detailed in Exhibit B-25
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page 29 of 64
Exhibit B.&AU
Washington State Health Care Authority Specific Provisions
In addition to the obligations set forth elsewhere in this Agreement, Beacon and Facilitya to
agree comply p y wi th the following
requirements with respect to Covered Services rendered to Eligible Individuals subject to Beacon's contract with the'
Washington
Health Care Authority. Capitalized terms used but not defined in this Exhibit B-8 shall have the meanings set forth in
g the Agreement.
I: Hold Harmless.
(1) Facility hereby agrees that in no event, including, but not limited to nonpayment b Beacon or Payor, Beacon' insolvency
or the insolvency of Payor, or breach of this contract will Facility bill, charge, collect a deposit from seek compensation,
p p anon,
remuneration, or reimbursement from, or have any recourse against an Eligible Individual or person actin on their behalf
other than Beacon or Payor, for Covered Services provided g '
p d pursuant to this contract. This provision does not prohibit
collection of deductibles, copayments, coinsurance, and/or payment for non -covered services, which have not otherwise
rwise
been paid by a primary or secondary issuer in accordance with regulatory standards for coordination of benefits.
(2) Facility agrees, in the event of Beacon or Payor's insolvency, to continue to provide the servicesromised in
p this contract
to Eligible Individuals for the duration of the period for which payments were made or until the Eligible Individual's
g dual s
discharge from inpatient facilities, whichever time is greater when both apply.
(3) Notwithstanding any other provision of this Agreement, nothing in this Agreement shall be construed to modify the rights
and benefits contained in the Member's Plan.
(4) Facility may not bill the Eligible Individual for Covered Services (except for deductibles copayments, or
coinsurance)
where Beacon or Payor denies payments because the provider or Facility has failed to comply with the terms or conditions
of this Agreement.
p Y dations
(5) Facility further agrees (i) that the provisions of (a), (b), (c), and (d) of this subsection shall survive termination of this
Agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of'
Eligible
Individuals, and (ii) that this provision supersedes any oral or written contrary agreement now existinghereafter
or entered
into between Facility and Eligible Individuals or persons acting on their behalf.
(6) In addition to the requirements of Section 3.5 of the Agreement, when Facility contracts with Practitioners to provide
covered services to Eligible Individuals with the expectation of receiving payment direct) or indirect) from Beacon r
Y Y o
Payor such Practitioners must agree to abide by the provisions of (a), (b), (c), (d), and e of this subsection.
(7) Facility acknowledges that Facility or its Practitioners that willfully collect or attempt to collect an amount from man Eligible
Individual knowing that collection to be in violation of this Agreement constitutes a class C felony under RCW 48.80.
030(5).
II: Amendments.
(1) Notwithstanding Sections 5.4(b) and 11.2 of the Agreement, Facility must beiven reasonable notice of not I '
9 less than sixty
(60) days of changes that affect Facility or its Practitioners' compensation or that affect health care service delivery unless
changes to federal or state law or regulations make such advance notice impossible, in which case notice must be
provided as soon as possible. Notice to Facility is considered notice to its Practitioners under this Agreement,
a. Subject to any termination and continuity of care provisions of the Agreement, Facilit may terminate th
Y Y e
Agreement without penalty if Facility does not agree with the changes, subject to the requirements in Article VIII
of the Agreement q
b. A material amendment to the Agreement may be rejected by Facility. The rejection will not affect the term
J sof
the existing Agreement. A material amendment has the same meaning as in RCW 48.39.005.
BHO_F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG VO STD FACILITY) Page 30 of 64
(2) No change to the Agreement may be made retroactive without the express written consent of the Facility.
III: Practitioner Relationships and Communication.
(1) Beacon will not in any way preclude or discourage Facility from informingEligible Individual
g sof the care they require,
including various treatment options, and whether in their view such care is consistent with medical necessity, medical
appropriateness, or otherwise covered by the individual's Plan. Beacon will not prohibit, discourage, or '
or its Practitioners otherwise practicing in co p � 9 � penalize Facility
p g compliance with the law from advocating on behalf of an Eligible Individual with
Beacon, a Payor, or a Plan. Nothing in this section shall be construed to authorize Facilityto bind B
for any service. Bacon or Payor to pay
(2) Beacon will not preclude or discourage Eligible Individuals or those paying for their coverage from discussing the
comparative merits of different Payors or Plans with Facility or its Practitioners. This
prohibition specifically fically includesprohibiting or limiting Facility participating in those discussions even if critical of.Beacon,
a Payor or a Plan.
(3) Beacon will not penalize Facility because Facility, in good faith, reports to state or federal au
b Beacon thatjeopardizes a thorities any act or practice
Y n individual's health or welfare or that may violate state or federal law.
(4) Communication
(1) Nothing under this Agreement prohibits, or otherwise restricts, a health care professional acting within the lawful
scope of practice, from advising or advocating on behalf of an individual who is his or her patient, for the '
p e following.
a. The individual's health status, medical care, or treatment options, includingan alternative treatment
may be self-administered.
Y fiment that
b. Any information the individual needs in order to decide among all relevant treatment options.
c. The risks, benefits, and consequences of treatment or non -treatment.
d. The individual's right to participate in decisions regarding his or her health care includingthe right fight to refuse
treatment, and to express preferences about future treatment decisions.
IV. Confidentiality of Health Records.
(1) In addition to the other requirements of the Agreement, Facility will make health records available to appropriate state and
federal authorities involved in assessing the quality of care or investigating the grievances or complaints of Eligible
Individuals subject to applicable state and federal laws related to the confidentiality of medical or health records.
(2) Information about Individuals, including their medical records, shall be kept confidential in a manner anner consistent with state
and federal laws and Regulations.
V. Discrimination Prohibited.
(1) Beacon is responsible for ensuring that Facility and its Practitioners furnish Covered Services'
to each Eligible
Individuals without regard to the individual's enrollment in a Plan as aprivate purchaser of a Plan or as a participant
in publicly financed programs of health care services. This requirement does nota I to circumstances
Facility should not render services du apply mstances when the
e to limitations arising from lack of training, experience, skill, or licensing
g
VI. Dispute Resolution,
(1) Notwithstanding those provisions in Article X of the Agreement, the parties are not required to '
p q engage in binding arbitration;
BHO_F-COM-MA-MCD/11/2015 Amend 1 —
(AG VO STD FACILITY) 4 PID 301052
Page 31 of 64
however, parties agree to otherwise follow the dispute resolution process prior to judicial remedies. Facilityhas thin
after the action giving rise to a dispute to complain an Y days
Y
p p d initiate the dispute resolution process. Beacon shall render a
decision on Facility complaints within a reasonable time for the type of dispute. In the case of billing disputes, utes, Beacon
must render a decision within sixty (60) days of the complaint.
VII. Payments.:
(1) Beacon shall pay Facility as soon as practical but at a minimum
a. Beacon shall pay ninety-five percent (95%) of the monthly volume of Clean Claims within thin(30)Ydays of
receipt. For purposes of this Section VII, Clean Claim means a claim that has no defect or impropriety, including lack of any required substantiating documentation, or particular circumstances requiring special treatment
that prevents timely payments from being made on the claim under this section.
b. Beacon shall pay or deny ninety-five percent (95%) of all claims within sixty days of receipt b Beacon and ninety-
nine y
nine percent (99%) of all claims within ninety (90) calendar days of receipt, except as otherwise agreed to in
writing by the parties on a claim -by -claim basis.
c. The receipt date of a claim is the date that Beacon receives either written or electronic notice of the claim.
Beacon shall have a reasonable method for responding to inquiries about claims.
d. In the event that Beacon fails to meet the requirements set forth in this Section 7, Beacon shallpaY interest on
undenied and unpaid Clean Claims more than sixty-one (61) days old until such time as Beacon meets
requirements of subsections 7 (a) and 7 (b). Interest shall be assessed at the rate of one(
ercent 1 °
p /°)per month
and shall be calculated monthly as simple interest prorated for any portion of the month. In the event that interest
is due and payable to the Facility, Beacon shall add the interest payable to the amount of the claim in question
without the necessity of Provider submittingan additional
claim. Any interests paid under this Section shall not
be applied by Beacon to an individual's deductible, copayment, coinsurance or other individual's cost share
obligation.
e. Denial of a claim by Beacon shall include specific reason that the claim was denied. If the denial was based on
medical necessity, then Beacon shall, upon the request of Facility, disclose the 'supporting basis for the '
pp g e denial.
f. Beacon's Provider Dispute Resolution (PDR) Process can be utilized for claims that den for administrative non -
clinical reasons as outlined in the WA State ASO Provider Handbook: Supplement.
g. The provisions of this Section 7 shall not apply to claims for which there is substantial evidence of fraud or
misrepresentation by Facility or to instances in which Beacon has not been granted reasonable access to
information under Facility's control.
h. Beacon and Facility are not required to comply with the provisions of this Section 7, if the failure to comply is
occasioned by any act of God, bankruptcy,act of a governmental p Y
g ental authority responding to an act of God or other
emergency, or the result of a strike, lockout, or other labor dispute.
(2) Beacon shall comply with terms and conditions of payment outlined in WAC 284-170-431.
(3) Beacon is the payor of last resort, therefore Facility agrees to:
a. Make reasonable efforts to determine if individuals being served have insurance or health coverage other than
through Payor, including conducing a benefit inquiry in the ProviderOne system, and promptly report ort anY
duplicate coverage to Beacon;
b. Ensure that services and benefits available under this Contract shall be secondary to all other coverage
g
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c. Attempt to recover any third -party resources available to individuals, includingpursuit of FF '
provided for AI/AN Individuals who p S Medicaid funds
did not opt into managed care, and make all records available for audit and
review
XIII: Accountability & Oversight.
(1) Regardless of any provision to the contrary, Washington State Health Care Authority (herein also referred to as 'Payor')
or their respective designees, oversee and monitor the provision of services to individuals on an on- '
responsible for compliance going basis and remain
accountable and res
p p e with the terms and conditions of their respective Contract, regardless of the
provisions of the Agreement or any delegation of administrative activities or functions to Beacon.
IX. Compliance.
(1) Comply with all applicable state and federal laws, rules, and regulations related to services rend Eligible '
and applicable requirements of the B erect to Eligible individuals,
q Beacon and Washington State Health Care Authority Contract.
(2) Comply with Beacon's Program Integrity requirements and HCA approved Program Integrity policies es and procedures.
