HomeMy WebLinkAboutAgreements/Contracts - RenewAMENDMENT #17 TO
BEACON FACILITY AGREEMENT
This seventeenth amendment ("Amendment") amends the Beacon Facility Agreement ("Agreement") entered into by Beacon
Health Options, Inc. ("Beacon") and County of Grant dba Renew ("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, 2022:
1. Exhibit A.A14 Facility Location(s) & Practitioners, Services & Payment is removed in its entirety and replaced with
Exhibit A.A17 Facility Location(s) & Practitioners, Services & Payment.
2. Exhibit A -4.A17 NWDM Youth Outpatient Substance Use Disorder Rate Schedule is added in its entirety.
3. Exhibit A -5.A17 NWMH Outpatient Mental Health Rate Schedule is added in its entirety.
4. Exhibit B -2.A15 Maximum Contract Amounts is removed in its entirety and replaced with Exhibit B -2.A17 Maximum
Contract Amounts.
5. Exhibit B -4.A15 Crisis Program Provisions (Mobile Crisis and Designated Crisis Responder) is removed in its entirety
and replaced with Exhibit B -4.A17 Crisis Program Provisions (Mobile Crisis and Designated Crisis Responder).
6. Exhibit B -7.A17 Mental Health Program Provisions is added in its entirety.
7. Exhibit B -8.A15 Washington State Health Care Authority Specific Provisions is removed in its entirety and replaced
with Exhibit B -8.A17 Washington State Health Care Authority Specific Provisions.
8. Exhibit B -10.A14 Mental Health Block Grant Program Provisions is removed in its entirety and replaced with Exhibit B -
10.A17 Mental Health Block Grant Program Provisions.
9. Addendum to B -11.A14 Mobile Outreach Team Peer Support Specialist is removed in its entirety and replaced with
Addendum to B -10.A17 Behavioral Health Community-based Outreach and Engagement.
10. Exhibit B -11.A14 Substance Use Disorder Program Provisions is removed in its entirety and replaced with Exhibit B -
11.A17 Substance Use Disorder Program Provisions.
11. Exhibit B -25.A15 Reporting Provisions is removed in its entirety and replaced with Exhibit B -25.A17 Reporting
Provisions.
12. This Amendment shall be effective upon the date set forth by Beacon following signature by both Beacon and Facility.
13. Except as amended herein, all other terms and conditions of the Agreement shall remain in full force and effect without
modification.
14. Scope of work pursuant with contract terms between Beacon and Health Care Authority as dictated in contract
amendment dated July 1, 2022.
Facility: County of Grand dba Renew Services
BHO-F-COM-MA-MCD/11/2015 Amend 17 — PID 301052
(AG — VO STD FACILITY) Page 1 of 72
Address: 840 E. Plum, Moses Lake, WA 98837
NPI: 1689677833;1982792537
BHO-F-COM-MA-MCD/11/2015 Amend 17 — PID 301052
(AG — VO STD FACILITY) Page 2 of 72
Exhibit A.A17
Facility Location(s) & Practitioners, Services & Payment
I: Facility Location(s) & Practitioners.
(1) The list of those Facility locations and Practitioners who are or will be rendering available Covered Services to Eligible
Individuals under this Agreement is set out in the most recently approved credentialing documentation.
II: Facility Services.
(1) All Behavioral Health Services: (a) available from Facility and/or Practitioners pursuant to their respective licensure or
certification; (b) for which Facility and/or Practitioners have been credentialed pursuant to Beacon's credential ing/re-
credentialing policies and procedures; and (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 Schedule(s) attached hereto and
incorporated herein by reference;
(b) The date of receipt of a claim is the date Beacon, or Payor, receives the claim, as indicated by its date stamp on
the claim;
(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, including without limitation, facility,
supplies, materials, drugs, equipment, x-ray, laboratory (technical, facility) and other diagnostic fees, semi -private
room 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 payment is due for the date of discharae.
(fl Crisis stabilization services are considered jUatient services with the length of stay calculated per the Health Care
Authority's (HCA) Inpatient Hospital billing guide. When admit and discharae are on same day one per diem unit will
bei
(2) No payment in addition to the applicable per diem rate for Covered Services above will be made for: (a) any outpatient
services rendered in the emergency room of Facility prior to an inpatient admission; or (b) any outpatient observation
services rendered prior to an inpatient admission.
BHO-F-COM-MA-MCD/11/2015 Amend 17 — PID 301052
(AG — VO STD FACILITY) Page 4 of 72
Exhibit A -4.A17
NWDM Youth Outpatient Substance Use Disorder (SUD) Rate Schedule
This Exhibit contain the Service Codes and billing rates that are allowed under the NWDM 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 in this Rate
Schedule.
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 Partnership Director for your Regional
Service Area (RSA).
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 Authority timely filing
requirements in the format outlined in this Rate Schedule.
b. Prepaid: Encounters submitted for health care reporting purposes, also known as the Prepaid payment type,
must be cleanly submitted to 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.
NWDM Rate Schedule.AV: Youth Outpatient Substance Use Disorder (SUD)
Service
Allowed
Add On
Interactive
Complexity
Service Description
04
M
W
Rate per
Allowed
Place of Service
Payment
Code
Code(s)
Add on
Code
NWDM
0
0
0
0
Unit
Billing Unit
Q C
W
(POS)
Type
BH Intervention w/ grp
03, 09, 11, 12, 13, 15,
96164
96165
N/A
(2 or more) face to face,
GT
$27.20
i
minutes)
mutes)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
first 30 minutes
62, 71, 72
BH Intervention wl grp
UN (1=30
03,09,11, 12, 13, 15,
96164
96165
N/A
(2 or more) face to face,
HD
GT
$27.20
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
first 30 minutes
57, 62, 71, 72
BH Intervention w/ grp
UN (1=30
03, 09,11,121 13, 15,
96164
96165
N/A
(2 or more) face to face,
HD
U5
GT
$27.20
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
first 30 minutes
57, 62, 71, 72
BH Intervention w/ grp
03, 09,11, 121 13, 15,
96164
96165
N/A
(2 or more) face to face,
HD
U5
$27.20
i
mnutes)
minutes)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
first 30 minutes
62, 71, 72
BH Intervention w/ grp
UN (1=30
03, 09, 11, 12, 13, 15,
96164
96165
N/A
(2 or more) face to face,
HD
$27.20
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
first 30 minutes
57, 62, 71, 72
BH Intervention w/ grp
03, 09, 11, 12, 13, 15,
96164
96165
N/A
(2 or more) face to face,
U5
GT
$27.20
i
minutes)
mutes)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
first 30 minutes
62, 71, 72
BH Intervention w/ grp
03, 09, 11, 12, 13, 15,
96164
96165
N/A
(2 or more) face to face,
U5
$27.20
i
mutes)
minutes)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
first 30 minutes
62, 71, 72
BH Intervention w/ grp
UN (1=30
03, 09, 11, 12, 13, 15,
96164
96165
N/A
(2 or more) face to face,
$27.20
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
first 30 minutes
57, 62, 71, 72
BH Intervention w/
03, 09, 11, 12, 13,15,
96167
96168
N/A
family & patient face to
GT
$55.82
i
mnutes)
minutes)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
face, first 30 minutes
62, 71, 72
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 5 of 72
Service
Allowed
Add On
Interactive
Comp exity
Service Description
Rate per
Allowed
°
Place of Service
Payment
Code
Code(s)
Add On
Code
NWDM
0
0
0
0
Unit
BillingUnit
a Cr
(POS)
Type
Yp
BH Intervention w/
03, 09, 11, 12, 13, 15,
96167
96168
N/A
family & patient face to
HD
$55.82
i
mutes)
minutes)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
face, first 30 minutes
62, 71, 72
BH Intervention w/
UN (1=30
03, 09, 11, 12, 13, 15,
96167
96168
N/A
family & patient face to
HD
U5
GT
$55.82
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
face, first 30 minutes
57, 62, 71, 72
BH Intervention w/
03, 09, 11, 12, 13, 15,
96167
96168
N/A
family & patient face to
HD
U5
$55.82
i
minutes)
mutes)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
face, first 30 minutes
62, 71, 72
BH Intervention w/
UN (1=30
03, 09, 11, 12, 13, 15,
96167
96168
N/A
family & patient face to
HD
GT
$55.82
minutes)
No
19, ?2, 32, 33, 34, 53,
FFS
face, first 30 minutes
57, 62, 71, 72
BH Intervention w/
03, 09, 11, 12, 13, 15,
96167
96168
N/A
family & patient face to
U5
GT
$55.82
i
minutes)
mutes)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
face, first 30 minutes
62, 71, 72
BH Intervention w/
UN (1=30
03, 09, 11, 12, 13,15,
96167
96168
N/A
family & patient face to
U5
$55.82
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
face, first 30 minutes
57, 62, 71, 72
BH Intervention w/
03, 09, 11, 12, 13, 15,
96167
96168
N/A
family & patient face to
$55.82
mutes)
i
minutes)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
face, first 30 minutes
62, 71, 72
BH Intervention w/
UN (1=30
03, 09, 11, 12, 13, 15,
96170
96171
N/A
family, no patient, face
GT
$55.82
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
to face, first 30 minutes
57, 62, 71, 72
BH Intervention w/
03, 09, 11, 12, 13, 15,
96170
96171
N/A
family, no patient, face
HD
GT
$55.82
i
minutes)
mutes)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
to face, first 30 minutes
62, 71, 72
BH Intervention w/
UN (1=30
03, 09, 11, 12, 13,15,
96170
96171
N/A
family, no patient, face
HD
$55.82
minutes)
No
19, ?2, 32, 33, 34, 53,
FFS
to face, first 30 minutes
57, 62, 71, 72
BH Intervention w/
03, 09, 11, 12, 13, 15,
96170
96171
N/A
family, no patient, face
HD
U5
GT
$55.82
i
minutes)
mutes)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
to face, first 30 minutes
62, 71, 72
BH Intervention w/
UN (1=30
03, 09, 11, 12, 13,15,
96170
96171
N/A
family, no patient, face
HD
U5
$55.82
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
to face, first 30 minutes
57, 62, 71, 72
BH Intervention w/
UN (1=30
03, 09, 11, 12, 13,15,
96170
96171
N/A
family, no patient, face
U5
GT
$55.82
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
to face, first 30 minutes
57, 62, 71, 72
BH Intervention w/
03, 09, 11, 12, 13, 15,
96170
96171
N/A
family, no patient, face
U5
$55.82
i
mutes)
minutes)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
to face, first 30 minutes
62, 71, 72
BH Intervention.w/
UN (1=30
03, 09, 11, 12, 13,15,
96170
96171
N/A
family, no patient, face
$55.82
minutes)
No
19, 22, 32, 33, 34, 53,
FFS
to face, first 30 minutes
57, 62, 71, 72
Behay. Hlth Intrvtn. w/
UN (1=15
Add on
NIA
NIA
grp (2 or more), face -to-
$13.60
minutes; 1 or
NI
Same as Primary CTP
FFS
96165
face; each additional 15
more)
A
/Rev Code
minutes
Behay. Hlth Intrvtn. w/
UN (1=15
Add on
NIA
NIA
fam. & pt. face to face,
$27.91
minutes; 1 or
N/
Same as Primary CTP
FFS
96168
each additional 15
more)
A
/Rev Code
minutes
Behay.Hlth. Intrvtn. w/
UN (1=15
Add on
N/A
N/A
fam; no pt, face to face,
$27.91
minutes; 1 or
N/
Same as Primary CTP
FFS
96171
each additional 15
more)
A
/ Rev Code
minutes
H0001
N/A
N/A
Alcohol/drug
52
$34.80
UN (1=15
minutes; 1 or
No
03, 09,11, 12, 13,15,
FFS
assessment
19, 22, 53, 57, 71, 72
more
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 6 of 72
Service
Allowed
Interactive
Complexity
Service Description
Rate per
Allowed
Place of Service
Payment
Code
Cod OS
()
Add on
Code
NWDM
0
0
0
0
Unit
Billing Unit
a
(POS)
Type
H0001
N/A
N/A
Alcohol/drug
53
$34.80
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
FFS
assessment
19, 22, 53, 57, 71, 72
more
H0001
N/A
N/A
Alcohol/drug
HD
$34.80
UN (1=15
minutes; 1 or
No
03,09, 11, 12, 13,15,
FFS
assessment
19, 22, 53, 57, 71, 72
more
H0001
N/A
N/A
Alcohol/drug
HD
U5
$34.80
UN (1=15
minutes; 1 or
No
03, 09, 11,12, 13,15,
FFS
assessment
19, 22, 53, 57, 71, 72
more
H0001
N/A
N/A
Alcohol/drug
HD
U5
52
$34.80
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
FFS
assessment
19, 22, 53, 57, 71, 72
more
H0001
N/A
N/A
Alcohol/drug
HD
U5
53
$34.80
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
FFS
assessment
19, 22, 53, 57, 71, 72
more
H0001
N/A
N/A
Alcohol/drug
HD
52
$34.80
UN (1=15
minutes; 1 or
No
03, 09, 11,12, 13, 15,
FFS
assessment
19, 22, 53, 57, 71, 72
more
H0001
N/A
N/A
Alcohol/drug
HD
53
$34.80
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
FFS
assessment
19, 22, 53, 57, 71, 72
more
H0001
N/A
N/A
Alcohol/drug
U5
52
$34.80
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
FFS
assessment
19, 22, 53, 57, 71, 72
more
H0001
N/A
N/A
Alcohol/drug
U5
53
$34.80
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
FFS
assessment
19, 22, 53, 57, 71, 72
more
H0001
N/A
N/A
Alcohol/drug
U5
$34.80
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
FFS
assessment
19, 22, 53, 57, 71, 72
more
H0001
N/A
N/A
Alcohol/drug
$34.80
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
FFS
assessment
19, 22, 53, 57, 71, 72
more
Presumptive Drug
Class Screening
H0003
N/A
N/A
(analysis completed
$25.20
UN (1 per UA)
No
03, 09, 11, 12, 13, 15,
19, 22, 53, 57, 71, 72
FFS
onsite by provider and
billed by provider
BH counseling and
UN (1=15
*02, 03, 09, 11, 12, 13,
H0004
N/A
N/A
therapy, per 15 minutes
GT
$32.03
minutes; 1 or
No
15, 19, 22, 32, 33, 34,
*57,
FFS
more)
53, 62, 71, 72
BH counseling and
UN (1=15
*02, 03, 09, 11, 12, 13,
H0004
NIA
NIA
therapy, per 15 minutes
HD
U5
$32.03
minutes; 1 or
No
15, 19, 22, 32, 33, 34,
*57,
FFS
more)
530 62, 71, 72
BH counseling and
UN (1=15
*02, 03, 09, 11, 12, 13,
H0004
N/A
N/A
therapy, per 15 minutes
HD
U5
GT
$32.03
minutes; 1 or
No
15, 19, 22, 32, 33, 34,
*57,
FFS
more)
53, 62, 71, 72
BH counseling and
UN (1=15
*02, 03, 09, 11, 12, 13,
H0004
N/A
N/A
therapy, per 15 minutes
HD
GT
$32.03
minutes; 1 or
No
15, 19, 22, 32, 33, 34,
*57,
FFS
more)
531 62, 71, 72
BH counseling and
UN (1=15
*02, 03, 09, 11, 12,13,
H0004
NIA
NIA
therapy, per 15 minutes
HD
$32.03
minutes; 1 or
No
15,19, 22, 32, 33, 34,
*57,
FFS
more)
531 62, 71, 72
BH counseling and
UN (1=15
*02, 03, 09, 11, 12, 13,
H0004
N/A
N/A
therapy, per 15 minutes
U5
$32.03
minutes; 1 or
No
15,19, 22, 32, 33, 34,
FFS
more)
531 57, 62, 71, 72
BH counseling and
UN (1=15
*02, 03, 09, 11, 12, 13,
H0004
N/A
N/A
therapy, per 15 minutes
U5
GT
$32.03
minutes; 1 or
No
15,19, 22, 32, 33, 34,
*57,
FFS
more)
53, 62, 71, 72
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 7 of 72
Service
Allowed
Add On
Interactive
Complexity
Service Description
Rate per
Allowed
.2
Place of Service
Payment
Code
Code(s)
Add On
NWDM
Unit
Billing Unit
a
(POS)
Type
BH counseling and
UN (1=15
*02, 03, 09, 11, 12, 13,
H0004
N/A
N/A
therapy, per 15 minutes
$32.03
minutes; 1 or
No
15, 19, 22, 32, 33, 34,
*57,
FFS
more
53) 62, 71, 72
Alcohol/drug services;
H0020
N/A
N/A
MAT admin. /dispense
HD
$16.60
Unit (1 per
No
11, 19, 22, 53, 57
FFS
services by a licensed
encounter)
program
Alcohol/drug services;
H0020
N/A
N/A
MAT admin. /dispense
HD
U5
$16.60
Unit (1 per
No
11, 19, 22, 53, 57
FFS
services by a licensed
encounter)
program
Alcohol/drug services;
H0020
N/A
N/A
MAT admin. /dispense
U5
$16.60
Unit (1 per
No
11, 19, 22, 53, 57
FFS
services by a licensed
encounter)
program
Alcohol/drug services;
H0020
N/A
N/A
MAT admin. /dispense
$16.60
Unit (1 per
No
11, 19, 22, 53, 57
FFS
services by a licensed
encounter)
program
H0023
N/A
N/A
Behavioral Health
GT
$ 10092
UN (1 per
No
19 15
22 32 33, 34 53
FFS
Outreach Service
.,
encounter)*57,62,71,72,991
,
H0023
N/A
N/A
Behavioral Health
GT
XE
$100.92
UN (1 per
No
03, 09, 11, 12, 13, 15,
19, 22, 32, 33, 34, 53,
FFS
Outreach Service
encounter)
*57,62,71,72,99
H0023
N/A
N/A
Behavioral Health
HW
$100.92
UN (1 per
No
03, 09, 11, 12, 13, 15,
19, 21, 22, 32, 33, 34,
FFS
Outreach Service
encounter)
533 57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health
HW
HD
GT
$ 100.92
UN (1 per
No
, 13,15
19 21� 32 22 3334
FFS
Outreach Service
encounter)
° �
*
531 57, 62, 71, 72, 99
H0023
NIA
NIA
Behavioral Health
HW
HD
U5
$100.92
UN (1 per
No
03, 09, 11, 12, 13, 15,
19, 21, 22, 32, 33, 34,
FFS
Outreach Service
encounter)
53, *57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health
HW
HD
U5
GT
$100.92
UN (1 per
No
03, 09, 11, 12, 13,15,
19, 21, 22, 32, 33, 34,
FFS
Outreach Service
encounter)
53, 57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health
HW
XE
$100.92
UN (1 per
No
03, 09, 11, 12, 13, 15,
19, 21, 22, 32, 33, 34,
FFS
Outreach Service
encounter)
533 57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health
HW
GT
XE
$100.92
UN (1 per
No
03, 09, 11, 12, 13,15,
19, 21, 22, 32, 33, 34,
FFS
Outreach Service
encounter)
531 57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health
HW
U5
GT
XE
$100.92
UN (1 per
No
03, 09, 11, 12, 13, 15,
19, 21, 22, 32, 33, 34,
FFS
Outreach Service
encounter)
533 57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health
HW
HD
XE
$ 10092
UN (1 per
No
1921 15
22 32, 33, 34
FFS
Outreach Service
.
encounter)
° * �
53, 57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health
HW
HD
GT
XE
$ 10092
UN (1 per
No
19 9, 11, 2, 15
21 22 32 33 34
FFS
Outreach Service
.