(3) Implement procedures to screen employees contractors, subcontractors volunteers
� � � � ,and Board of Directors to ensure
individuals are not excluded from participation in Federal programs. Screening will be completed upon hire and monthly
Y
a. Facility agrees to immediately disclose to Beacon Health Options an exclusion or other event ent which makes
them ineligible to perform work related directly or indirectly to Federal health carero rams.
p g
b. Facility will submit a completed monthly attestation regarding exclusions checks to Bea
later than the 10th of each month. exclusionary con Health Options no
c. Facility will make evidence of monthly checks available upon request.
(4) Guard against Fraud, Waste and Abuse by creating a Compliance Plan that includes:
a. Implementing written policies, procedures and standards of conduct, including whistleblower
protection
b. Designating a Compliance Officer and Compliance Committee
c. Conducting effective ongoing training and education of employees and volunteers
d. Developing effective lines of communication
e. Enforcing standards though well-publicized disciplinary guidelines
f. Conducting internal monitoring and auditing
g. Responding promptly to detected offenses and developing corrective actions;
(5) Participate in Beacon required or HCA sponsored Quality Improvement activities.
(6) Provide Beacon and/or Payors with timely access to records, information and data necessary for Beacon and/or Payors
to meet their respective obligations under their Contract,
(7) Submit all reports and clinical information required by Beacon and/or Payors that may '
Y y be required by Contract(s) and to
131-10-F-COM-MA-MCD/11 /2015
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ensure the quality, appropriateness and timeliness of contracted services;
(8) Notify Beacon when a Washington State entity performs any audit related to the activities contained in this contract, and
submit any report and corrective action plan related to the audit to Beacon.
X. AudiVAccess to Records.
(1) Facility shall comply with all applicable required audits including authority to conduct a Facility inspection, coon, and the federal
Office of Management and Budget (OMB) Super Circular, 2 C.F.R. 200.501 and 45 C.F.R. 75.501 audits.
(2) Upon request, the Facility shall allow HCA or any authorized state or federal agency or authorized representative, access
to all records pertaining to this Contract, including computerized data stored by the Facility, The Facility shall provide and
furnish the records at no cost to the requesting agency.
(3) On -Site Inspections
a. The Facility must provide any record or data pertaining to this Contract including, but not limited to:
i. Medical records;
ii. Billing records;
iii. Financial records;
iv. Any record related to services rendered, quality, appropriateness, and timeliness of service; and
v. Any record relevant to an administrative, civil or criminal investigation or prosecution.
b. Upon request, the Facility shall assist in such review, including the provision of complete copies of re
p p cords.
c. The Facility must provide access to its premises and the records requested to any state or federal agency Hcy or
entity, including, but not limited to: HCA, OIG, MFCD, Office of the Comptroller of the Treasury, whether the
visitation is announced or unannounced.
(4) Beacon may not access medical records unrelated to Eligible Individuals served under this contract. Except that this
provision shall not limit Beacon's or Payor's right to ask for and receive information relatingto the ability of the Facility
deliver health care services that meet the ac Y acility to
accepted standards of medical care prevalent in the community.
(5) Access to medical records for the purpose of audit by Beacon, or the Payors is limited to only that n
Y y necessary to perform
the audit.
(6) The billing audit rights granted to Beacon and the Payors are reciprocal so that Facilitymay audit the '
y denial of its claims.
XI. Miscellaneous.
(1) Compliance with law. Beacon and Facility shall comply with all applicable Washington laws governing
and the provision of Covered Services Eligible Individuals. g 9 Hing this Agreement
P es to Eligible Individuals. In the event that any applicable Washington law conflicts
with the terms of this Exhibit B-8, such terms shall be deemed amended to the extent necessaryfor
applicable Washington law. consistency with the
(2) Conflicts or inconsistencies. In the event of any conflict or inconsistencybetween the terms of this
Exhibit B-8 and the
terms in any other section of the Agreement including other Exhibit Bs, then this Exhibit B-8 shall control; t ol, provided
however, that if Beacon and Facility are capable of complying with both the requirements of such other
q section and this
BHO_F-COM-MA-MCD/11/2015 Amend 14 — PID 30
(AG VO STD FACILITY) 1052
Page 34 of 64
Exhibit B-8, nothing herein shall be construed as waiving the obligations of Beacon or Facilityunder
such other section.
XII. Additional Provisions Re uired of the Washin ton State Health Care Authorifi (HCA).
(1) The Facility shall inform, post, and guarantee that each Individual has the followingrights in c -
341-0600: g compliance with WAC 246
a. To information regarding the Individual's behavioral health status.
b. To receive all information regarding behavioral health treatment options including any alternative or self-
administered treatment, in a culturally -competent manner.
c. To receive information about the risks, benefits, and consequences of behavioral health treatment(i'ncluding the
option of no treatment).
d. To participate in decisions regarding his or her behavioral health care, includingthe right to refuse
to express references about future g e treatment and
p treatment decisions.
e. To be treated with respect and with due consideration for his or her dignity privacy.
and rivac .
f. To be free from any form of restraint or seclusion used as a means of coercion discipline,
retaliation. �convenience, or
g. To request and receive a copy of his or her medical records, and to request that the be amended
as specified in 45 C.F.R. Part 164. Y or corrected,
h. To be free to exercise his or her rights and to ensure that to do so does not adverse) affect the '
treats the Individual.
Y way the Facility
(2) The Facility shall ensure Individual self-determination by:
a. Obtaining informed consent prior to treatment from Individuals, or persons authorized to consent on
behalf of an
Individual, as described in RCW 7.70.065;
b. Complying with the provisions of the Natural Death Act (Chapter 70.122 RCW
Advance Dir ) and state rules concerning
Directives (WAC 182-501-0125); and,
c. When appropriate, informing Individuals of their right to make anatomical ifts(Chapter68.64 RCW9 )
(3) Facility shall use the Integrated Co -Occurring Disorder Screening Tool -SS found at htfi s://
( p www.hca,wa, jit-tPs://www.hca.wa.ggv/billeir-
providers-partners/behavioral-health-recovery/gain-ss) for all services except DCR services and shall '
p train staff that will
be using the tool(s) to address the screening and assessment process, the tool and quadrant I '
implement and maintain the process may re � q placement. Failure to
p y sult in corrective action.
(4) Ensure that all services and activities provided under this Contract shall be designed and del'
sensitive to the needs of the diverse populationg delivered in a manner
.
(5) Initiate actions to develop or improve access, retention, and cultural relevance of treatment services f , relapse prevention or
other appropriate orethnic minorities and other diverse populations in need of services under this Contract
as identified in their needs assessment,
(6) Participate in training when requested by the HCA. Exceptions must be in writingand include
required information shall be e a plan for how the
q provided to staff.
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(7) Provide interpreter services free of change for Individuals with a preferred language other than English. '
g sh. This includes
the provision of interpreters for Individuals who are Deaf, DeafBlind, or Hard of Hearing. This includes oral interpretation
terpretation
Sign Language (SL), and the use of Auxiliary Aids and Services as defined in 42 C.F.R. § 438-10(d)(4)).
(8) The following provisions are required by (i) federal statutes and regulations applicable to medical assistance ce programs for
the indigent, (ii) state statutes and regulations applicable to medical assistance programs for the indigent, g g or contracts
and agreements between the Health Plan and the state agencies responsible for regulating risk-based medical assistance
programs for the indigent. These provisions shall be automatically modified to conform to subsequent amendments n is fio
such statutes, regulations, and agreements. Further, any purported modifications to theserovisions inconsistent stent with
such statutes, regulations, and agreements shall be null and void.
(9) Facility shall provide reasonable access to facilities and financial and medical records for dulyauthorized
Department of Social & Health representatives
of the CMS, HCA, De
p lth Services ("DSHS") or the Department of Health & Human Services
("DHHS") for audit purposes and immediate access for Medicaid fraud investigators.
(10) Facility shall investigate and disclose to Beacon and HCA immediately upon becomingof
aware any person in their
employment who has been convicted of a criminal offense related to that person's involvement in an program Y p g m under
Medicare, Medicaid, or Title XX of the Social Security Act since the inception of those programs.
(11) Facility shall require nondiscrimination 'in employment and Individual services.
(12) Facility shall conduct criminal background checks and maintain related policies androcedures and
p personnel files
consistent with requirements in Chapter 43.43 RCW and, Chapter 246-341 WAC.
(13) Facility shall completely and accurately report encounter data to Beacon. Facility shall have the capacity ty to submit all
required data to enable Beacon to meet the requirements in the Encounter Data Transaction Guideublished b
p y HCA._
(14) Facility shall comply with Beacon's fraud and abuse policies and procedures.
(15) Facility shall not assign this Agreement without Beacon's written agreement.
(16) Facility shall comply with any term or condition of Beacon's contracts with HCA that is applicable to the '
performed by Facility.
pp e services to be
(17) Facility shall accept payment from Beacon as payment in full and shall not request payment from HCA or any Eligible
Individual for Covered Services performed under this Agreement.
(18) Facility agrees to hold harmless HCA and its employees, CMS and its employees, and all enrollees
served under the
terms of this Agreement in the event of non-payment by Beacon. Facility further agrees to indemnify and hold
HCA and its employees a against all in' liabilities,
, judgments,
Y harmless
g juries, deaths, losses, damages, claims, suits, liabilities, costs and
expenses which may in any manner accrue against HCA or its employees through the intentional misconduct negligence,
or omission of Facility, its agents, officers, employees or contractors,
(19) If, at any time, Beacon determines that Facility is deficient in the performance of its obligations under
g the Agreement,
Beacon may require Facility to develop and submit a corrective action plan that is designed to correct such deficiency,
g e iciency.
a. Beacon shall approve, disapprove, or require modifications to the corrective actionIan based on its reasonable
able
judgment as to whether the corrective action plan will correct the deficiency.
b. Facility shall, upon approval of Beacon, immediately implement the corrective actionppp Ian as approved or
modified by Beacon.
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(AG — VO STD FACILITY) Page 36 of
g 64
c. Facility's failure to implement any corrective action plan may, in the sole discretion of Beacon,
breach of the Agreement, subject to be considered
g 1 any and all contractual remedies including termination of the Agreement
with or without notice.
(20) Facility shall make reasonable accommodation for enrollees with disabilities in accord with the Americans with Disabilities
Act, for all Covered Services and shall assure physical and communication barriers shall n
disabilities from obtaining Covered Services. of inhibit enrollees with
(21) Facility shall comply with all Program Integrity provisions as documented in Beacon's Provider Manual and as set forth by
42 CFR 438.608 and Beacon's contracts with HCA.
(22) Facility shall ensure that all persons receiving services under this Agreement are
Specifically, Facility shall: g creeped for financial eligibility.
Y Y
a. Capture sufficient demographic, financial, and other information to support eligibility decisions
requirements. pp 9 Y slops and reporting
b. Check Medicaid eligibility, including conducing a benefit inquiry in the ProviderOne system, prior to each servicedeliver .
C. Conduct an inquiry regarding each Eligible Individual' s continued financial eligibility le
month. g Y no ss than once each
d. Document the evidence of each financial screening in the individual's records.
e. Update funding information when the funding source changes.
f. To be eligible for any non -crisis behavioral health service under this Agreement, an individual dual must meet: (i) the
financial eligibility criteria; and (ii) the clinical or program eligibility criteria for the General Fund State (GFS) .For
services in which medical necessity criteria applies, all services must be medically necessary.
ry
g. Funding for services where medical necessity does not apply can onlybe used under the follow ow circumstances.
i. Based on available resources
1, Service type(s) allowable by fund source
2. Individual meets financial eligibility criteria
ii. Based on identified treatment need
1. Individual meets criteria for the fund source where specified
2. Individual meets service criteria
3. Services that directly support an Individual's progress in treatment
4. Services are identified within the Individual's treatment plan.
h. Eligibility criteria for non -crisis behavioral health services funded by GFS are as follows:
i. Not qualify for Medicaid.
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ii. Individuals who have a gross monthly income (adjusted for familysize that does no
the Federal PGuidelines, ) t exceed 220 /o of
Poverty
iii. And meet one of the following criteria:
1. Are uninsured
2. Have insurance, but are unable to meet the co -pay or deductible for services
3. Are using excessive SUD or mental health crisis services due to inabilityto
behavioral health services access non -
crisis
4. Have more than 5 visits over 6 months to the emergency department,
g Ywithdrawal
management facility, or the sobering center due to a SLID
(23) Facility may offer a sliding scale fee schedule to Individuals who are not eligible '
consideration an Individual'sability g for Medicaid coverage that takes into
circumstances and ability to pay. If the Facility selects to developa fee schedule,
schedule must comply with the followingand must be reviewed e, the fee
ewed and approved by Beacon:
a. Put the sliding fee schedule in writing that is non-discriminatory;
b. Include language in the sliding fee schedule that no Individual shall be denied services'
due to inability to pay;
c. Provide signage and information to Individuals to educate them on the slidingfee schedule;
u e,
d. Protect Individual's privacy in assessing fees;
e. Maintain records to account for each Individual's visit and any charges incurred;
9 ,
f. Charge Individuals at or below 100 percent of Federal PovertyLevel(FPQa nominal nal fee or no fee at all. The
Federal Poverty Guidelines can be found at htt s:Has e.hhs. ov/ overt - uidelines,
g. Develop at least three (3) incremental amounts on the slidingfee scale for Individual
percent FPL. s between 101 to 220
h. Facility will reduce the amount billed to Beacon b an sliding'
fee schedule
Individuals.
Y Y amounts collected from Eligible
(24) In compliance with RCW 71.32 pertaining to mental health advance directive for behavioral health care, Facility shall:
a. The Facility shall maintain a written Mental Health Advance Directive(MHAD)olic andan Indiv' � � policy procedure that respects
Individual's Advance Directive. Policy and procedures must comply with Chapter 71.32 RCW.
b. Inform all individuals of their right to a mental health advance directive and provide
who express an interest in � p technical assistance to those
p developing and maintaining a mental health advance directive
c. Maintain current copies of any mental health advance directive in the individual's utilization ton records.
d. Inform individuals that complaints concerning noncompliance with a mental health a '
referred to the Washington advance directive should be
g State Department of Health by calling 1-360-236-2620 orb following the written
instructions contained in the mental health benefit booklet. Y g
(25) The Facility shall implement a Grievance process that complies with WAC 182-538C-1
10. The Facility shall.
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a. Grievance means an expression of dissatisfaction about any matter other than an
Action. Action means the
denial or limited authorization
of a Contracted Service based on medical necessity. Possible subjects for
grievances may include, but are not limited to, theualit of
q Y care or services provided, and aspects of
interpersonal relationships such as rudeness of a provider or employee, or failure
regardless of whether re to respect the Individual's
rights re
g medial action is requested. Grievance includes an Individual's right to dispute an
authorization decision
extension of time proposed by the Contractor to make an g p
.
b. Inform Individuals of their right to file a Grievance or Appeal in the case of:
i. Denial or termination of service related to medical necessity determinations
ii. Failure to act upon a request for services with reasonable promptness
c. Ensure that termination of this contract shall not be grounds for an Appeal, Administrative '
Grievance for individuals if � pp Hearing, or a
similar services are immediately available in the service area.
(26) The Facility shall ensure that the offer hours of operation for individuals serve '
d under this contract with Beacon are no
less than the hours of operation offered to any other individual.
(27) If the Facility is a faith -based organization (FBO), it shall meet the requirements q is of 42 CFR Part 54 as follows:
a. Individuals requesting or receiving SUD services shall be provided with a choice of
SUD treatment providers.
b. The FBO shall facilitate a referral to an alternative provider within a reasonablei
t me frame when requested by
the recipient of services. The FBO shall report to the Contractor all referrals made to alternative Iternafiive providers.
c. The FBO shall provide individuals served with a notice of their rights,
d. The FBO provides individuals served with a summary of services that includes an '
y inherently religious activities.
e. Funds received from the FBO must be segregated in a manner consistent with federal
regulation
f. No funds may be expended for religious activities
(28) Facility shall ensure that all services and activities provided under this Agreement 9 ent shall be designed and delivered in a
manner sensitive to theneeds of the diverse population. Additionally, Facility shall initiate actions to ensure or
access, retention, and cultural relevance of treatment, prevention or other appropriate improve
other diverse populations in n � pp priate services, for ethnic minorities and
p p need of services under this Agreement as identified in their needs assessment.
(29) Critical Incident Reporting.
a. Facility shall comply with all critical incidents reporting in accordance with WAC 246-341-02003
246-341-0410 and 246-341- 246-341-0365,
0420. All critical incidents shall be reported within 1 business da of becoming
aware of the incident. Y g
(30) For providers in twenty-four (24) hour settings, a requirement torovide discharge arge planning services which shall, at a
minimum:
a. Coordinate a community-based discharge plan for each individual served under this
procure the b Agreement beginning at
intake in order to
p est available recovery plan and environment for the individual. Discharge planning
shall apply to all individuals regardless of length of stay or whether g
9 Y they complete treatment.
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b. Coordinate exchange of assessment, admission, treatment progress, and continuing car i
nformation with the
referring entity. Contact with the referral agency shall be made within the first week of residential treatment.
c. Establish referral relationships with assessment entities, outpatient providers, vocational
services, and courts which specify p � or employment
p y aftercare expectations and services, including procedure for involvement of
referents in treatment activities.
d. Coordinate, as needed, with Department of Behavioral Health and RehabilitationDBHR
( )prevention services,
vocational services, housing services and supports, and other community resources and services that maybe
appropriate, including the Division of Children and Family Services, the CommunityServices Division '
Community Service Offices(CSOs),Tribal ov on including
governments and Non -Tribal IHCPs.
e. Coordinate services to financially -Eligible Individuals who are in need of medical services.
(31) Performance Evaluation. Beacon shall:
a. At its discretion, upon reasonable notice during normal business hours, perform periodic programmatic andfinancial reviews. These may include on-site inspections and audits by Beacon
or its agents of the records of
Provider relating to the provision of contracted services.
b. Provide reasonable notice to Provider prior to any on-site visit to conduct an audit and further notify Provider of
any records Beacon wishes to review.
c. Review and evaluate Provider for its successful performance of all contractual obligations a
with the terms of the Agreement.
g and its compliance
d. Inform Provider of the results of any performance evaluations and of an dissatisfaction '
performance and reserve the ' Y tion with Provider's
right to demand a corrective action plan or to terminate the Agreement.
(32) Loss of Program Authorization
a. Should any part of the work under this Contract relate to a state program that is no longer 9 g authorized by law
(e.g., which has been vacated by a court of law, or for which authorityhas been withdrawn or '
of a legislative repeal),Facile which is the subject
g Facility must do no work on that part after the effective date of the loss ofra
ro
authority. If Facility works on a program or activitylonger authorized p g m
no ger ed by law after the date the legal authority
for the work ends, Facility will not be paid for that work. If Facility wasaid in advance to work ork on a no -longer -
authorized program or activity and under the terms of this Contract the work was to be performed
the legal authorityended the payment p d after the date
p y ent for that work must be returned. However, if Facility worked on a program
ram or activity, or activity prior to the date legal authority ended for that program g
p g t sty, and the state included the cost of
performing that work in its payments to Facility, Facility may keep the payment for that work even ro y en if the payment
was made after the date the
program or activity lost legal authority.
(33) Facility shall create and maintain a business continuity and disaster recoveryIan that ens '
Individual information system follow' p ensures timely reinstitution of the
y following total loss of the primary system or a substantial loss of functionality. The Ian shall
include the following; p
a. A mission or scope statement
b. Information services disaster recovery person(s)
c. Provision for back up of key personnel, emergency procedures, and emergency telephone 9 Y p numbers
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d. Procedures for effective communication, application inventoryand business recovery '
and software vendor lists ry priorities, and hardware
e. Documentation of updated system and operations and a process for fre frequent back u of
q p systems and data
f. Off-site storage of system and data backups and ability to recover data ands stems from om back-up files
g. Designated recovery options
h. Evidence that disaster recovery tests or drills have been performed
(34) Facility shall submit an annual certification statement indicatingthere is an u to date business p siness continuity disaster plan in
place. Certification must be received by December 31 of each
BeaconWAASO@beaconhealthoptions.com.contract year to
XIII. Documents Incorporated by Reference.
(1) Each of the documents listed below are incorporated by this reference into this Contract as though fully set forth herein
provided including any amendments, modifications or supplements thereto. All services shall be
documents and legal authorities: p ed in accordance with these,
a. Beacon's contracts, program agreements, exhibits, amendments, and an other
Washington State Health Care Authority;
Y agreements with the
b. The Medicaid State Plan and the 1915(b) Medicaid Waiver;
C. The Health Care Authority policies, the State Medicaid Manual (SMM) as applicable, the BARS ARS Manual and any
applicable BARS Supplemental Instructions;
d. State laws and regulations including the Revised Code of Washington and the Washington Administrative strative Code;
e. Beacon External Policies and Procedures, including Beacon's Provider Handbook and W
Provider Handbook: Supplemental � Washington State ASO
pp tal Appendix;
f. CPT Manual, HCPC Manual, and Washington State Service Encounter Reporting
p g Instructions;
g. The Code of Federal Regulations Title 45 CFR and Title 42 CFR; and,
h. Title XIX of the Social Security Act.