encounter)
� * � �
53, 57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health
HW
HD
U5
XE
$100.92
UN (1 per
No
03, 09, 11, 12, 13,15,
19, 21, 22, 32, 33, 34,
FFS
Outreach Service
encounter)
53, 57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health
XE
$100.92
UN (1 per
No
03, 09, 11, 12,13,15,
19, 22, 32, 33, 34, 53,
FFS
Outreach Service
encounter)
*57,62,71,72,99
H0023
N/A
N/A
Behavioral Health
$100.92
UN (1 per
No
03, 09, 11, 12, 13,15,
19, 22, 32, 33, 34, 53,
FFS
Outreach Service
encounter)
*57,62,71,72,99
H0025
N/A
N/A
Behavior Health
HD
$78.75
UN (1 per
No
03,11, 12,13, 15,19,
22, 32, 33, 34, 53, *571
FFS
Prevention Education
encounter)
62)71,72
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 8 of 72
Service
Allowed
Add On
Interactive
Complexity
Service Description
r
N
M
If*
Rate per
Allowed
.a
Place of Service
Payment
Code
Code(s)
Add On
NWDM
Unit
Billing Unit
Q r
(POS)
Type
H0025
N/A
N/A
Behavior Health
HD
GT
$78.75
UN (1 per
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
Prevention Education
encounter)
62)71,72
H0025
N/A
N/A
Behavior Health
HD
U5
$78.75
UN (1 per
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
Prevention Education
encounter)
62, 71, 72
H0025
N/A
N/A
Behavior Health
HD
U5
GT
$78.75
UN (1 per
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
Prevention Education
encounter)
62)71,72
H0025
N/A
N/A
Behavior Health
U5
$78.75
UN (1 per
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
Prevention Education
encounter)
62, 71, 72
H0025
N/A
N/A
Behavior Health
U5
GT
$78.75
UN (1 per
No
03,11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
Prevention Education
encounter)
62)71,72
H0025
N/A
N/A
Behavior Health
U5
HD
$78.75
UN (1 per
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
Prevention Education
encounter)
62, 71, 72
H0025
N/A
N/A
Behavior Health
U5
HD
GT
$78.75
UN (1 per
No
03, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
Prevention Education
encounter)
62, 71, 72
H0025
N/A
N/A
Behavior Health
$78.75
UN (1 per
No
03,11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
Prevention Education
encounter)
62171,72
H0038
NIA
NIA
Self-help/peer services, per 15 minutes
$12.92
UN (1=15
minutes; 1 or
No
11, 12, 15, 53, *57, 99
FFS
more
03, 04, 06, 09, 11, 12,
Mental health services,
UN (1=<15
13,14,15, 16, 18, 20,
H0046
N/A
N/A
NOS, less than 15
UB
$29.45
minutes; 1 per
No
21, 22, 23, 31, 32, 51,
FFS
minutes
encounter)
53, 55, 56, *57, 62, 71,
72 99
Alcohol/drug services,
UN (1=15
03, 09, 11, 12, 13, 15,
H0050
N/A
N/A
per 15 minutes
GT
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
*57,
FFS
more
62, 71, 72
Alcohol/drug services,
UN (1=15
03, 09, 11, 12, 13,15,
H0050
N/A
N/A
per 15 minutes
HD
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
*57,
FFS
more
62, 71, 72
Alcohol/drug services,
UN (1=15
03, 09, 11, 12, 13,15,
H0050
N/A
N/A
per 15 minutes
HD
GT
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
*57,
FFS
more)
62, 71, 72
Alcohol/drug services,
UN (1=15
03, 09, 11, 12, 13,15,
H0050
N/A
N/A
per 15 minutes
HD
U5
GT
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
*57,
FFS
more)
62, 71, 72
Alcohol/drug services,
UN (1=15
03, 09, 11, 12, 13,15,
H0050
N/A
N/A
per 15 minutes
HD
U5
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
*57,
FFS
more
62, 71, 72
Alcohol/drug services,
UN (1=15
03, 09, 11, 12, 13, 15,
H0050
N/A
N/A
per 15 minutes
U5
GT
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
*57,
FFS
more)
62, 71, 72
Alcohol/drug services,
UN (1=15
03, 09, 11, 12, 13,15,
H0050
N/A
N/A
per 15 minutes
U5
$23.26
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
*57,
FFS
more)
62, 71, 72
Alcohol/drug services,
UN (1=15
03, 09, 11, 12, 13,15,
H0050
NIA
NIA
per 15 minutes
$23.26
minutes; 1 or
No
19) 22, 32, 33, 34, 53,
FFS
more
57, 62, 71, 72
Sign Lang/Oral
Interpreter Services
(Note: submit
UN (1= 15
03, 09, 11,12, 13,15,
T1013
N/A
N/A
encounters for reporting
GT
$0.01
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
*57,
Prepaid
and invoice for
more)
62, 71, 72
reimbursement
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 9 of 72
Service
Allowed
Add On
Interactive
Complexity
Service Description
GT
Telemedicine via interactive audio and video telecommunication
H9
Court-ordered
Rate per
Allowed
.a
Place of Service
Payment
Code
Code(s)
Add On
NWDM
0
0
0
0
Unit
Billing Unit
a �
(POS)
Type
UB
Request for Services
UD
Sign Lang/Oral
XE
Separate encounter, distinct service
25
Significant and separately identifiable E&M
52
Reduced services
53
Discontinued procedure
Interpreter Services
(Note: submit
UN (1= 15
03, 09, 11, 12, 13,15,
T1013
N/A
N/A
encounters for reporting
$0.01
minutes; 1 or
No
19, 22, 32, 33, 34, 53,
x`57,
Prepaid
and invoice for
more)
62, 71, 72
reimbursement
T1016
NIA
NIA
Case management,
GT
$14.67
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
FFS
each 15 minutes
19, 22, 53, 57, 71, 72
more
T1016
NIA
NIA
Case management,
HD
U5
GT
$14.67
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
FFS
each 15 minutes
19, 22, 53, 57, 71, 72
more
T1016
NIA
NIA
Case management,
HD
$14.67
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
FFS
each 15 minutes
19, 22, 53, 57, 71, 72
more
T1016
N/A
NIA
Case management,
HD
GT
$14.67
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
FFS
each 15 minutes
19, 22, 53, 57, 71, 72
more
T1016
N/A
NIA
Case management,
U5
$14.67
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13,15,
FFS
each 15 minutes
19, 22, 53, 57, 71, 72
more
T1016
N/A
NIA
Case management,
U5
GT
$14.67
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
FFS
each 15 minutes
19, 22, 53, 57, 71, 72
more
T1016
NIA
NIA
Case management,
$14.67
UN (1=15
minutes; 1 or
No
03, 09, 11, 12, 13, 15,
FFS
each 15 minutes
19, 22, 53, 57, 71, 72
more
Modifier
Description
ET
Crisis fund only
GT
Telemedicine via interactive audio and video telecommunication
H9
Court-ordered
HD
Pregnant/parenting women's program
HH
Integrated Mental Health/Substance Abuse Program
HK
Services provided involve multiple staff for safety purposes
HT
Multi -disciplinary team
HW
Funded by state mental health agency or ITA
HZ
Funded by Criminal Justice Treatment Account
U5
Individuals Using 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/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 10 of 72
Exhibit A -5-A17
NWMH Outpatient Mental Health Services Rate Schedule
This Exhibit contain the Service Codes and billing rates that are allowed under the NWMH 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 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 Authority timely filing
requirements in the format outlined in this Rate Schedule.
b. Prepaid: Encounters submitted for health care reporting purposes, also known as the Prepaid payment type,
must be cleanly submitted to 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.
NWMH Rate Schedule.AV: Outpatient Mental Health Services
Service
Code
Allowed
Add On
Interactive
Complexity
Add On
Service Description
NWMH
s-.
0
�'
0 N
L
0 M
L
Rate .
per Unit
p
Allowed
Billing Unit
� S
a
Place of Service (POS)
Payment
Type
Code(s)
Code
UN (1 per
*02, 03, 09, 11, 12, 13,
90791
N/A
90785
Psychiatric diagnostic evaluation
52
$108.71
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
62, 71, 72
UN (1 per
*02, 03, 09, 11, 12, 13,
90791
N/A
90785
Psychiatric diagnostic evaluation
53
$108.71
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
62, 71, 72
UN (1 per
*02, 03, 09,11, 12, 13,
90791
N/A
90785
Psychiatric diagnostic evaluation
GT
$108.71
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
62, 71, 72
UN (1 per
*02, 03, 09, 11, 12, 13,
90791
N/A
90785
Psychiatric diagnostic evaluation
GT
52
$108.71
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
62, 71, 72
UN (1 per
*02, 03, 09, 11, 12, 13,
90791
N/A
90785
Psychiatric diagnostic evaluation
GT
53
$108.71
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
62, 71, 72
UN (1 per
*02, 03, 09, 11, 12, 13,
90791
N/A
90785
Psychiatric diagnostic evaluation
$108.71
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
62, 71, 72
90792
N/A
90785
Psychiatric diagnostic evaluation
52
$152.51
UN (1 per
No
*02, 03, 09, 11, 12, 13,
15, 19, 22, 32, 33, 34, 53,
FFS
w/medical services
ENC)
*57, 62, 71, 72
90792
NIA
90785
Psychiatric diagnostic evaluation
53
$152.51
UN (1 per
No
*02, 03, 09, 11, 12, 13,
15, 19, 22, 32, 33, 34, 53,
FFS
w/medical services
ENC)
*571 621 71, 72
90792
NIA
90785
Psychiatric diagnostic evaluation
GT
$152.51
UN (1 per
No
*02, 03, 09, 11, 12, 13,
15, 19, 22, 32, 33, 34, 53,
FFS
w/medical services
ENC)
*57, 62, 71, 72
90792
NIA
90785
Psychiatric diagnostic evaluation
GT
52
$152.51
UN (1 per
No
*02, 03, 09, 11, 12, 13,
15, 19, 22, 32, 33, 34, 53,
FFS
w/medical services
ENC)
*57, 62, 71, 72
90792
NIA
90785
Psychiatric diagnostic evaluation
GT
53
$152.51
UN (1 per
No
*02, 03, 09, 11, 12, 13,
15, 19, 22, 32, 33, 34, 53,
FFS
w/medical services
ENC)
*57, 62, 71, 72
90792
NIA
90785
Psychiatric diagnostic evaluation
$152.51
UN (1 per
No
*02, 09 11 12 13
03, ,
, , ,
15, 19, 22, 32, 33, 34, 53,
FFS
w/medical services
ENC)
*57, 62, 71, 72
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 11 of 72
Service
Code
Allowed
Add On
Interactive
Complexity
AddOnNWMH
Service Description
L
T
L
N
L
M
L
Rate
Allowed
-a
� .
a
Place of Service (POS)
Payment
Code(s)
per Unit
Billing Unit
E
Type
yp
90832
N/A
90785
Psychotherapy w/patient and/or
GT
$57.03
UN (1=16-
37 minutes;
No
*02, 03, 09, 11, 12, 13,
15, 19, 22, 32, 33, 34, 53,
FFS
family member, 30 minutes
1 per
*57, 62, 71, 72
encounter
90832
N/A
90785
Psychotherapy w/patient and/or
$57.03
UN (1=16-
37 minutes;
No
*02, 03, 09, 11, 12, 13,
15,19, 22, 32, 33, 34, 53,
FFS
family member, 30 minutes
1 per
*57, 62, 71, 72
encounter
90834
N/A
90785
Psychotherapy w/patient and/or
GT
$89.54
UN (1= 38-
52 minutes;
No
*02, 03, 09, 11, 12,13,
15, 19, 22, 32, 33, 34, 53,
FFS
family member, 45 minutes
1 per
57, 62, 71, 72
encounter
90834
N/A
90785
Psychotherapy w/patient and/or
$89.54
UN (1= 38-
52 minutes;
No
*02, 03, 09, 11, 12, 13,
15, 19, 22, 32, 33, 34, 53,
FFS
family member, 45 minutes
1 per
*57, 62, 71, 72
encounter