IX. Term & Termination.
(1) In addition to and notwithstanding the provisions set forth in the Agreement, any Exhibit t may be suspended or terminatedb Beacon immediately upon written notice if:
a. Facility is disqualified, terminated, suspended, debarred, or otherwise excluded from or ineligible'
under the program or an other for participation
p 9 y state or federal government-sponsored health program; or
b. The Agreement is terminated or not renewed.
X. Confidential Information.
(1) Nothing contained in the Beacon Facility Agreement or associated Exhibits shall be'
construed as prohibiting Facility from
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sharing information with the public as required by federal, state or local law.
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Exhibit B -10.A14
Mental Health Block Grant Program Provisions
This Exhibit contains additional provisions applicable to Covered Services render '
ed to Eligible Individuals (as defined below)
covered under Mental Health Block Grant (MHBG) Program (as defined below offered '
Health Care Authority) and/or administered by Washington State
(HCA). In the event of any conflict between the provisions of the Agreement(including' ' 'Exhibit B-10 and sub ect to the rovisions set o ' ' �.g , Exhibit B-8), and this
J p out in Exhibit B-10, the provisions of this Exhibit control as related to services re
to individuals receiving Mental Health Block Grant (MHBG)ram
9 es.
Pro services.
rendered
General Provisions.
(1) Whenever in this Exhibit B-10 the term "Facility" is used to describe an obligation
be the responsibility of e individual g fiion or duty, such obligation or duty will also
p y each individual licensed health care practitioner, Facility, ando rovider employed
under contract with Facility, as the context may require.
pr owned by or
(2) Facility agrees.
a. Follow all rules and regulations of CFDA 93.958 for provision of services for th
Mental Health(MHBG)e Block Grants for Community
II: Definitions.
(1) Cultural Humility: The continuous application in professional practice of self -reflection and partnership p f reflection and self -critique, learning from
p p p building, with an awareness of the limited ability to understand theatient's wort '
and communities. p dview, culture(s),
(2) Culturally Appropriate Care: Health care services provided with Cultural Humility
and an understanding of the patients
culture and community, and informed by Historical Trauma and the resultin c
(ACEs), g y cl
e of Adverse Childhood Experiences
(3) Eligible individuals: For purposes of this Exhibit B-10, Eligible Individual means eans any non -Medicaid individual eligible to
receive services through the MHBG Program offered by the Washington State He
services not covered b Medicaid Medicaid individual.
� g Health Care Authority and for MHBG
y , any Medicaid individual.
(4) Mental Health Block Grant (MHBG): Means those funds ranted b the Secretary
Services(DHHS),throu g Y etary of the Department of Health and Human
through the Center for Mental Health Services(CMHS),Substance AbAdminis use and Mental Health Services
Administration (SAMHSA), to states to establish or expand an organized community-based '
Y d system for providing mental
health services for adults with Serious Mental Illness (SMI) and children who are seriously emotionally disturbed (SED).
(5) Mental Health Block Grant (MHBG) Program: The program is the provision
within this Exhibit B-10 g p on of those MHBG services further described
which are reimbursable pursuant to the contract between Beacon and the Washin
Care Authority, gton State Health
III. Services. Facility agrees to:
(1) Facility may use block grant funds to help Individuals satisfycost-sharing '
health g requirements for MHBG-authorized mental
t services. The Facility must ensure that:
a. The provider is a recipient of block grant funds;
b. Cost-sharing is for a block grant authorized service;
c. Payments are in accordance with MHBG laws and regulations;
BHO-F-COM-MA-MCD/11 /2015
(AG — VO STD FACILITY) Amend 14 — PID 301052
Page 43 of 64
d. Cost-sharing payments are made directly to the provider of the service; and
e. A report is provided. to Beacon upon request that identifies:
i. The number of Individuals provided cost-sharing assistance;
ii. The total dollars paid out for cost-sharing; and
iii. Providers who received cost-sharing funds.
(2) Deliver MHBG services as described in the regional MHBG Project Plan for the current fiscal year approved by Beacon
and the Health Care Authority.
(3) Provide MHBG services to promote recovery for an adult with a SMI and resiliencyfor SED children in accordance
federal and state requirements.
ordance with
(4) Ensure that MHBG funds are used only for services to individuals who are not enrolled in Medicaid or for services thatare
not covered by Medicaid as described in the following table:
Benefits Services Use MHBG Funds Use Medicaid
Individual is not a Medicaid
recipient Any Allowable Type Yes No
Individual is a Medicaid
recipient Allowed under Medicaid No Yes
Individual is a Medicaid Not Allowed under
recipient Medicaid Yes No
(5) MHBG funds cannot be used for the following:
a. Construction and/or renovation.
b. Capital assets or the accumulation of operating reserve accounts.
c. Equipment costs over $5,000.
d. Cash payments to Consumers
e. Grant funds may not be used, directly or indirectly, to purchase, prescribe, or provide marijuana or treatment
t
using marijuana. Treatment in this context includes the treatment of opioid use disorder. Grant funds also cannot
be provided to any individual who or organization that provides or permits marijuana use for the purposes 1 p p of
treating substance use or mental disorders. See, e.g., 45 C.F.R. § 75.300(a) (requiringHHS to "ensure that
Federal fundin is ended... in full accor
g expended dance with U.S. statutory... requirements."); 21 U.S.C. §§ 812(c) (10)
and 841 (prohibiting the possession, manufacture, sale, purchase or distribution of marijuana). This prohibition
does nota I providing � � 1 � )
apply to those providing such treatment in the context of clinical research permitted by the DEA and
under the FDA -approved investigational new drug application where the article being evaluated is marijuana or
der federal law,
a constituent thereof that is otherwise a banned substance un 1
.
(6) MHBG funds may not be used to pay for services provided prior to the execution of this Exhibit to a .All contracts and am � or pay i n advance of
service delivery. amendments must be in writing and executed by both parties prior to any services being
g
(7) Participate in annual peer review by individuals with expertise in the field of mental health treatment when requested by
BHO_F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG VO STD FACILITY) Page e 44 of 64
HCA (42 U.S.C. 300x-53 (a) and 45 C.R.R. 96.136, MHBG Service Provisions).
(8) Send a representative to the regional Behavioral Health Advisory Board (BHAB) meetings to report on program data and
results.
IV. Reportinq Requirements are detailed in Exhibit B-25
BHO_F-COM-MA-MCD/11/2015 Amend 14 —
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Page 45 of 64
Addendum to Exhibit B -10.A14
Mobile Outreach Team Peer Support Specialiso
t
This Addendum contains additional provisions applicable to administration of the Mobile Outreach Team Peer Support
Specialist under Exhibit B-10.
Objective:
Engage Peer Support Specialists to provide Mobile Outreach Services to identified clients in support '
of positive recovery
outcomes. Mobil Outreach Services pp
will include peer support, support for education activities, resource referral, sharingtheir
Yp p
lived experience with behavioral health issues and recover principles.
Services:
1) Provide outreach to engage identified clients in services or referrals by listening, encouraging, coaching, empowering
and connecting with resources to enhance client recovery needs.
2) Work in conjunction with community partners, law enforcement, medical community
and other b
staff. Y, ehavioral health
3) Provide peer support, support for education activities, resource referral, share lived experience '
issues and recover principles.
p with behavioral health
recovery p
4) Services are provided countywide, where people are. Peer Support Specialist will go to homeless encampments,
food banks when open, the warming center when open, and the jail. The will travel with the Gran
Syringe program.
Y t County Safe
Reporting Requirements are detailed in Exhibit B-25.
BHO_F-COM-MA-MCD/11/2015 Amend 14 —
(AG VO STD FACILITY) PID 301052
Page 46 of 64
Exhibit B -11-A14
Substance Use Disorder Program Provisions
This Exhibit contains additional provisions applicable to Covered Services rendered to Eligible Individuals g ble Individuals (as defined below)
covered under Substance Use Disorder (SUD) Program (as defined below) offered and/or administered
Care Authority In the event of an by Washington State Health
y conflict between the provisions of the Agreement(includingExhib' -
B-11 and sub ect to the rov ..g ,, it B 8), and this Exhibit
1 provisions set out in Exhibit B-11, the provisions of this Exhibit control as related to services rendered to
individuals receiving SUD Program services.
General Provisions.
(1) Whenever in this Exhibit B-11 the term "Facility" is used to describe an obligation or duty, '
be the responsibility of each individual g y, such obligation or duty will also
p y vidual licensed health care practitioner, Facility, and provider employed or owned b or
Y
under contract with Facility, as the context may require. Y Y
(2) Facility agrees:
a. Facility shall provide substance use disorder services in accordance with the Beacon Level'
of Care Guidelines
and under the Beacon Service Instruction Manual, which are incorporated herein by reference.
b. Follow all rules and regulations of CFDA 93.959 for provision of services for the Substancece Abuse Prevention
and Treatment Block Grant
(SABG) program when funding is used.
c. Facility shall provide alcohol and drug treatment serviceser RCW CW 70.96A as described in the Services below.
d. If applicable, Facility shall provide alcohol and drug treatment services pursuant to the
Account DMA program provisions p Dedicated Marihuana
p g p ons as promulgated by the Washington State Health Care Authority when that
funding is used.
i. DMA funds shall be used to fund SUD treatment services for youth livingat or below 220
federal povertylevel without insurance percent of the
rance coverage or who are seeking services independent of their
parent/guardian;
ii. DMA funds may be used for development, implementation, maintenance and evaluation
ort intervention treat � n of programs
that support treatment, and Recovery Support Services for middle school and high school
aged students.
e. If applicable, provide Outpatient Treatment Services in accordance with WAC 246-341 for
Specialty Court orCJTA eligible patients. Specifically, Facility shall.
i. Provide alcohol and drug treatment and treatment support serviceser RCW 70.96A when CJTA
funding is utilized.
p
ii. Provide services to individuals with an addiction or a substance abuseroblem that if
would result in addiction against p not treated
g t whom a prosecuting attorney in Washington State has filed charges.' g
iii. Provide alcohol and drug treatment services and treatment support services to nonviolent olent offenders
within a drug court program as defined in RCW 70.96A.056 and RCW 2.28.170.
iv. In accordance with RCW 2.30.040, counties are required to provide a dollar -for -dollar '
match for CJTA funded se Individuals p a participation
services for Individuals who are under the supervision of a therapeutic court,
BHO-F-COM-MA-MCD/1 1/2015
(AG — VO STD FACILITY) Amend 14 — PID 301052
Page 47 of 64
1. No more than 10 percent of the total CJTA funds can be used for the followingtreatment
support services combined: ent
a. Transportation; and
b. Child Care Services.
v. The Facility, under the provisions of this contract and in accordance with RCS 71.24.580(9),will abide
b the following guidelines � bide
Y g g eines related to CJTA funding that supports therapeutic courts: The Facility shall
have policy and procedures in place that:
1. Allow Individuals at any point in their course of treatment to be prescribed an medication
approved the b the FED for the treatment Y on
Y of SUD.
2. Do not deny admission into therapeutic court programs and related services for Individuals
who are prescribed any medication approved by the FDA for the treatment of SUD' and
3. Do not mandate titration of any medication approved by the FDS for the treatment of SUD
a condition of individual beingadmitted into the program, , as
p gram, continuing in the program, or
graduating from the program; with the understanding that decisions
concerning
medication
adjustment are made sole) between the. In Individual and their prescribing providers.
4. Coordinates care with agencies that are able to provide or facilitate the induction of an
medication approved by the FDA for the treatment of SUD.
Y
vi. CJTA funding shall be used to supplement, not supplant, other federal, state, and local funds used for
SUD treatment per RCW 71.24.580(8).
II: Definitions.
(1) Acute Withdrawal Management: Means services provided to an Individual to assist in thero '
p cess of withdrawal from
psychoactive substance in a safe
and effective manner. Medically monitored withdrawal management provides medical
care and physician supervision for withdrawal from alcohol or other drugs.
(2) American Society of Addiction Medicine Level of Care GuidelinesASAM Guidelines): Mean '
( ) s a professional society
dedicated to increasing access and improving the quality addiction treatment. ASAM Guidelinesr '
r a e a set of criteria
promulgated by ASAM used for determining treatment placement, continued stay and transfer/discharge of individuals
with addiction conditions.
(3) Behavioral Health Medical Director: means a physician licensed in Washington State to practice '
9 p medicine, oversee
operations, set policies, and help to make informed medical/behavioral health decisions.
(4) Brief Intervention for SUD: Means a time limited, structured behavioral intervention usingtechniques
based motivational infierviewin and ref services
ques such as evidence -
g, referral to treatment services when indicated. Services may be provided at sites
exterior to treatment facilities such as hospitals, medical clinics, schools or other non-traditional settings.
(5) Certified Peer Counselor (CPC): Means individuals who: have self -identified as a consumer of behavioral ehavioral health
services; have received specialized training provided/contracted by HCA, Division of Behavioral Health
and Recovery
(DBHR); have passed a written/oral test, which includes both written and oral components of the training;
round check' p Hing; have passed a
Washington State background , have been certified by DBHR, and are a registered Agency Affiliated Counselor
with the Department of Health (DOH)..
(6) Criminal Justice Treatment Account (CJTA): Means an account created b the state for expenditure
Yon. a) SUD
treatment and treatment support services for offenders with a SUD that, if not treated, would result in addiction,
against
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PI
(AG — VO STD FACILITY) D 301052
Page 48 of 64
whom charges are filed by a prosecuting attorney in Washington State; b) the provision of drug and alcohol treatment
services and treatment support services for nonviolent offenders within a drug court program (RCW 71.24.580)..
(7) Cultural Humility: The continuous application in professional practice of self -reflection and self -critique, learning from
patients, and partnership building, with an awareness of the limited ability to understand the patient's worldview, culture(s),
and communities.
(8) Culturally Appropriate Care: Health care services provided with Cultural Humility and an understanding of the patient's
culture and community, and informed b Historical Tr i
Y y Trauma and the resulting cycle of Adverse Childhood Experiences
(ACEs).
(9) Eligible Individuals: For purposes of this Exhibit B-11, Eligible Individual means any non -Medicaid individual eligible to
receive services through the SUD Program offered by the Washington State Health Care Authority, and for SABG funded
services not covered by Medicaid, any Medicaid individual.
(10) Outreach & Engagement: Means identification of hard -to-reach Individuals with a possible SUD and/or Severe Mental
Illness (SMI) and engagement of these Individuals in assessment and ongoing treatment services as necessary.
(11) Interim Services: Means services to individuals who are currently waiting to enter a treatment program to reduce the
adverse health effects of substance abuse, promote the health of the individual, and reduce the risk of transmission of
disease.
(12) Inpatient/Residential Substance Use Treatment Services: Means rehabilitative services, including diagnostic evaluation
and face-to-face individual or group counseling using therapeutic techniques directed toward Individuals who are harmfully
affected by the use of mood -altering chemicals or have been diagnosed with a Substance Use Disorder (SUD).
Techniques have a goal of abstinence (assisting in their Recovery) for Individuals with SUDs. Provided in certified
residential treatment facilities with sixteen (16) beds or less. Residential treatment services require additional program -
specific certification by DOH, and include: Intensive inpatient services; Recovery house treatment services; Long-term
residential treatment services; and Youth residential services.
(13) Intensive Inpatient Residential Services: Means a concentrated program of SUD treatment, individual androu
9 p
counseling, education, and related activities including room and board in a 24 -hour -a -day supervised Facility in
accordance with Chapter 246-341 WAC (The service as described satisfies the level of intensity in ASAM Level 3.5
(14) Intensive Outpatient SUD Treatment: means services provided in a non-residential intensive patient centered outpatient
program for treatment of SUD (The service as described satisfies the level of intensity in ASAM Level 2.1).
(15) Long -Term Care Residential SUD Services: Means the care and treatment of chronically impaired individuals diagnosed
with substance use disorder with impaired self -maintenance capabilities including personal care services and a
concentrated program of substance use disorder treatment, individual and group counseling, education, vocational
guidance counseling and related activities for individuals diagnosed with substance use disorder, excluding room and
board in a twenty -four -hour -a -day, supervised facility accordance with WAC 246-341-1114. (The service as described
satisfies the level of intensity in ASAM Level 3.3.)
(16) Medically Necessary Services: A requested service which is reasonably calculated to prevent, diagnose, correct, cure
alleviate, or prevent worsening of conditions in the Individual that endanger life, cause suffering of pain, result in an illness
or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other
equally effective, more conservative or substantially less costly course of treatment available or suitable for the client
Individual requesting the service. "Course of treatment" may include mere observation or, where appropriate, no treatment
at all
(17) Medication Assisted Treatment (MAT): Means the use of medications, in combination with counseling and behavioral
therapies, to provide a whole -patient approach to the treatment of SUDs.
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page 49 of 64
(18) Opioid Substitution Treatment: Means assessment and treatment to opioid dependent patients. Services include
prescribing and dispensing of an approved medication, as specified in 212 CFR Part 291, for opioid substitution services
in accordance with WAC 246-341-1000 through 246-341-1025. Both withdrawal management and maintenance are
included, as well as physical exams, clinical evaluations, individual or group therapy for the primary patient and their family
or significant others. Additional services include guidance counseling, family planning and educational and vocational
information. (The service as described satisfies the level of intensity in ASAM Level 1).
(19) Pregnant and Post -Partum Women (PPW): Means: (i) women who are pregnant; (ii) women who are postpartum during
g
the first year after pregnancy completion regardless of the outcome of the pregnancy or placement of children; or(iii)
women who are parenting children, including those attempting to gain custody of children supervised by the Department
of Children, Youth and Families (DCYF).
(20) Pregnant, Post -Partum or Parenting (PPW) Women's Housing Support Services: Means the costs incurred top rovide
support services provided to PPW individuals with children under the age of six (6) in a transitional residential housing
program designed exclusively for this population.
(21) Recovery House Residential Treatment: Means a program of care and treatment with social, vocational, and recreational
activities designed to aid individuals diagnosed with substance use disorder in the adjustment to abstinenceassistin ' ' ( g in
their Recovery) and to aid in job training, reentry to employment, or other types of community activities, excluding room
and board in a twenty -four -hour -a -day supervised facility in accordance with WAC 246-341, (The service as described
satisfies the level of intensity in ASAM Level 3.1).
(22) Recovery Support Services: Means a broad range of non -clinical services that assist individuals and families to initiate
stabilize, and maintain long-term Recovery from behavioral health disorders including mental illness and substance use
disorders.
(23) Sobering Services: Means short-term (12 hours or less) emergency shelter, screening, and referral services top ersons
who are intoxicated or in active withdrawal. .
(24) Sub -Acute Withdrawal Management (Detoxification): Means services provided to an individual to assist in withdrawal
from psychoactive substance in a safe and effective manner. Sub -Acute is nonmedical detoxification/withdrawal
management or patient self -ad ministration of withdrawal medications ordered by a physician, provided in a home -like
environment.
(25) Substance Abuse Block Grant (SABG) Block Grant: Means the Federal Substance Abuse Block Grant Program
authorized by Section 1921 of Title XIX, Part B, Subpart II and III of the Public Health Service Act.
(26) Substance Use Disorder Outpatient Treatment: Means services provided in a non-residential substance use disorder
treatment facility. Outpatient treatment services must meet the criteria in Chapter 246-341 WAC. (The service as
described satisfies the level of intensity in ASAM Level 1).
(27) Substance Use Disorder Professional (SUDP): Means an individual who is certified according to chapter 18.205 RCW
and the certification requirements of WAC 246-811-030 to provide Substance Use Disorder (SUD) services.
(28) Substance Use Disorder (SUD) Program: The program is the provision of those SUD services further described within
this Exhibit B-11 which are reimbursable pursuant to the contract between Beacon and the Washington State Health Care
Authority.
(29) Youth: Means a person from age ten (10) through seventeen (17). However, under SABG, Youth Support Services can
be billed for individuals through age twenty (20) if the individual is not developmentally living as adults after eighteen
age
(18). g
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page 50 of 64
(30) Waiting List: Means a list of Eligible Individuals who qualify for SABG-funded services for whom services have not been
scheduled due to lack of capacity.