90837
99354
90785
Psychotherapy w/patient and/or
GT
$107.44
UN (1=53
68 minutes;
No
*02, 03, 09, 11, 12, 13,
15 19, 22, 32, 33, 34, 53,
FFS
99355
family member, 60 minutes
1 per
,
*57, 62, 71, 72
encounter
90837
99354
90785
Psychotherapy w/patient and/or
$107.44
UN (1=53
68 minutes;
No
*02, 03, 09, 11, 12, 13,
15, 19, 22, 32, 33, 34, 53)
FFS
99355
family member, 60 minutes
1 per
*57, 62, 71, 72
encounter
Family psychotherapy w/o
m n (1=11
02209, 11, 12, 13, 15, 19,
90846
N/A
N/A
patient
GT
$90.43
minutes;
No
, 32, 33, 34, 53, *57,
FFS
or more)
621 71, 72
Family psychotherapy w/o
UN (1=15
03, 09, 11, 12, 13, 15, 19,
90846
N/A
N/A
patient
$90.43
minutes;1
No
22, 32, 33, 34, 531 *57)
FFS
or more
62, 71, 72
Family psychotherapy w/ patient
UN 1=15
03, 09, 11, 12, 13, 15, 19,
90847
N/A
N/A
present
GT
$102.00
minutes;1
No
22, 32, 33, 34, 531 *571
FFS
or more
62, 71, 72
Family psychotherapy w/ patient
UN (1=15
03, 09, 11, 12, 13, 15, 19,
90847
N/A
N/A
present
$102.00
minutes;1
No
22, 32, 33, 34, 53) *571
FFS
or more
62, 71, 72
UN (1=15
09, 11, 12, 13, 15, 19, 22,
90849
N/A
N/A
Multifamily group psychotherapy
$30.53
minutes;1
No
32, 33, 34, 53) *57, 62,
FFS
or more
71772
UN (1=15
09, 11, 12, 13, 15, 19, 22,
90853
N/A
90785
Group Psychotherapy
$29.74
minutes;1
No
32, 33, 34, 53) *57, 62,
FFS
or more
71,72
96372
N/A
N/A
Injection for ther/proph/diag
$16.02
UN (1 per
No
11, 12, 53, 56, *57
FFS
purposes SQ or IM
ENC
90833
90836
Office/0P visit, new patient,
UN (1 per
*02, 03, 09, 11, 12, 13,
99202
90838
90785
straightforward MDM or 15-29
g
52
$69.75
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
99354
total time of encounter
62, 71, 72
99355
90833
90836
Office/0P visit, new patient,
UN (1 per
*02, 03, 09, 11, 12, 13,
99202
90838
90785
straightforward MDM or 15-29
g
53
$69.75
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
total time of encounter
*57, 62, 71, 72
99355
90833
90836
Office/OP visit, new patient,
U
*02, 03, 09, 11, 12, 13,
99202
90838
90785
straightforward MDM or 15-29
GT
$69.75
ENC)er
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
total time of encounter
*57, 62, 71, 72
99355
90833
90836
Office/0P visit, new patient,
U
*02, 03, 09, 11, 12, 13,
99202
90838
90785
straightforward MDM or 15-29
GT
52
$69.75
ENC)er
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
total time of encounter
*57, 62, 71, 72
99355
90833
90836
Office/0P visit, new patient,
U
*02, 03, 09, 11, 12, 13,
99202
90838
90785
straightforward MDM or 15-29
GT
53
$69.75
ENC)er
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
total time of encounter
*57, 62, 71, 72
99355
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 12 of 72
Service
Code
Allowed
Add On
Interactive
Complexity
Service Description
NWMH
L
o
L
o N
L
o M
L
o
Rate
per Unit
Allowed
Billing Unit
a a-
Place of Service POS
( )
Payment
Type
Code(s)
Code
90833
90836
Office/0P visit, new patient,
UN (1 per
*02, 03, 09, 11, 12, 13,
99202
90838
90785
straightforward MDM or 15-29
$69.75
ENC)
No
15,19, 22, 32, 33, 34, 53,
FFS
99354
total time of encounter
*57, 62, 71, 72
99355
90833
90836
Office/0P visit, new patient, low
UN (1 per
*02, 03, 09, 11, 12, 13,
99203
90838
90785
MDM or 30-44 total time of
52
$104.28
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
encounter
*57, 62, 71, 72
99355
90833
90836
Office/0P visit, new patient, low
UN (1 per
*02, 03, 09, 11, 12, 13,
99203
90838
90785
MDM or 30-44 total time of
53
$104.28
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
encounter
*57, 62, 71, 72
99355
90833
90836
Office/OP visit, new patient, low
UN (1 per
*02, 03, 09, 11, 12, 13,
99203
90838
90785
MDM or 30-44 total time of
GT
$104.28
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
encounter
*57, 62, 71, 72
99355
90833
90836
Office/0P visit, new patient, low
U er
*02, 03, 09, 11, 12, 13,
99203
90838
90785
MDM or 30-44 total time of
GT
52
$104.28
ENC )
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
encounter
*57, 62, 71, 72
99355
90833
90836
Office/0P visit, new patient, low
U er
*02, 03, 09, 11, 12, 13,
99203
90838
90785
MDM or 30-44 total time of
GT
53
$104.28
ENC )
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
encounter
*57, 62, 71, 72
99355
90833
90836
Office/OP visit, new patient, low
UN (1 per
*02, 03, 09, 11, 12, 13,
99203
90838
90785
MDM or 30-44 total time of
$104.28
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
encounter
*57, 62, 71, 72
99355
90833
90836
Office/0P visit, new patient,
UN (1 per
*02, 03, 09, 11, 12, 13,
99204
90838
90785
moderate MDM or 45-59 total
52
$150.01
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
time of encounter
*57, 62, 71, 72
99355
90833
90836
Office/0P visit, new patient,
UN (1 per
*02, 03, 09, 11, 12, 13,
99204
90838
90785
moderate MDM or 45-59 total
53
$150.01
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
time of encounter
*57, 62, 71, 72
99355
90833
90836
Office/0P visit, new patient,
UN (1 per
*02, 03, 09, 11, 12, 13,
99204
90838
90785
moderate MDM or 45-59 total
GT
$150.01
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
time of encounter
*57, 62, 71, 72
99355
90833
90836
Office/OP visit, new patient,
U er
*02, 03, 09, 11, 12, 13,
99204
90838
90785
moderate MDM or 45-59 total
GT
52
$150.01
ENC )
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
time of encounter
*57, 62, 71, 72
99355
90833
90836
Office/0P visit, new patient,
UN (1 per
*02, 03, 09, 11, 12, 13,
99204
90838
90785
moderate MDM or 45-59 total
GT
53
$150.01
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
time of encounter
*57, 62, 71, 72
99355
90833
90836
Office/OP visit, new patient,
UN (1 per
*02, 03, 09, 11, 12, 13,
99204
90838
90785
moderate MDM or 45-59 total
$150.01
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
99354
time of encounter
*57, 62, 71, 72
99355
Office/0P visit, new patient, high
UN (1 per
*02,03,09, 11, T2,13,
99205
G2212
90785
MDM or 60-74 total time of
52
$188.66
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
I
I encounter
*57, 62, 71, 72
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 13 of 72
Service
Code
Allowed
Add On
Interactive
Complexity
AddOnNWMH
Service Description
L
L
N
L
M
L
Rate
Allowed
$
� •
a
place of Service (POS)
Payment
Code(s)
per Unit
Billing Unit
�
Type
Office/OP visit, new patient, high
UN (1 per
*02, 03, 09, 11, 12, 13,
99205
G2212
90785
MDM or 60-74 total time of
53
$188.66
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
encounter
62, 71, 72
Office/OP visit, new patient, high
UN (1 per
*02, 03, 09, 11, 12, 13,
99205
G2212
90785
MDM or 60-74 total time of
GT
$188.66
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
encounter
62, 71, 72
Office/0P visit, new patient, high
UN (1 per
*02, 03, 09, 11, 12,13,
99205
G2212
90785
MDM or 60-74 total time of
GT
52
$188.66
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
encounter
62, 71, 72
Office/OP visit, new patient, high
UN (1 per
*02, 03, 09, 11, 12, 13,
99205
G2212
90785
MDM or 60-74 total time of
GT
53
$188.66
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
encounter
62, 71, 72
Office/OP visit, new patient, high
UN (1 per
*02, 03, 09, 11, 12, 13,
99205
G2212
90785
MDM or 60-74 total time of
$188.66
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
encounter
*57, 62, 71, 72
90833
90836
Office/OP visit, established
* 02, 09, 11, 12, 13, 15,
99211
90838
90785
patient may not require
physician/QHP, minimal
GT
$22.58
UN (1 per
ENC)
No
19, 22, 32, 33, 34, 53,
FFS
99354
presenting problem
*57, 62, 71, 72
99355
90833
90836
Office/0P visit, established
* 02 09, 11, 12, 13, 15,
99211
90838
90785
patient may not require
physician/QHP, minimal
$22'58
UN (1 per
ENC)
No
19, 22, 32, 33, 34, 53,
FFS
99354
presenting problem
*57, 62, 71, 72
99355
90833
36
Office/0P visit, established
*02' 09, 11, 12, 13,15,
99212
90838
90785
patient straightforward MDM,
10-19 minutes total time of
GT
$41.14
UN 1 er
( p
ENC)
No
19, 22, 32, 33, 34, 53,
FFS
99354
encounter
*57, 62, 71, 72
99355
90833
90836
Office/OP visit, established
*02, 09, 11, 12, 13, 15,
99212
90838
90785
patient, straightforward MDM,
10-19 minutes total time of
$41.14
UN (1 per
ENC)
No
19, 22, 32, 33, 34, 53,
FFS
99354
encounter
*57, 62, 71, 72
99355
90833
90836
Office/0P visit, established
UN (1 per
*02, 09, 11, 12, 13, 15,
99213
90838
90785
patient, low MDM, 20-29 minutes
GT
$56.33
ENC)
No
19, 22, 32, 33, 34, 53,
FFS
99354
total time of encounter
*57, 62, 71, 72
99355
90833
90836
Office/OP visit, established
UN (1 per
*02, 09, 11, 12, 13, 15,
99213
90838
90785
patient, low MDM, 20-29 minutes
$56.33
ENC)
No
19, 22, 32, 33, 34, 53,
FFS
99354
total time of encounter
*57, 62, 71, 72
99355
90833
90836
Office/0P visit, established
UN (1 per
*02, 09, 11, 12, 13,15,
99214
90838
90785
patient, moderate MDM, 30-39
GT
$88.59
ENC)
No
19, 22, 32, 33, 34, 53,
FFS
99354
minutes total time of encounter
*57, 62, 71, 72
99355
90833
90836
Office/0P visit, established
UN (1 per
*02, 09, 11, 12, 13, 15,
99214
90838
90785
patient, moderate MDM, 30-39
$88'59
ENC)
No
19, 22, 32, 33, 34, 53,
FFS
99354
minutes total time of encounter
*57, 62, 71, 72
99355
Office/OP visit, established
UN (1 per
*02, 09, 11, 12, 13, 15,
99215
62212
90785
patient, high MDM, 40-54
g
GT
$129.65
ENC)
No
19, 22, 32, 33, 34, 53,
FFS
minutes total time of encounter
*57, 62, 71, 72
Office/OP visit, established
UN (1 per
*02, 09, 11, 12, 13, 15$
99215
G2212
90785
patient, high MDM, 40-54
g
$129.65
ENC)
No
22 32 33 34 53
19, ,
FFS
minutes total time of encounter
*57, 62, 71, 72
99356
Initial visit at nursing facility E/M,
UN (1 per
*02, 03, 09, 11, 12, 13,
99304
99357
90785
per day, low severity, 25 minutes
52
$81.19
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
w/patient and/or family/caretaker
*57,62,71,72
99356
Initial visit at nursing facility E/M,
UN (1 per
*02, 03, 09, 11, 12, 13,
99304
99357
90785
per day, low severity, 25 minutes
53
$81.19
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
w/patient and/or family/caretaker
1
1
*57,62,71,72
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 14 of 72
Service
Code
Allowed
Add On
Interactive
Complexity
AddOnNWMH
Service Description
L
t-
L
N
L
M
L
.�.