III. Services. Facility agrees to:
(1) Facility may use block grant funds to help Individuals satisfy cost-sharing requirements for SABG-authorized SUD
services. The Facility must ensure that:
a. The provider is a recipient of block grant funds;
b. Cost-sharing is for a block grant authorized service;
c. Payments are in accordance with SABG laws and regulations;
d. Cost-sharing payments are made directly to the provider of the service; and
e. A report is provided to Beacon upon request that identifies:
i. The number of Individuals provided cost-sharing assistance;
The total dollars paid out for cost-sharing; and
Providers who received cost-sharing funds.
(2) Services in the table below are allowable as defined by the HCA when utilizing funds in the priority identified when that
funding is received. ASAM criteria is used to determine appropriate levels of care. Authorization from a Beacon Care
Manager is required for Withdrawal Management and Residential Treatment. Facilities seeking reimbursement for
providing services without an associated Fee for Service (FFS) billing code in Facility's rate schedule, shall confirm such
services are part of the RSA's current SABG Plan and obtain approval from the RSA's Account Partnership Director before
submission of a cost reimbursement invoice.
BHO-F-COM-MA-MCD/11/2015
(AG - VO STD FACILITY)
SABG: 1st priority
for non -offender
adults or services
not covered by
DMA
CJTA-Drug Court:
X
X
1st Priority for
DMA: 1st priority
Service
qualifying
for youth or
X
nonviolent
perinatal women
X
offender
X
Brief Intervention (Any Level,
X
X
Assessment not Required
X
x
Acute Withdrawal Management
ASAM Level 3.7WM
X
X
Sub -Acute Withdrawal
Management (ASAM Level
X
X
3,2WM
Outpatient Treatment (ASAM
Level 1
x
X
Intensive Outpatient Treatment
ASAM Level 2.1)x
X
Brief Outpatient Treatment
(ASAM Level 1
x
x
Opioid Substitution Treatment
ASAM Level 1
X
X
Case Management (ASAM Levels
1.2)
X
X
BHO-F-COM-MA-MCD/11/2015
(AG - VO STD FACILITY)
SABG: 1st priority
for non -offender
adults or services
not covered by
DMA
GFS: Default
funding after all
others
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Amend 14 - PID 301052
Page 51 of 64
*includes assessments done while in jail
(3) If Facility is providing Inpatient Medically Monitored Intensive Inpatient Detoxification Services
(Level 3.7), as authorized
by .Beacon, the following shall be included:
a. Must provide 24hr/7 days per week medically -monitored services
b. 24-hour nursing care with physician availability
Must accept admissions 24hrs/7 days per week.
BHO-F-COM-MA-MCD/11/2015 Amend 14 - P
(AG - VO STD FACILITY) ID 301052
Page 52 of 64
CJTA-Drug Court:
SABG:1st priority
Service
1 st Priority for
DMA: 1 st priority
for non-offender
GFS: Default
qualifying
for youth or
adults or services
funding after all
nonviolent
perinatal women
not covered by
others
offender
DMA
Intensive Inpatient Residential
Treatment (ASAM Level 3.5
X
X
X
X
Long-term Care Residential
Treatment ASAM Level 3.3
X
X
X
X
Recovery House Residential
Treatment ASAM Level 3.1
X
X
X
X
Assessment
X*
X
X
X
Engagement and Referral
X
X
Alcohol/Drug Information School
X
ADIS
X
X
X
Opioid Dependency Outreach
X
X
X
X
Interim Services
X
X
X
X
Community Outreach and
Engagement
X
X
X
X
Crisis Services
X
Soberin Services
X
X
X
X
Involuntary Commitment
Investigations and Treatment
X
X
X
Therapeutic Interventions for
Children
X
X
X
Transportation
X
X
X
X
Childcare Services provided by
licensed childcare providers
X
X
X
X
PPW Housing Support Services
X
X
X
FamilyHardship
Recoyea Support Services
X
X
X
X
X
Continuing Education
X
X
Urinal sis
X
X
X
X
Employment services and job
trainingX
X
X
Relapse prevention
X
X
X
X
-Family/marriage education
X
X
Peer-to-peer services, mentoring
X
and coachingX
X
X
X
Self-help and support groups
X
X
X
Housing support services (rent
and/or deposits)
X
X
X
Life skills
X
X
X
Education
X
X
X
Parent education and child
development
X
X
X
*includes assessments done while in jail
(3) If Facility is providing Inpatient Medically Monitored Intensive Inpatient Detoxification Services
(Level 3.7), as authorized
by .Beacon, the following shall be included:
a. Must provide 24hr/7 days per week medically -monitored services
b. 24-hour nursing care with physician availability
Must accept admissions 24hrs/7 days per week.
BHO-F-COM-MA-MCD/11/2015 Amend 14 - P
(AG - VO STD FACILITY) ID 301052
Page 52 of 64
d. Must have written admission and discharge criteria.
e. Must provide medical diagnostic services on-site or by contract.
f. Must provide a full range of treatment programming 7 days per week.
g. Must provide individualized treatment plans.
h. Must provide emergency psychiatric/medical services on-site or by contract.
i. Must require and/or encourage family involvement in treatment.
j. Must provide structured recovery support groups.
k. Must have an Addictionologist either on staff or contracted or Medical Director must have three3
exexperience treating sub () years'
p g stance abuse patients as evidenced in resume.
I. Must receive oversight from a Medical Director.
(4) If Facility is providing Intensive Outpatient services, the following shall be included:
a. Must have a written program narrative.
b. Must provide individualized treatment plans.
c. Must have written procedures for handling medical/psychiatric emergencies.
d. Must provide or make available any structured recovery support groups.
e. Must have the supervision of a licensed clinician.
f. Must have written admission and discharge criteria.
g. Must have a written schedule of program activities.
h. Must provide services at least 3hrs per day, 3 to 5 days per week.
(5) If Facility is providing Clinically Managed High Intensity Residential Services(Level 3.5 authorized b Be. ), y Beacon, the
following shall be included:
a. Must provide 24hr/7 days per week coverage by licensed staff.
b. Must accept admissions 24hrs/7 days per week.
c. Must have written admission and discharge criteria.
d. Must provide medical diagnostic services on-site or by contract.
e. Must provide a full range of treatment programming 7 days per week.
f. Must provide individualized treatment plans.
BHO_F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG VO STD FACILITY) Page 53 of 64
g. Must provide emergency psychiatric/medical services on-site or by contract.
h. Must require and/or encourage family involvement in treatment.
i. Must provide structured recovery support groups and aftercare.
j. Must have an Addictionologist either on staff or contracted or Medical Director must have three (3) years
experience treating substance abuse patients as evidenced in resume.
k. Must receive oversight from a Medical Director.
(6) Conduct an inquiry regarding each patient's continued financial eligibility no less than one time
g Y per month.
(7) Document the evidence of each financial screening in individual patient records.
(8) For all engagement and outreach services provided prior to an intake, the Facility shall:
a. If more than three engagement and outreach services provided in a 90 -da period to the same
provided, the Facility Y p person and an
intake has not been
p ity shall ensure a note is included in the chart indicating why individual
has not received an intake.
b. Facility should track outcomes of outreach and engagement in converting individuals into ongoing ng treatment.
(9) Ensure that, as a Facility receiving funding under the Block Grant and providing '
96.959 Facility p iding services required by CFR Title 45, Section
shall make every effort, including the establishment of systems for eligibility determination '
collection, to: g Y ,billing, and
a. Collect reimbursement for the costs of providing such services to persons who are entitled to insurance benefits
under the Social Security Act, including programs under Title XVIII and Title XIX. Additional programs includeany State compensation program, other public assistance program for medical
expenses, grant programs,
private health insurance, or any other benefit program; and
b. Secure payments from individuals for services in accordance with their ability to pay.
(10) Meet the needs of priority populations, in priority order below, as identified in the SABG or
limited to:
by HCA, including but not
a. Pregnant individuals injecting drugs.
b. Pregnant individuals with SLID,
c. Women with dependent children.
d. Individuals who are injecting drugs or substances.
e. The following additional priority populations, in no particular order:
i. Postpartum women (up to one year, regardless of pregnancy outcome).
ii. Patients transitioning from residential care to outpatient care.
iii. Youth.
BHO-F-COM-MA-MCD/1 1/2015
(AG — VO STD FACILITY)
Amend 14 — PI D 301052
Page 54 of 64
iv. Offenders as defined in RCW 70.96.350.
(11) For SABG funded services, the Facility shall ensure the following:
a. Within available resources, ensure that SABG services are not denied to an Eligible Individual regardless Y 9 g Bless of.
i. The individual's drug(s) of choice.
ii. The fact that the individual is taking FDA approved medically -prescribed medications.
iii. The fact that the individual is using over the counter nicotine cessation medications ora actively
participating in a nicotine replacement therapy regimen
b. Deliver SABG services as described in the regional SABG Project Plan for the current fiscalear
Beacon and the Health Care Authority.
Y approved by
c. Ensure that SABG funds are used only for services to individuals who are not enrolled in Medicaid orfor or services
that are not covered by Medicaid as described in the following table:
Benefits Services
Individual is not a Medicaid
recipient Any Allowable Type
Individual is a Medicaid
recipient Allowed under Medicaid
Individual is a Medicaid Not Allowed under
recipient Medicaid
Use SABG Funds
Use Medicaid
Yes
No
No
Yes
Yes
No
d. Have protocols for maintaining waiting lists and providing interim services for SABGriori
p ty population
individuals, as defined in this Contract, who are eligible to receive services but for whom SLID treatment services
are not available due to limitations in provider capacity or available resources.
i. The waiting list interim record must include:
1. Application form that includes the applicant's full name (last, first and middle initial),birth date
gender, race (including Spanish/Hispanic origin), Social Security Number, address and hone
number p
2. A unique individual identifier for each individual
3. Service plan record noting proposed treatment modalities, tentative treatment dates
4. Record of all contacts and referrals.
e. Ensure interim services are provided by for pregnant and parenting women and intravenous drug users.
f. Interim services shall be made available within forty-eight (48) hours of seekingtreatment for
parenting women and intravenous drug users.
pregnant and
g. Admission to treatment services for the intravenous drug user shall be provided within fourteen14 patient makes the request,( ) d ays after
the
p regardless of funding source.
h. If there is no treatment capacity within fourteen (14) days of the initialatient request, the Facility p q y shall have up
to one hundred twenty (120) days, afterthe date of such request, to admit the patient into treatment while
offering
BHO_F-COM-MA-MCD/11/2015 Amend 14 — PID
(AG . VO STD FACILITY) 301052
Page 55 of 64
or referring to interim services within forty-eight (48) hours of the initial request for treatment services. Interim
nterim
services must be documented in the system platform designated by the HCA and include, at a minimum;
i. Counseling on the effects of alcohol and drug use on the fetus for the
pregnant patient.
g
ii. Prenatal care for the pregnant patient.
iii. Human immunodeficiency virus (HIV) and tuberculosis (TB) education.
iv. HIV or TB treatment services if necessary for an intravenous drug user.
v. The interim service documentation requirement is specifically for the admission of priority populations
s
with any funding source and any patient being served with SABG Block Grant funds.
A pregnant woman who is unable to access residential treatment due to lack of capacity and is in
p y need of
detoxification, can be referred to a Chemical Using Pregnant (CUP) program for admission typically '
twenty-four(24)hours. , Yp y within
j. Facility shall notify Beacon, in writing, when the Facility is at ninety(90)ercent ca acit and '. p capacity must maintain
records using the Capacity Management Form, in accordance with (42 USC 300-23 and 42 USC 30OX 27).
k. On a quarterly basis, on the last day of the month following the close of the quarter, Facility shall
submit theDBHR Capacity Management Form. The Capacity Management Form will identify
PPW and IUID providers
receiving SABG funds, who are at (90) percent capacity, and what was or is being done to address capacity.
ty.
I. SABG funds cannot be used for the following;
i. Construction and/or renovation.
ii. Capital assets or the accumulation of operating reserve accounts.
iii. Equipment costs over $5,000.
iv. Cash payments to Consumers
v. Grant funds may not be used, directly or indirectly, to purchase, prescribe, or provide marijuanamarijuana. Treatment p �uana or
treatment using 1 nt in this context includes the treatment of opioid use disorder.
Grant funds also cannot be provided to any individual who or organization that provides or permits
marijuana use for the purposes of treating substance use or mental disorders. See,
e.g., 45 C.F.R. §
75.300(a) (requiring HHS to "ensure that Federal funding is expended... in full accordance with U.S.
statutory... requirements."); 21 U.S.C. §§ 812(c) (10) and 841 (prohibiting the possession manufacture
sale, purchase or distribution of marijuana). This prohibition does not applyto those p providing such
treatment in the context of clinical p g
research permitted by the DEA and under the FDA -approved
investigational new drug application where the article being evaluated is marijuana or a constituent
thereof that is otherwise a banned substance under federal law.
m. SABG funds may not be used to pay for services provided prior to the execution of this Exhibit or
to pay in
advance of service delivery. All contracts and amendments must be in writing and executed by both parties prior any services being provided
n. Participate in annual peer review by individuals with expertise in the field of drugabuse treatment
requested b HCA(42 U.S.C. 300x-5 nt when
Y 3 (a) and 45 C.R.R. 96.136)
BHO_F-COM-MA-MCD/11/2015 Amend 14 — PID 3
(AG VO STD FACILITY) 01052
Page 56 of 64
o. Send a representative to the regional Behavioral Health Advisory Board (BHAB)to re ort on meetings g p program
data and results.
p. Facility shall ensure compliance with tuberculosis screening, testing and referral, in accordance with4
(2 USC
300x -24(a) and 45 CFR 96.127), in the following manner:
i. Coordinating with other public entities to make tuberculosis services available to each Eligible Individual
receiving SABG-funded SLID treatment.
ii. The services will include tuberculosis counseling, testing, and providingfor or referring infected
g with
tuberculosis for appropriate medical evaluation and treatment.
iii. In the case of an Eligible Individual in need of treatment service who is denied admission
to the
tuberculosis program on the basis of lack of capacity, the Facility will refer the Eligible Individual
provider of tuberculosis services.g to
another
p
iv. Contract for case management activities to ensure the Eligible Individuals receive tuberculosis services
(12) Charitable Choice Requirements of 42 CFR Part 54 are followed and Faith -Based Organizations g (FBO) are provided
opportunities to compete with traditional alcohol/drug abuse treatment providers for funding.
g
a. Contracted FBOs are required to meet the requirements of 42 C.F.R. Part 54 as follows:
i. Eligible Individuals requesting or receiving SUD services shall be provided with a choice of
SUD
treatment providers.
ii. The FBO shall facilitate a referral to an alternative Facility within a reasonable time frame when
requested by the recipient of service
iii. The FBO shall report to Beacon all referrals made to alternative providers.
iv. The FBO shall provide Eligible Individuals with a notice of their rights.
v. The FBO provides Eligible Individuals with a summary of services that includes an religious activities.
Y g t es.
vi. Funds received from the FBO must be segregated in a manner consistent with federal Regulations.
g s.
vii. No funds may be expended for religious activities.
(13) Youth Support Services can be billed for individuals through age twentyif the individual is not de 'as adults after age eighteen (18).
developmentally living
a. Youth funds may be used for family support services including:
i. Youth group therapy for youth and young adults ages ten (10) through twenty (20).
ii. Services to family of Youth admitted to treatment and costs incurred to provide recreational
supervised p tional
activities in conjunction with a SUD outpatient program. Family services must be coded as family
support services and Supervised Therapeutic Recreation must be coded as group therapy.
iii. Youth Individual Therapy for youth and young adults ages 10-20.
iv. This also includes services to family and significant others of persons in treatment and should'
billed
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 3
(AG — VO STD FACILITY) 01052
Page 57 of 64
according to contracted codes.
(14) Prior Authorization is required for all residential patients.
(15) Facility may provide the following services, as authorized by Beacon, using funds from the Designated Marijuana Account
when that funding is used:
g j
a. Substance Use Disorder Outpatient Adolescent Treatment utilizing individual, group y and family treatment
modalities
b. Assessment
c. Residential Treatment Services — Adolescent
(16) When CJTA funding is used, Facility shall participate in the development and implementation of an local
p y CJTA plans
established under RCW 71.24.580(6) developed by the CJTA panel and approved by HCA and/or the CJTA Panel
in
accordance with 71.24.580(5)(b).
(17) When CJTA funding is used for treatment in the jail:
a. CJTA funding used for this purpose may not supplant any locally funded programs within a cit count or tribal
jail. y' y'
b. SUD treatment service provided in jail may include, but are not limited to the following:
g
i. Engaging Individuals in SUD treatment
ii. Referral to SUD services;
iii. Administration of Medications for the treatment of SUDs including Opioid Use Disorder to include the
following
iv. Screening for medications for SUDs
v. Cost of medications for SUDs
vi. Administration of medications for SUDs
c. Coordinating care;
d. Continuity of Care; and
e. Transition planning
IV. Reportinq Requirements are detailed in Exhibit B-25.
BHO-F-COM-MA-MCD/11/2015 Amend 14 — PID 301052
(AG — VO STD FACILITY) Page e 58 of 64
CRISIS TRIAGE/STABILIZATION CENTERS Exhibit B -20.A14
AND INCREASING PSYCHIATRIC RESIDENTIAL TREATMENT BEDS
f Formerly ESSB 5883 Start Up Funds)
This exhibit contains the requirements for Facilities funded for crisis stabilization and triage centers or the addition of
'
residential treatment beds.
General Provisions.
(1) Status updates on the implementation plan shall be submitted to Beacon no later than September 30, 2020 and monthly
thereafter until the facility is fully operational. The plan update must include:
a. Implementation timeline update
b. Any update or change in how the funding will be used for start-upcosts
to implementation
c. Any new barriers or challenges
.
(2) The funding available may be used for staffing, training, facilityrental fees furniture '
or required equipment, etc. Proviso
funds may not be used for capital costs, such as remodeling existingfacilities or building facilities.
g new facilities.
(3) Payment will be made on invoice with clear detail that capital costs are not included ' '
in bill.
(4) Utilization of the funds is contingent on programs becoming operational b September la y p er 30, 2020.
(5) Once operational, Facilities that received ESSB 5883 Start U Funds for either a Crisis
p sis Center or to
increase psychiatric residential treatment beds for Individuals transitioningfrom psychiatric in
p y patient settings shall continue
submitting quarterly reports to Beacon using the HCAs Crisis Triage/Stabilization and Increasing'
reporting template provided b Be Psychiatric Bed Capacity
p p y Beacon. Reports are due twenty (20) calendar days after the end of the state SFYq uarter.
BHO-F-COM-MA-MCD/11/2015
(AG — VO STD FACILITY) Amend 14 — PID 301052
Page 59 of 64
Exhibit B -25.A14
Reporting Provisions
This Exhibit contains additional provisions applicable to reporting on Covered Services off administered erect and/or administered by Washington
State Health Care Authority (HCA). In the event of any conflict between therovisions
ec p of the Agreement (including Exhibit B-8),
and this Exhibit B-25 and subject to the provisions set out in Exhibit B-25, the provisions of this Exhibit control as related
on services rendered to individuals receiving Covered Services. to reporting
General Provisions.
(1) Whenever in this Exhibit B-18 the term "Facility" is used to describe an obligation or '
be the responsibility of each individual � , , g duty, such obligation or duty will also
p y licensed health care practitioner, Facility, and provider employed or owned
under contract with Facility, as the context may require.
by or
II: Global Reportinq Requirements
(1) HCA reporting templates are located at: https://www,hca.wa Dov/billers-providers-partners/aro rams and
services/model-managed-care-contracts
(2) Provision of required reports is a condition for payment.
(3) Facility will use Beacon's Provider Connects portal to register Eligible Individuals 9 g for services to ensure they are
assigned a unique ID. Registrations must include, but are not limited to, appropriate start d '
encounters/claims reporting.For tho ate and fund assignment for
se with Medicaid, the individual's Provider One ID must be provided soro er
allocation of cost can be distinguished for the Payor. p p
a. Funding registration ends after one year. Individuals continuing to receive services must be re-
registered
(4) Facility must submit complete and accurate reports and data required under this Contract ontract that complies with HCA Service
Encounter Reporting Instructions (SERI) Guide, HCA Encounter Data Reporting Guide
Supplemental Transactions that p g (EDRG), and Behavioral Health
Sup
p at complies with the Behavioral Health Data System (BHDS)Guide. Behavioral HSupplemental Transactions related � Health
to services provided to Individuals must be submitted within thin(30)calendar dafrom the date of service or event.Y Ys
(5) Unless there is an established SFTP site with Beacon, reports should be submitted
to the following email address, which
is monitored multiple times each day: BeaconWAASQO. beacon healtho tions.com.
included in the email subject line.
p The name of the report should be
(6) Facility will submit a completed monthly attestation regardingexclusionary checks '
the 10th of each month. Y to Beacon Health Options no later than
(7) Facility must provide claims and/or encounter codes to Beacon for reporting to the
p g Washington State Health Care Authority
in accordance with the
Rate Schedules in this Contract. Claims submitted for health carea ments also known
Fee for Service (FFS) payment type, must be submitted p Y � own as the
within current Washington State Health Care Authority timely
filing requirements or they will be denied for timely filing. Encounters submitted for healthPrepaid care reporting purposes, also
known as the Pre
p payment t type, must be submitted to Beacon monthly for the previous month. Claims and encounter
provided and directly
submissions are used to reconcile services
p t y impact future rate setting and/or funding available in the
RSA. Failure to submit claims and/or encounters for services rendered as outlined ino
y ur rate schedule(s) may result in
future budget reductions.