Rate
Allowed
�
Place of Service (POS)
Payment
Code(s)
per Unit
Billing Unit
a
Type
99356
Initial visit at nursing facility E/M,
IN (1 per
*02, 03, 09, 11, 12, 13,
99304
99357
90785
per day, low severity, 25 minutes
$81.19
ENC)
No
15, 19, 22, 32, 33, 34, 53,
FFS
w/patient and/or family/caretaker
*57, 62, 71, 72
Initial visit at nursing facility E/M,
*02, 03, 09, 11, 12, 13,
99305
99356
99357
90785
per day, moderate severity, 35
minutes w/patient and/or
52
$107.78
IN (1 per
ENC)
No
15 , 19, 22, 32, 33, 34, 53,
*57,
FFS
family/caretaker
62, 71, 72
Initial visit at nursing facility E/M,
*02, 03, 09, 11, 12, 131
99305
99356
99357
90785
per day, moderate severity, 35
minutes w/patient and/or
53
$107.78
IN (1 per
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
family/caretaker
62, 71, 72
Initial visit at nursing facility E/M,
*02, 03, 09,11,12, 13,
99305
99356
99357
90785
per day, moderate severity, 35
minutes w/patient and/or
$107.78
IN (1 per
ENC)
No
15 , 19, 22, 32, 33, 34, 53,
*57,
FFS
family/caretaker
62, 71, 72
Initial visit at nursing facility E/M,
*02, 03, 09, 11, 12, 13,
99306
99356
99357
90785
per day, high severity, 45
minutes w/patient and/or
52
$132.51
IN (1 per
ENC)
No
15 ,19, 22, 32, 33, 34, 53,
*57,
FFS
family/caretaker
62, 71, 72
Initial visit at nursing facility E/M,
*02, 03, 09, 11, 12, 13,
99306
99356
99357
90785
per day, high severity, 45
minutes w/patient and/or
53
$132.51
IN (1 per
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
family/caretaker
62, 71, 72
Initial visit at nursing facility E/M,
*02, 03, 09, 11, 12, 13,
99306
99356
99357
90785
per day, high severity, 45
minutes w/patient and/or
$132.51
IN (1 per
ENC)
No
15 , 19, 22, 32, 33, 34, 53,
*57,
FFS
family/caretaker
62, 71, 72
Subsequent nursing facility visit,
99356
per day, E/M, stable or
IN 1 per
*02, 09, 11, 12, 13, 15,
99307
99357
90785
recovering or improving, 10
GT
$41.99
ENC)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
minutes w/patient and/or
62, 71, 72
family/caregiver
Subsequent nursing facility visit,
99356
per day, E/M, stable or
IN (1 per
*02, 09, 11, 12, 13, 15,
99307
99357
90785
recovering or improving, 10
$41.99
ENC)
No
19, 22, 32, 33, 34, 53,
FFS
minutes w/patient and/or
*57, 62, 71, 72
family/caregiver
Subsequent nursing facility visit,
per day, E/M, responding
02, 09, 11, 12, 13, 15,
99308
99356
99357
90785
inadequately to therapy or has
developed a minor complication,
GT
$69'99
IN (1 per
ENC)
No
19 , 22, 32, 33, 34, 53,
FFS
15 minutes w/patient and/or
57, 62, 71, 72
family/caregiver
Subsequent nursing facility visit,
per day, E/M' responding
*02, 09, 11, 12, 13, 15,
99308
99356
99357
90785
inadequately to therapy or has
developed a minor complication,
$69'99
IN (1 per
ENC)
No
19 22, 32, 33, 34, 53,
,
FFS
15 minutes w/patient and/or
57, 62, 71, 72
family/caregiver
Subsequent nursing facility visit,
per day, E/M, developed a
*02, 09, 11, 12, 13, 15,
99309
99356
99357
90785
significant complication or
significant new problem, 25
GT
$97'98
IN (1 per
ENC)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
minutes w/patient and/or
62, 71, 72
family/caregiver
Subsequent nursing facility visit,
per day, E/M, developed a
*02, 09, 11, 12, 13, 15,
99309
99356
99357
90785
significant complication or
significant new problem, 25
$97'98
IN (1 per
ENC)
No
19 22, 32, 33, 34, 53,
,
*57,
FFS
minutes w/patient and/or
62, 71, 72
family/caregiver
Subsequent nursing facility visit,
per day, E/M, unstable or may
02, 09, 11, 12, 13, 15,
99310
99356
90785
have developed a significant new
GT
$122.72
IN (1 per
No
19, 22, 32, 33, 34, 53,
FFS
99357
problem requiring immediate
ENC)
*57, 62, 71, 72
physician attention, 35 minutes
w/patient and/or family/caregiver
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 15 of 72
Service
Code
Allowed
Add On
Interactive
Complexity
Add on
Service Description
NWMH
L
0
L
N
0
L
M
L
Rate
Allowed
a
Ei
Place of Service (POS)
Payment
Code(s)
Code
;�
per Unit
Billing Unit
¢
Type
Subsequent nursing facility visit,
per day, E/M, unstable or may
02, 09, 11, 12, 13, 15,,
99310
99356
90785
have developed a significant new
$122'72
UN (1 per
No
19, 22, 32, 33, 34, 53,
FFS
99357
problem requiring immediate
ENC)
*57, 62, 71, 72
physician attention, 35 minutes
w/patient and/or family/caregiver
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99324
99356
99357
90785
new patient E/M, low severity, 20
minutes w/patient and/or
52
$72'32
UN (1 per
ENC)
No
15 , 19, 22, 32, 33, 34, 53,
*57,
FFS
family/caretaker
62, 71, 72
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99324
99356
907$5
new patient E/M, low severity, 20
53
$72.32
UN (1 per
No
15 19, 22, 32, 33, 34, 53,
FFS
99357
minutes w/patient and/or
ENC)
,
*57, 62, 71, 72
family/caretaker
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99324
99356
99357
907$5
new patient E/M, low severity, 20
minutes w/patient and/or
HK
$72.32
UN (1 per
ENC)
No
15 , 19, 22, 32, 33, 34, 53,
*57,
FFS
family/caretaker
62, 71, 72
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99324
99356
99357
907$5
new patient E/M, low severity, 20
minutes w/patient and/or
$72'32
UN (1 per
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
family/caretaker
62, 71, 72
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99325
99354
99355
907$5
new patient E/M, moderate
severity, 30 minutes w/patient
52
$105.45
UN (1 per
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
and/or famil /caretaker
62, 71, 72
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99325
99354
99355
907$5
new patient E/M, moderate
severity, 30 minutes w/patient
53
$105.45
UN (1 per
ENC)
No
15 19, 22, 32, 33, 34, 53,
,
*57,
FFS
and/or family/caretaker
62, 71, 72
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99325
99354
99355
90785
new patient E/M, moderate
severity, 30 minutes w/patient
HK
$105.45
UN (1 per
ENC)
No
15,19, 22, 32, 33, 34, 53,
*57,
FFS
and/or family/caretaker
62, 71, 72
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99325
99354
99355
90785
new patient E/M, moderate
severity, 30 minutes w/patient
$105.45
UN (1 per
ENC)
No
15 19, 22, 32, 33, 34, 53,
,
*57,
FFS
and/or family/caretaker
62, 71, 72
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99326
99354
99355
907$5
new patient E/M, moderate to
high severity, 45 minutes
52
$152.11
UN (1 per
ENC)
No
15 , 19, 22, 32, 33, 34, 53,
FFS
w/patient and/or family/caretaker
57, 62, 71, 72
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99326
99354
99355
907$5
new patient E/M, moderate to
high severity, 45 minutes
53
$152.11
UN (1 per
ENC)
No
15 , 19, 22, 32, 33, 34, 53,
FFS
w/patient and/or family/caretaker
57, 62, 71, 72
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99326
99354
99355
907$5
new patient E/M, moderate to
high severity, 45 minutes
HK
$152.11
UN (1 per
ENC)
No
15 , 19, 22, 32, 33, 34, 53,
FFS
w/patient and/or family/caretaker
57, 62, 71, 72
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99326
99354
99355
907$5
new patient E/M, moderate to
high severity, 45 minutes
$152.11
UN (1 per
ENC)
No
15 , 19, 22, 32, 33, 34, 53,
FFS
w1patient and/or family/caretaker
57, 62, 71, 72
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99327
99354
99355
90785
new patient E/M, high severity,
60 minutes w/patient and/or
p
52
$200.16
UN 1 per
ENC )
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
family/caretaker
62, 71, 72
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99327
99354
99355
90785
new patient E/M, high severity,
60 minutes w/patient and/or
p
53
$200.16
UN 1 per
ENC )
No
15,19, 22, 32, 33, 34, 53,
*57,
FFS
family/caretaker
62, 71, 72
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99327
99354
99355
90785
new patient E/M, high severity,
60 minutes w/patient and/or
HK
$200.16
UN (1 per
ENC)
No
15 , 19, 22, 32, 33, 34, 53,
*57,
FFS
1
1 family/caretaker
62, 71, 72
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 16 of 72
Service
Code
Allowed
Add On
Interactive
Complexity
Add on
Service Description
NWMH
L
L
N
L
M
L
CD
,�
Rate
per Unit
Allowed
Billing Unit
s
a
Place of Service (POS)
Payment
T e
Type
Code(S)
Code
Domiciliary or rest home visit for
*02, 03, 09, 11, 12, 13,
99327
99354
99355
90785
new patient E/M, high severity,
60 minutes w/patient and/or
$200.16
UN (1 per
ENC)
No
15,19, 22, 32, 33, 34, 53,
*57,
FFS
family/caretaker
62, 71, 72
Domiciliary or rest home visit for
new patient E/M, unstable or has
*02, 03, 09, 11, 12, 13,
99328
99354
99355
90785
developed significant new
problem requiring immediate MD
52
$247.76
IN (1 per
ENC)
No
, 19, 22, 32,
15 33, 34, 53,
*57,
FFS
attention, 75 minutes w/patient
62, 71, 72
and/or family/caretaker
Domiciliary or rest home visit for
new patient E/M, unstable or has
*02, 03, 09, 11, 12, 13,
99328
99354
99355
90785
developed significant new
problem requiring immediate MD
53
$247.76
IN (1 per
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
attention, 75 minutes w/patient
62, 71, 72
and/or family/caretaker
Domiciliary or rest home visit for
new patient E/M, unstable or has
*02, 03, 09, 11, 12, 13,
99328
99354
99355
90785
developed significant new
problem requiring immediate MD
HK
$247.76
IN (1 per
ENC)
No
, 19, 22, 32,
15 33, 34, 53,
*57,
FFS
attention, 75 minutes w/patient
62, 71, 72
and/or family/caretaker
Domiciliary or rest home visit for
new patient E/M, unstable or has
*02, 03, 09, 11, 12, 13,
99328
99354
99355
90785
developed significant new
problem requiring immediate MD
$247.76
IN (1 per
ENC)
No
15, 19, 22, 32, 33, 34, 53,
*57,
FFS
attention, 75 minutes w/patient
62, 71, 72
and/or family/caretaker
Domiciliary or rest home visit for
*02, 09, 11, 12, 13, 15,
99334
99354
99355
90785
established PT EM self-limited
or minor, 15 minutes w/patient
$55'99
UN (1 per
ENC)
No
19, 22, 32, 33, 34, 53,
*57,
FFS
and/or family/caregiver
62, 71, 72
Domiciliary or rest home visit for
*02, 09, 11, 12, 13, 15,
99335
99354
99355
90785
established PT EM low to
moderate severity, 25 minutes
$88'19
IN (1 per
ENC)
No
, 22, 32, 33, 34 ,
19 53,
FFS
W/patient and/or family/caregiver*57,
62, 71, 72
Domiciliary or rest home visit for
*02, 09, 11, 12, 13, 15,
99336
99354
90785
established PT EM moderate to
$135.31
IN (1 per
No
1922, 32, 33, 34, 53,
FFS
99355
high severity, 40 minutes
ENC)
,
*57, 62, 71, 72
w/patient and/or family/caregiver
Domiciliary or rest home visit for
established PT E/M, unstable or
*02, 09, 11, 12, 13, 15,
99337
99354
90785
may have developed a significant
$199.24
IN (1 per
No
19, 22, 32, 33, 34, 53,
FFS
99355
new problem requiring immediate
ENC)
*57, 62, 71, 72
MD attention,60 minutes
w/patient and/or family/caregiver
99354
Home visit for new patient E/M,
IN (1 per
99341
99355
90785
low severity, 20 minutes face-
52
$33.57
ENC)
No
12113, 15, 32, 33, 34, 99
FFS
face w/patient and/or family
99354
Home visit for new patient E/M,
IN (1 per
99341
99355
90785
low severity, 20 minutes face-
53
$33.57
ENC)
No
12, 13, 15, 32, 33, 34, 99
FFS
face w/patient and/or family
99354
Home visit for new patient E/M,
IN (1 per
99341
99355
90785
low severity, 20 minutes face-
HK
$33.57
ENC)
No
12, 13, 15, 32, 33, 34, 99
FFS
face w/patient and/or family
99354
Home visit for new patient E/M,
IN (1 per
99341
99355