(8) Failure to meet reporting requirements may result in a Corrective Action Plan CAP
III: If Facility is providin services outlined in Exhibit B-4 Crisis Program Provisions additional the following additional re orcin
B H O -F -C 0 M- MA -MCD/ 11 /2015
(AG - VO STD FACILITY) Amend 14 - PID 301052
Page 60 of 64
requirements apply.
(1) When reporting encounters, thefund code and, forthose with Medicaid, the individual's Provider One ID, must be provided
so proper allocation of cost can be distinguished for the Payor.
(2) Facility must collect and report to Beacon all applicable transactions described in the Health
Care Authority (HCA) most
current Behavioral Health Data System (BHDS) Guide, including but not limited to the following within 24 hours:
a. Demographics 020.08
b. DCR Investigation 160.05
c. ITA Hearing 162.05
(3) Facility shall submit Daily Crisis Logs that provide summary of all crisis interventions including '
ding but not limited to, core
demographics, date of contact, referral reason, intervention provided, outcome follow u services � p es to be provided, and
recommendations for further clinical care coordination by MCO or Beacon. Facility shall enter the Eligible Individual's
Beacon assigned identification number in the field titled "Client ID".
(4) Facility shall obtain and provide to Beacon monthly updates on all LRA/CR orders in their county(ies).
(5) Facility shall administer a client satisfaction survey upon completion of services and provide
analysis of survey results an minimum, p de an annual report with an
Y y d recommendations to Beacon. At minimum, the analysis shall include: number of surveys
completed, percentage of completed surveys relative to clients served results of sure Y
surveys, comparison of results over time,
trends found in population and actions taken or to be taken by crisis provider to improve client satisfaction.
is due by January10 for the previous c � p action. Annual report
p calendar year.
(6) Facility will provide a quarterly report of progress towards execution and/or mai inter -
agency including � maintenance of inter agency
a
9 g the following information: organizations with executed agreements and maintenance
status, organizations in discussion and status of discussions, organizations noteta approached
engagement. Y pp ched and plans for
(7) Facility shall report dashboard data monthly to Beacon to fulfill reporting requirements p g q is to key stakeholders and the HCA,
including but not limited to, the elements outlined in the following Crisis Dashboard Reporting Elements
services are provided b the Facility:
p g ments tables when those
Y Y
a. Data must be submitted by the 10th day of the following month.
b. Definitions of each element as well as formatting requirements will be provided by Beacon upon request or when
there is a change to an element or formatting.
BHO_F-COM-MA-MCD/11/2015 Amend 1 -
(AG VO STD FACILITY) 4 PID 301052
Page 61 of 64
Crisis Dashboard Reporting Elements
Data
Reported by
Key
IP = In Person
MCI (Adult/Youth)
/ Youth)
TH = Telehealth
Responses that do
DCR
not require a DCR
Referral Source
Regional Crisis Line
X
MCI
X
Law Enforcement (Sheena's Law)
X
Warm hand off in clinic or brought over to facility
X
Family Member Petition (Joel's Law)
X
Co -responder Team
X
Jail or Juvenile Detention
X
Other (provide details)
X
Total number referrals received
X
X
Response Time
For Initial Dispatch (average minutes)
X
From Request to Face -to -Face Arrival (average minutes)
X
X
encounters in initial 2 -person response
X
X
Emergent (respond within 2 hours)
X
Emergent Performance Incentive (respond within 90 minutes)
X
X
Urgent (as scheduled within 24 hours), defined as:
X
By next judicial day for someone in secure setting
X
No more than 6 hours post medical clearance: ER observation,
refused voluntary treatment
Brought by Peace Officer, up to 12 hours post medical clearance:
Definitions provided for information only,
crisis stabilization, E&T, hos
hospital ED tri
p age, secure detox, SUD
subcategory reporting of Urgent response
Within 3 hours must be assessed; determination within 12 hours of
times not currently required.
notice
Up to 12 hours to evaluate minors (13 + years old) brought to E&T,
hospital ER, secure detox
Location of Intervention
Community
X
ER/Hospital
X
Jail or Juvenile Detention
X
Other (provide details)
X
X
X
Placement
# Unavailable bed reports
# Single Bed Certs
X
# Out of County Placements
E-7
X
X
Outcomes
Phone Consult Only: Inappropriate Referral
X
BHO-F-COM-MA-MCD/11/2015
(AG - VO STD FACILITY) Amend 14 - PID 301052
Page 62 of 64
Data
Key
IP = In Person
TH = Telehealth
Phone Consult Only: Refused Service/Declined IP Response (individual
or family)
Refer to Community Stabilization (TH or IP)
Refer to DCR (TH or IP)
Resolved (TH or IP): # result in Referral to 7 -day Crisis CM Services
Resolved (TH or IP): % seen in 7 day CM follow-up
Resolved (TH or IP): Follow-up contact made within 24 hours
Resolved (TH or IP): Seen by follow-up PCP/OP in 7 days
# Face -to -Face crisis contacts (TH or OP)
diverted from Higher Level of Care (HLOC)
with unplanned contact/return to crisis system
Results in Referral to OP Treatment
Results in Referral to Voluntary IP Treatment
Results in Detention under ITA: MH Detention
Results in Detention under ITA: Referral to AOT, LRA, CR
Results in Detention under ITA: SUD Detention (Ricky's Law)
Referred to Law Enforcement
Unable to Contact / Refused Service
Other or No Further Steps
Total number of ITA Investigations
Total number of ITA Investigations Conducted via TH
Total number unique individuals served
Court Hear
# 14 -day hearing outcomes
# 90 -day hearing outcomes
# 180 -day hearing outcomes
# LRA/CR in place
Individuals monitored during reporting period
Individual unique ID #
Type of Service Provided
Start and End dates
Treatment Provider and Phone #
Health insurance coverage
# LRA/CR revoked
utcomes
Reported by
MCI (Adult/Youth)
Responses that do
not require a DCR
X
X
X
DCR
IV: If Facility is Providinq services outlined in Exhibit B-7 Mental Health Program Provisi
ons the followinq additional reporting
requirements apply.
V: If Facility is rovidin services outlined in Exhibit B-10 Mental Health Block Grant Pr
additional reLofting requirements a o ram Provisions the follow
p q q pplY,
B H O -F -C 0 M- MA -MCD/ 11 /2015
(AG - VO STD FACILITY) Amend 14 - PID 301052
Page 63 of 64
(1) Using the template provided by Beacon, the Facility shall submit a Monthl MHBG P
each month; Y erformance Report by the 10th of
(2) Provide any additional reporting as detailed in the block grant plan.
(3) Using the template provided by Beacon, the Contractor shall submit an Annual MHBG Performance Report 2 weeks prior
to the HCA due date of each contract year.
(4) Any other reports deemed necessary by Beacon to meet its reportingrequirements urs
with the Washington State Heal q pursuant to the terms of its agreement
g Health Care Authority and deemed necessary by Beacon to meets its requirements to ensure
g
quality of care and services provided to Eligible Individuals. q
(5) If Facility is providing services outlined in an Addenda listed below, the followingadditional nal reporting requirements apply.
a. Addendum to Exhibit B-10 Mobile Outreach Team Peer Support Specialist
i' owing month, regarding Report monthly data, by the 10 of the following 9 the unique q number of individuals
served, number of services provided, and year to date number of unduplicated individuals served.
ii. Provide a quarterly narrative by the 10 of the month following the end of theuarter d
activities, outcomes barriers an q describing the
d lessons learned.
VI: If Facility is Providing services outlined in Exhibit B-11 Substance Use Disorder Pro ram' '
Provisions the following
additional reporting requirements apply.
(1) On a quarterly basis, on the last day of the month following the close of the quarter, Facility shall submit the DBHRCapacity Management Form. The Capacity Management Form will identify
PPW and I U I D providers receivingSAB
funds, who are at (90) percent capacity, and what was or is G
Y being done to address capacity.
(2) For all SABG block grant funded service, Facility will provide all data required for state and nd federal reporting.
(3) Using the template provided by Beacon, the Facility shall submit a Monthl SABG Pe
each month Y rformance Report by the 10th of
(4) Provide any additional reporting as detailed in the block grant plan
(5) Using the template provided by Beacon, the Facility shall submit an Annual SABG Performance'
HCA due date of each contract Year. Report 2 weeks prior to
(6) Any other reports deemed necessary by Beacon to meet its reporting requirements pursuant to the terms of its agreementwith the Washington State Health Care Authority and deemed necessary
by Beacon to meets its requirements to ensure
quality of care and services provided to Eligible Individuals. q
VII: If Facility is providinq services outlined in Exhibit B-20 Crisis Triage/Stabilization Center '
Centers And Increasing Ps chiatric
Residential Treatment Beds the followinq additional re ortin re uirements
Nv
(1) Submit quarterly reports to Beacon using the RCA's Crisis Triage/Stabilization and Increasing easing Psychiatric Bed Capacity
reporting template provided by Beacon. Reports are due twenty (20) calendar days after the end o
Y f the SFY quarter.
B H O-F-COM-MA-MCD/11 /2015
(AG - VO STD FACILITY) Amend 14 - PID 301052
Page 64 of 64
r w
e ie
Grant Behavioral Health & Wellness
840 E. Plum Street
Moses Lake, WA 98837
Phone: (509) 765-9239
Fax: (509) 765-1582
Consent Agenda Week Week of 11/8/2021
Item Contract Amendment
Entity/Contracted Business
Beacon Health Options
Amendment 14
Contract Number
Confidential
No
This is an Amendment to our Beacon Health Options Agreement effective
7/1/21. Beacon is the Behavioral Health Administrative Services Organization
(ASO) for our region. They cover crisis services for Grant County.
No, scanned is perfect.
One
Dell Anderson, Ext 5472
Description
Original Needed?
Copies Attached
Contact for Questions
NOV - 5 2021
1.
A T
-# 0
INI r �M �";. �P"9
f'S