90785
low severity, 20 minutes face-
$33.57
ENC)
No
12, 13, 15, 32, 33, 34, 99
FFS
face w/patient and/or family
99354
Home visit for new patient E/M,
IN (1 per
99342
99355
90785
moderate severity, 30 minutes
52
$48.30
ENC)
No
12, 13, 15, 32, 33, 34, 99
FFS
face -face w/patient and/or family
99354
Home visit for new patient E/M,
IN (1 per
99342
99355
90785
moderate severity, 30 minutes
53
$48.30
ENC)
No
12, 13, 15, 32, 33, 34, 99
FFS
face -face w/patient and/or family
99354
Home visit for new patient E/M,
IN (1 per
99342
99355
90785
moderate severity, 30 minutes
HK
$48.30
ENC)
No
12, 13, 15, 32, 33, 34, 99
FFS
face -face w/patient and/or family
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 17 of 72
ServiceAdd
Code
Allowed
On
Interactive
complexity
AddOnNWMH
Service Description
L
L
N
L
M
L
Rate
Allowed
-a
place of Service (POS)
Payment
Code(s)
per Unit
Billing Unit
a
Type
99354
Home visit for new patient E/M,
UN (1 per
99342
99355
90785
moderate severity, 30 minutes
$48.30
ENC)
No
12,13, 15, 32, 33, 34, 99
FFS
face -face w/patient and/or family
Home visit for new patient E/M,
99343
99354
99355
90785
moderate to high severity, 45
minutes face -face w/patient
52
$79.05
IN (1 per
ENC)
No
12, 13, 15, 32, 33, 34, 99
FFS
and/or family
Home visit for new patient E/M,
99343
99354
99355
90785
moderate to high severity, 45
minutes face -face w/patient
53
$79.05
IN (1 per
ENC)
No
12, 13, 15, 32, 33, 34, 99
FFS
and/or family
Home visit for new patient E/M,
99343
99354
99355
90785
moderate to high severity, 45
minutes face -face w/patient
HK
$79.05
IN (1 per
ENC)
No
12, 13, 15, 32, 33, 34, 99
FFS
and/or family
Home visit for new patient E/M,
99343
99354
99355
90785
moderate to high severity, 45
minutes face -face w/patient
$79.05
IN (1 per
ENC)
No
12,13, 15, 32, 33, 34, 99
FFS
and/or family
99354
Home visit for new patient E/M,
IN (1 per
99344
99355
90785
high severity, 60 minutes face-
52
$110.89
ENC)
No
12, 13, 15, 32, 33, 34, 99
FFS
face w/patient and/or family
99354
Home visit for new patient E/M,
IN (1 per
99344
99355
90785
high severity, 60 minutes face-
53
$110.89
ENC)
No
12, 13, 15, 32, 33, 34, 99
FFS
face w/patient and/or family
99354
Home visit for new patient E/M,
IN (1 per
99344
99355
90785
high severity, 60 minutes face-
HK
$110.89
ENC)
No
12,13, 15, 32, 33, 34, 99
FFS
face w/patient and/or family
99354
Home visit for new patient E/M,
IN (1 per
99344
99355
90785
high severity, 60 minutes face-
$110.89
ENC)
No
12113, 15, 32, 33, 34, 99
FFS
face w/patient and/or family
Home visit for new patient E/M,
unstable or has developed a
99345
99354
99355
90785
significant new problem requiring
immediate physician attention,
52
$134.50
IN (1 per
ENC)
No
12,13, 15, 32, 33, 34, 99
FFS
75 minutes face -face w/patient
and/or family
Home visit for new patient E/M,
unstable or has developed a
99345
99354
99355
90785
significant new problem requiring
immediate physician attention,
53
$134.50
IN (1 per
ENC)
No
12,13, 15, 32, 33, 34, 99
FFS
75 minutes face -face w/patient
and/or family
Home visit for new patient E/M,
unstable or has developed a
99345
99354
99355
90785
significant new problem requiring
immediate physician attention,
HK
$134.50
IN (1 per
ENC)
No
12, 13, 15, 32, 33, 34, 99
FFS
75 minutes face -face w/patient
and/or family
Home visit for new patient E/M,
unstable or has developed a
99345
99354
99355
90785
significant new problem requiring
immediate physician attention,
$134.50
IN (1 per
ENC)
No
12,13, 15, 32, 33, 34, 99
FFS
75 minutes face -face w/patient
and/or family
90833
90836
Home visit for established PT
99347
90838
90785
E/M self-limited or minor, 15
minutes are spent face - face
$33.79
IN (1 per
ENC)
No
12,13, 15, 32, 33, 34, 99
FFS
99354
99355
w/patient and/or family
90833
90836
Home visit for established PT
99348
90838
90785
E/M low to moderate severity, 25
minutes are spent face - face
$51.33
IN (1 per
ENC)
No
12, 13, 15, 32, 33, 34, 99
FFS
99354
99355
w/patient and/or family
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 18 of 72
Service
Code
Allowed
Add On
Interactive
Complexity
Add On
Service Description
NWMH
L
L
N
L
M
L
Rate
Allowed
place of Service (POS) Payment
Code(s)
Code
per Unit
Billing Unit
a
Type
90833
90836
Home visit for established PT
99349
90838
90785
E/M moderate to high severity,
40 minutes are spent face - face
$78.18
UN (1 per
ENC)
No
12, 13, 15, 32, 33, 34, 99 FFS
99354
99355
w/patient and/or family
Home visit for established PT
90833
E/M moderate to high severity,
90836
the patient may be unstable or
99350
90838
90785
may have developed a significant
new problem requiring immediate
$108'29
UN (1 per
ENC)
No
12, 13, 15, 32, 33, 34, 99 FFS
99354
99355
MD attention, 60 minutes are
spent face - face w/patient
and/or family
Add on
N/A
90785
Psychotherapy, w/ PT and/or
fam. mem., approx. 30 minutes,
$36.65
UN (1=16-
37 minutes;
N/
Same as Primary CTP /
FFS
90833
performed w/ an E/M code
1 per
A
Rev Code
encounter
Add on
N/A
90785
Psychotherapy approx. 45
minutes w/ PT and/or fam. mem.;.
$46.4 1y
(1= 38-
52Nminutes;
N/
Same as Prim
ar CTP / FFS
90836
performed w/ an E/M service
1 per
A
Rev Code
encounter
Add on
N/A
90785
Psychotherapy approx. 60
minutes w/ PT and/or fam. mem.;
$61.55
LIN (1=53
68 minutes
N/
Same as Primary CTP
y / FFS
90838
performed w an E M service
p / / s ce
1 per
A
Rev Code
encounter
Same as
Add on
N/A
N/A
Interactive complexity
$7 57
Primary
N/
Same as Primary CTP / FFS
90785
CTP / Rev
A
Rev Code
Code
Prolong psychotherapy services,
O/P (beyond the typical service
time of the primary procedure)
Add on
direct patient contact beyond the
UN (1= first
N/
Same as Primary CTP /
99354
N/A
NIA
usual service; first hour OR
$76.90
hour; 1 per
A
Rev Code FFS
Office or 0/P prolonged E/M or
encounter)
psychotherapy services (beyond
the typical service time of the
primary procedure); 1st hour
Prolong psychotherapy services,
0/P, each additional 30 minutes
UN (1=
Add on
N/A
N/A
OR Office or O/P prolonged E/M
or psychotherapy services
$56.74
additional
N/
Same as Primary CTP /
FFS
99355
(beyond the typical service time
30 minutes;
A
Rev Code
of the primary procedure); each
1 or more)
additional 30 minutes.
Inpatient or observation
UN (1= first
Add on
N/A
N/A
prolonged service requiring
$58.27
hour; 1 per
N/
Same as Primary CTP / FFS
99356
unit/floor time beyond the usual
ENC)
A
Rev Code
service; 1 st hour
Inpatient or observation
Add on
N/A
N/A
prolonged service requiring
unit/floor time beyond the usual
$58.49
UN (1= 30
minutes/1 or
N/
Same as Primary CTP /
FFS
99357
service; each additional 30
more)
A
Rev Code
minutes
Add on
N/A
N/A
Prolonged office/OP visit, each
$18 72
UN (1 =15
N/
Same as Primary CTP / FFS
G2212
additional 15 minutes
min.)
A
Rev Code
BH counseling and therapy, per
UN (1=15
*02, 03, 09, 11, 12, 13,
H0004
N/A
NIA
15 minutes
GT
$26.90
minutes; 1
No
15, 19, 22, 32, 33, 34, 53, FFS
or more)
1 *57, 62, 71, 72
BH counseling and therapy, per
UN (1=15
*02, 03, 09, 11, 12,13,
H0004
NIA
N/A
15 minutes
HK
$26.90
minutes; 1
No
15, 19, 22, 32, 33, 34, 53, FFS
or more)
*57, 62, 71, 72
BH counseling and therapy, per
UN (1=15
*02, 03, 09, 11, 12, 13,
H0004
N/A
N/A
15 minutes
$26.90
minutes; 1
No
15, 19, 22, 32, 33, 34, 53,
FFS
or more)
*57, 62, 71, 72
H0023
N/A
N/A
Behavioral Health Outreach
HW
$82'12
UN (1 per
No
03, 09, 11, 12, 13, 15, 19,
21, 22, 32, 33, 34, 53,
FFS
Service
encounter)
*57, 62, 71, 72, 99
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 19 of 72
Service
Code
Allowed
Add On
Interactive
Complexity
AddOnNWMH
Service Description
L
T
L
N
L
M
L
Rate
Allowed
-p
Place of Service (POS)
Payment
Code(s)
per Unit
Billing Unit
a �
Type
H0023
N/A
NIA
Behavioral Health Outreach
HW
XE
$8212
UN (1 per
No
03, 09, 11, 12, 13, 15, 19,
21, 22, 32, 33, 34, 53,
FFS
Service
encounter)
*57, 62, 71, 72, 99
H0023
N/A
NIA
Behavioral Health Outreach
HW
GT
XE
$82.12
UN (1 per
No
03, 09, 11, 12, 13, 15, 19,
21, 22, 32, 33, 34, 53,
FFS
Service
encounter)
*57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health Outreach
XE
$82.12
UN (1 per
No
03, 09, 11, 12, 13, 15,
19, 22, 32, 33, 34, 53,
FFS
Service
encounter)
*57, 62, 71, 72, 99
H0023
N/A
N/A
Behavioral Health Outreach
$82.12
UN (1 per
No
03, 09, 11, 12, 13,15,
19, 22, 32, 33, 34, 53,
FFS
Service
encounter)
*57, 62, 71, 72, 99
BH prev. educ. services (delivery
03, 11, 12, 13, 15, 19, 22,
H0025
NIA
NIA
of services with target population
to affect knowledge, attitude
GT
$8.18
UN (1 per
encounter)
No
32, 33, 34, 53, *57, 62,
FFS
and/or behavior)
71,72
BH prev. educ. services (delivery
03, 11, 12, 13, 15, 19, 22,
H0025
N/A
NIA
of services with target population
to affect knowledge, attitude
$8.18
UN (1 per
encounter)
No
32, 33, 34, 53, *57, 62,
FFS
and/or behavior)71,
72
H0031
N/A
N/A
MH health assessment bynon-
52
$39.94
U N (1=
15minutes;
No
03, 09, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53) *57,
FFS
MD
1 or more
62, 71, 72
H0031
N/A
N/A
MH health assessment by non-
53
$39.94
U N (1=
15minutes;
No
03, 09, 11, 12, 13,15, 19,
22, 32, 33, 34, 53, *57,
FFS
MD
1 or more)
62)71,72
H0031
N/A
90785
MH health assessment by non-
HK
$39.94
UN (1=
15minutes;
No
03, 09, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53) *571
FFS
MD
1 or more
62, 71, 72
H0031
N/A
90785
assessment by non-
MD
$39.94
UN (1=
15minutes;
No
03, 09, 11, 12, 13, 15, 19,
32 33
22 34, 53) *57,
FFS
health
1 or more
, , ,
62, 71, 72
UN (1=15
03, 11, 12, 13, 15, 19, 22,
H0032
N/A
N/A
MH services plan dev by non -MD
GT
$128.90
minutes; 1
No
32, 33, 34, 53) *57, 62,
FFS
or more
71,72
UN (1=15
03, 11, 12,13, 15, 19, 22,
H0032
N/A
N/A
MH services plan dev by non -MD
HT
$128.90
minutes; 1
No
32, 33, 34, 531 *57, 62,
FFS
or more)
71, 72
UN (1=15
03, 11, 12, 13, 15, 19, 22,
H0032
N/A
N/A
MH services plan dev by non -MD
HT
GT
$128.90
minutes; 1
No
32, 33, 34, 531 *57, 62,
FFS
or more)
71,72
UN (1=15
03, 11, 12, 13, 15, 19, 22,
H0032
N/A
N/A
MH services plan dev by non -MD
$128.90
minutes; 1
No
32, 33, 34, 531 *57, 62,
FFS
or more)
71,72
Oral Medication administration
UN (1=15
041 11, 12, 15, 13, 19, 22,
H0033
N/A
NIA
direct observation
$8.95
minutes; 1
No
32, 33, 34, 531 * 57, 62,
FFS
or more)
71, 72, 99
H0034
N/A
N/A
Medication training and support,
$8.21
UN (1=15
minutes; 1
No
041 11, 12, 15, 13, 19, 22,
32, 33, 34, 53, *57, 62,
FFS
per 15 minutes
or more)
71, 72, 99
Community psychotherapy face-
UN (1=15
03, 09, 11, 12, 13, 15, 19,
H0036
N/A
N/A
face supplemental treatment, per
GT
$6.34
minutes; 1
No
22, 32, 33, 34, 53, *57,
FFS
15 minutes
or more)
62, 71, 72
Community psychotherapy face-
UN (1=15
03) 09, 11, 12, 13, 15, 19,
H0036
N/A
N/A
face supplemental treatment, per
HK
$6.34
minutes; 1
No
22, 32, 33, 34, 531 *57,
FFS
15 minutes
or more
62, 71, 72
Community psychotherapy face-
UN (1=15
03, 09, 11, 12, 13, 15, 19,
H0036
N/A
N/A
face supplemental treatment, per
$6.34
minutes; 1
No
22, 32, 33, 34, 531 *57,
FFS
15 minutes
or more)
62, 71, 72
H0038
N/A
N/A
Self-help/peer services, per 15
minutes
$12.55
UN (1=15
minutes;1
No
11,12,15, 53, *57, 99
FFS
or more
H0046
N/A
N/A
Mental health services, NOS,
GT
$2861
UN (1=<15
minutes; 1
No
*02, 03, 09, 11, 12, 13,
15,19, 22, 32, 33, 34, 53,
FFS
less than 15 minutes
.
per
*57, 62, 71, 72
1
1
1
encounter
BHO-F-COM-MA-MCDl11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 20 of 72
Service
Code
Allowed
Add On
Interactive
Complexity
Add on
Service Description
NWMH
L
r
L
N
L
M
L
�.
Rate
per Unit
Allowed
Billing Unit
-o
a
Place of Service (POS)
Payment
T
Type
Code(s)
Code
Ce
H0046
N/A
N/A
Mental health services, NOS,
HK
$28.61
UN (1=<15
minutes; 1
No
*02, 03, 09, 11, 12, 13,
15,19, 22, 32, 33, 34, 53,
FFS
less than 15 minutes
per
*57, 62, 71, 72
encounter
UN (1=<15
03, 04, 06, 09, 11, 12, 13,
H0046
N/A
NIA
Mental health services, NOS
UB
$28.61
minutes; 1
No
14, 15, 16, 18, 20, 21, 22,
FFS
per
23, 31, 32, 51, 53, 55,
encounter)
56, *57, 62, 71, 72 99
H0046
N/A
N/A
Mental health services, NOS,
$28.61
UN (1=<15
minutes; 1
No
03, 09, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
less than 15 minutes
per
62171,72
encounter
H2O12
N/A
N/A
Behavioral Health Day
Treatment, per hour
$13.85
UN (1=
hour; 1 or
Ye
11) 15, 19, 22, 53, 99
FFS
more
S
H2O14
N/A
N/A
Skills training and development,
GT
$14.78
UN (1=15
minutes; 1
No
03, 09, 11, 12, 13, 15, 19,
22, 32, 33, 34, 531 *57)
FFS
per 15 minutes
or more
62, 71, 72
H2O14
NIA
NIA
Skills training and development,
$14.78
UN (1=15
minutes; 1
No
03, 09, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53) * 57,
FFS
per 15 minutes
or more
62171,72
H2O15
N/A
N/A
Comprehensive community
GT
$11.78
UN (1=15
minutes; 1
No
03, 09, 11, 12, 13, 15, 19,
22, 32, 33, 34, 531 *57,
FFS
support services, per 15 minutes
or more)
62, 71, 72
H2O15
N/A
N/A
Comprehensive community
GT
XE
$11.78
UN (1=15
minutes; 1
No
03, 09, 11, 12, 13, 15, 19,
22, 32, 33, 34, 531 *57,
FFS
support services, per 15 minutes
or more)
62)71,72
Comprehensive community
UN (1=15
03, 09, 11, 12, 13, 15, 19,
H2O15
N/A
N/A
support services, per 15 minutes
XE
$11.78
minutes; 1
No
22, 32, 33, 34, 53) *57,
FFS
or more
62, 71, 72
H2O15
NIA
NIA
Comprehensive community
$11.78
UN (1=15
minutes; 1
No
03, 09, 11, 12, 13, 15, 19,
32, 33,
22 34, 531 *57,
FFS
support services, per 15 minutes
or more)
,
62, 71, 72
H2O17
N/A
N/A
Psychosocial rehabilitation
GT
$14.80
UN (1=15
minutes;1
No
03, 09, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53) *57,
FFS
services, per 15 minutes
or more
62, 71, 72
Psychosocial rehabilitation
UN (1=15
03, 09, 11, 12, 13, 15, 19,
H2O17
N/A
N/A
services, per 15 minutes
$14.80
minutes; 1
No
22, 32, 33, 34, 53) *57,
FFS
or more
62171,72
Comm. based wraparound
UN (1=15
03, 11, 12, 13, 15, 19, 22,
H2O21
N/A
N/A
services, per 15 min
GT
$27.03
minutes; 1
No
32, 33, 34, 53, *57, 62,
FFS
or more)
71772
Comm. based wraparound
UN (1=15
03, 11, 12, 13, 15, 19, 22,
H2O21
N/A
NIA
services, per 15 min
$27.03
minutes; 1
No
32, 33, 34, 53, *57, 62,
FFS
or more)
71,72
UN (1=a
H2O22
N/A
NIA
Community wraparound service,
$45.08
day; 1 per
encounter)
No
03, 11, 12, 13, 15, 19, 22,
32, 33, 34, 53, *57, 62,
FFS
per diem
All -Inclusive
71,72
per diem
UN (1=15
03, 09, 11, 12, 13, 15, 19,
H2O23
N/A
N/A
Supported employ, per 15 min
GT
$27.03
minutes; 1
No
22, 32, 33, 34, 53) *571
FFS
or more
62171,72
UN (1=15
03, 09, 11, 12, 13, 15, 19,
H2O23
N/A
N/A
Supported employ, per 15 min
$27.03
minutes; 1
No
22, 32, 33, 34, 53, *57,
FFS
or more
62, 71, 72
H2O25
N/A
N/A
Supported maintenance employ,
GT
$27.03
UN (1=15
minutes; 1
No
031 09, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *571
FFS
per 15 min
or more)
62, 71, 72
H2O25
N/A
N/A
Supported maintenance employ,
$27.03
UN (1=15
minutes; 1
No
03, 09, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, *57,
FFS
per 15 min
or more)
62, 71, 72
H2O27
N/A
N/A
Psycho -education service, per 15
GT
$14.92
UN (1=15
minutes; 1
No
03, 11, 12, 13, 15, 19, 22,
32, 33, 34, 53) *57, 62,
FFS
minutes
or more
71,72
Psycho -education service, per 15
UN (1=15
03, 11, 12, 13, 15, 19, 22,
H2O27
N/A
N/A
minutes
$14.92
minutes; 1
No
32, 33, 34, 53, *57, 62,
FFS
or more)
71,72
BHO-F-COMMA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 21 of 72
Service
Code
Allowed
Add On
Interactive
Complexity
Add On
Service Description
NWMH
L
L
N
L
M
L
�*
Rate
Allowed
Billing Unit
-a
•s
Q Cr
place of Service POS
(POS)
Payment
Services provided involve multiple staff for safety purposes
Code(s)
Code
HW
Funded by state mental health agency or ITA
HZ
Funded by Criminal Justice Treatment Account
U5
per Unit
U6
Brief Intervention
U9
Type
UB
Request for Services
UD
WA -PACT
XE
Separate encounter, distinct service
25
Si nificant and separately identifiable E&M
52
UN (1= a
53 1
Discontinued procedure
H2O31
N/A
N/A
MH clubhouse services, per diem
$22.59
day; 1 or
more) All-
Ye
11 12 13 15 19 22, 32,
, , , , ,
FFS
Inclusive per
s
33, 34, 53, *57, 62, 71, 72
diem
H2O33
N/A
90785
Multisystem therapy for juveniles,
per 15 minutes
$17.47
UN (1=15
minutes; 1
No
03111, 12, 13, 15, 19, 22,
32, 33, 34, 53, *57, 62,
FFS
or more
71, 72
PT educ., not otherwise
S9446
N/A
N/A
classified, by non- physician
provider, in group setting, per
GT
$6.15
UN ( 1=15
minutes; 1
No
03, 11, 12, 13, 15, 19, 22,
32, 33, 34, 53, *57, 62,
FFS
session
or more)
71,72
PT educ., not otherwise
S9446
N/A
N/A
classified, by non- physician
provider, in group setting, per
$ 6.15
UN 1=15
minutes; 1
No
03, 11, 12, 13, 15, 19, 22,
32, 33, 34, 53, 57, 62,
FFS
session
or more)
71,72
UN (1=a
S9480
N/A
N/A
Intensive OP psychiatric
services, per deem
$ 31.51
day; 1 per
encounter)
)
No
03 11 , 19, 22, 53, 57, 99
FFS
All -Inclusive
per diem
UN (1=1
S9484
N/A
N/A
Crisis intervention, per hour
GT
$65.26
hour; 1 or
No
11, 12, 15, 23, 53,99
FFS
more
UN (1=1
S9484
N/A
N/A
Crisis intervention, per hour
HK
$65.26
hour; 1 or
No
11, 12, 15, 23, 53,99
FFS
more
UN (1=1
S9484
N/A
N/A
Crisis intervention, per hour
$65.26
hour; 1 or
No
11, 12, 15, 23, 53,99
FFS
more
T1001
N/A
N/A
Nursingassessment/
$20.93
UN (1 per
No
03, 09, 11, 12, 13, 15, 19,
22, 32, 33, 34, 53, 57,
FFS
ENC)
62, 71, 72
Sign Lang/Oral Interpreter
T1013
N/A
N/A
Services (Note: submit
encounters for reporting and
GT
$ 0.01
UN 1=15
minutes 1
No
03, 09, 11, 12, 13,15, 19,
22 , 32, 33, 34, 53, 57,
Prepaid
invoice for reimbursement
or more)
62, 71, 72
Sign Lang/Oral Interpreter
T1013
N/A
N/A
Services (Note: submit
encounters for reporting and
$ 0.01
UN 1=15
minutes; 1
No
03, 09, 11, 12, 13,15, 19,
22 , 32, 33, 34, 53, *57,
Prepaid
invoice for reimbursement)
or more)
62, 71, 72
Program intake assessment
screening to determine
T1023
N/A
NIA
appropriateness of an individual
for participation in a special
$23.15
UN(1=15
minutes; 1
No
03, 11, 12, 13, 15, 19, 22,
32, 33, 34, 53, *57, 62,
FFS
program, project or treatment
or more)
71,72
protocol, per encounter
Modifier
Description
ET
Crisis fund only
GT
Telemedicine via interactive audio and video telecommunication
H9
Court-ordered
HD
Pregnant/parenting women's program
HH
Integrated Mental Health/Substance Abuse Program
HK
Services provided involve multiple staff for safety purposes
HT
Multi -disciplinary team
HW
Funded by state mental health agency or ITA
HZ
Funded by Criminal Justice Treatment Account
U5
Individuals Using Intravenous Drugs IUID
U6
Brief Intervention
U9
Rehabilitation Case Management Intake
UB
Request for Services
UD
WA -PACT
XE
Separate encounter, distinct service
25
Si nificant and separately identifiable E&M
52
Reduced services
53 1
Discontinued procedure
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 22 of 72
Exhihit R-2 A17
Maximum Contract Amounts
Beacon shall have no obligation to pay for costs or claims in excess of the amounts listed below for the identified periods, 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 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. 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.
b. Capital Purchases made for programs funded under this agreement are to be utilized explicitly for the funded
program under which the purchase was made. Assets for this program will be used at the level of 90%
specifically. De minimus use will be allowed. If the program funding is discontinued, the State of Washington can
decide to re -purpose the assets for the benefit of this or other programs. Capital purchases may include
technology and transportation and other costs associated with operations.
i. Capital purchases $5,000 and over must receive prior approval from Beacon.
ii. When vehicle purchases are approved, a vehicle usage policy must be submitted to Beacon for approval.
1. The vehicle usage policy shall include maintenance of a transportation log to track, at a
minimum, the following data: trip date, trip start time, driver identification, passenger
identification, pick up location, drop off location, and trip end time.
a. A copy of the transportation log shall be included with the monthly invoice.
2. Facility agrees, at its sole expense, to obtain and maintain the following vehicle insurance:
a. Comprehensive motor vehicle coverage subject to limits of at least $1,000,000 for any
one person, $1,000,000 for any one accident for bodily injury, and $1,000,000 for
property damage, and uninsured motorist.
II: Definitions.
(1) Claims, also known as Fee for Service (FFS) payment type, means an attempt to cause a health care payer to 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 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 receive payment for
direct services provided.
b. Prepaid:
BHO-F-COM-MA-MCD/11/2015 Amend 17 — PID 301052
(AG — VO STD FACILITY) Page 23 of 72
i. Capacity means the Facility will submit monthly invoices to Beacon for the funding period total divided
by the number of months in the funding period and will also submit encounters to document all direct
services provided. Direct Services are those details in the current Rate Schedule(s). Encounters must
be submitted monthly for the previous month.
ii. Cost Reimbursement means the Facility will submit monthly invoices to Beacon for the deliverable,
performance measure, or 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. At a
minimum, invoices should include itemization of staff time (hourly rate x items charged), overhead,
supplies, deliverables, etc.
iii. Staffing means the Facility will submit monthly invoices to Beacon for the funding period total divided
by the number of months in the funding period to obtain reimbursement for the funded staff. Invoices
should not be submitted if a funded position becomes vacant. If invoices are submitted for vacant
funded positions they will not be paid. At a minimum, invoices should include itemization of staff time
(hourly rate x items charged), overhead, supplies, etc.
1. If funded staff provide direct services for which there is a service code in the Facility's rate
schedule(s), that service code shall not be submitted to Beacon for FFS reimbursement. The
service code shall be submitted as a prepaid encounter for reporting purpose.
2. With prior approval, funds may be used for recruiting costs to fill vacant funded positions.
(2) Timely Filing Limit:
a. For all fund codes except Federal Block Grant (FBG), timely filing limit means Facility will submit FFS claims
within current Washington State Health Care Authority timely filing requirements.
b. For FBG fund codes, timely filing limit means:
i. Mental Health Block Grant (MHBG) and Substance Abuse Block Grant (SABG) FFS claims must be
submitted by July 10 for dates of service prior to July 1.
ii. MHBG COVID and SABG COVID FFS claims must be submitted by March 24 for dates of service prior
to March 14.
III: Maximum Contract Amounts.
(1) The following table outlines the maximum amounts funded under this contract for the stated period. Unspent funds from
the first 6 -month period may be spent in the second 6 -month period. Unspent funds do not carry over after June 30, 2023.
(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 by Beacon to
Facility and any remaining funds available for that fiscal year.
(3) Invoices shall be submitted monthly within 20 calendar days of the end of the month being billed. Final invoices must be
submitted within 20 calendar days of the end of state fiscal year or grant funding year. Invoices not received within
these timeframes may be denied for payment.
a. Payment may be withheld if contractual obligations, including but not limited to the timely provision of required
reports, are not met.
BHO-F-COM-MA-MCD/11/2015 Amend 17 — PID 301052
(AG — VO STD FACILITY) Page 24 of 72
Table 1.A17
Maximum Contract Amounts
July 1, 2022 - June 30, 2023
Contingent upon Beacon's receipt of signed HCA Amendment confirmin_g funding for this period.
BHO-F-COM-MA-MCD/11/2015 Amend 17 - PID 301052
(AG - VO STD FACILITY) Page 25 of 72
Funding Period
Program or
Exhibit
Payment
Funding Source
Fund
July 2022
Jan 2023
Total
Service
Method
Code
- Dec
- June
2022
2023*
FY22123
Mobile Crisis
and Desi n ated
g
Non -Medicaid
State
$193,535
$1933535
$3873070
Crisis
Responder
$4513582
$451,582
$903,164
Services
B-4
Capacity
Medicaid
NWRF
Youth Mobile
$116,939
$116,939
$2333878
Crisis
5092(65) Added
Intervention
Crisis
121712
Team
Teams/including
child crisis teams
Outpatient
Mental Health
B-7
Fee for Service
MHBG
NWMH
$10,000
$10,000
$20,000
Services
Behavioral
Health
B-10, B-
MHB G
$453000
$45,000
$90,000
Community-
11 and
Cost
based Outreach
Addendum
Reimbursement
N/A
$15,000
$153000
$30,000
& Engagement
SABG
Safe Syringe
Program
$5,000
$5,000
$10,000
Outpatient
Substance Use
Disorder
NW SA
$10,000
$103000
$20,000
Services
B-11
Fee For Service
and approved
Outpatient
Youth
invoices
Dedicated
Substance Use
Cannabis Acct
NWDM
$10,000
$103000
$20,000
Disorder
(DCA)
Services
Grand Total
$1,957,537
Contingent upon Beacon's receipt of signed HCA Amendment confirmin_g funding for this period.
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(AG - VO STD FACILITY) Page 25 of 72
Exhibit B -4.A17
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 any conflict between 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.
I: 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 or owned by or
under contract with Facility, as the context may require.
(2) Facility agrees:
a. Facility shall provide crisis intervention services in accordance with WAC 246-341; as well as the Beacon Level
of Care Guidelines which are incorporated herein by reference.
b. Crisis System Operations Requirements
i. Crisis Services shall be available 24 hours a day, seven (7) days a week.
ii. MCI teams will respond in the following timeframes:
1. Triage calls within 15 minutes or less of initial request
2. Mobile crisis services provided are available within two hours of contact for emergent, within
24 hours for an urgent crisis, and best practice is a response within 60 minutes for all call
types
iii. Each mobile crisis team will consist of 11 full time equivalents (FTEs) and have the capacity to provide
community-based services in the community 24 hours per day, seven days per week, 365 days per
year. The 11 -member team will include one MHP supervisor.
iv. Implementation must include the following elements:
1. Each team will adhere to the HCA crisis team model.
2. Each team will require at a minimum, an MHP to provide clinical assessment and a peer
trained in Crisis Services, responding jointly. Mental Health Care Provider (MHCPs) can
respond jointly with a peer in place of an MHP, as long as at least one MHP is available 24/7
for any MHCP or peer to contact for consultation, this MHP does not have to be the supervisor.
3. All peers must complete the HCA sponsored peer crisis training.
4. All individuals providing mobile crisis services, whether they are new or previously existing
staff, must complete the HCA training in Trauma Informed Care, De-escalation Techniques,
and Harm Reduction.
v. The standards for the youth teams will incorporate the values and practices of the MRSS model and
the National Association of State Mental Health Program Directors (NASMHPD) guidance on Improving
the Child and Adolescent Crisis System: Shifting from a 9-1-1 to a 9-8-8 Paradigm and will include the
BHO-F-COM-MA-MCD/11/2015 Amend 17 — PID 301052
(AG — VO STD FACILITY) Page 26 of 72
following components:
1. Responders will provide developmentally appropriate services.
2. Responders are intentionally inclusive of family/caregivers and natural supports throughout a
stabilization period.
3. Responders are able to serve children, youth, young adults and families or caregivers in their
natural environments including (but not limited to) at home or in school.
vi. Crisis interventions will include partnerships with children, youth, young adults and family/caregivers to
identify, restore and increase family and community connections and create linkages to necessary
resources.
c. Mobile Crisis Outreach goals should:
i. Support and maintain Individuals in their current living situation and community environment, reducing
the need for out -of -home placements, which reduces the need for inpatient care and residential
interventions.
ii. Support Individuals, youth, and families by providing trauma informed care.
iii. Promote and support safe behavior in home, school, and community settings.
iv. Reduce the use of emergency departments (ED), hospital boarding, and detention centers due to a
behavioral health crisis.
v. Assist Individuals, youth, and families in accessing and linking to ongoing support and services,
including intensive clinical and in-home services, as needed.
d. Crisis System Staffing Requirements
i. Facility shall ensure compliance with applicable staffing requirements of WAC 246-341.
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 Substance Use Disorder Professional (SUDP) and one Certified Peer
Counselor (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 ITA services policies and procedures, as applicable, that implement
WAC 246-341-0810 and the following requirements:
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(AG — VO STD FACILITY) Page 27 of 72
1. No DCR or crisis worker shall be required to respond to a private home or other private
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.
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.
e. Facilities shall provide mobile crisis outreach services in accordance with WAC 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).
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 (AI/AN), 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) Certified Peer Counselor (CPC): Individuals who: have self -identified as a consumer of behavioral health services; have
BHO-F-COM-MA-MCD/1 1/2015 Amend 17 — PID 301052
(AG — VO STD FACILITY) Page 28 of 72
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; have passed a Washington
State background check; have been certified by DBHR; and are a registered Agency Affiliated Counselor with the
Department of Health (DOH).
(2) 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.
(3) Conditional Release (CR): When a treating Facility determines that an Individual committed to an inpatient treatment
Facility can be appropriately treated by outpatient treatment in the community prior to the end of the commitment period,
the Individual may be discharged under a CR. A CR differs from a less restrictive order in that the CR is filed with the
court, as opposed to being ordered by the court. The length of the CR is the amount of time that remains on the current
inpatient commitment order.
(4) 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.
(5) 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.
(6) 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 individual's health or safety.
(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 by Historical Trauma and the resulting cycle of Adverse Childhood Experiences
(ACEs).
(9) 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.
(10) 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 to pay,
county of residence, or level of income.
(11) 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 necessary, individuals 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).
(12) 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.
(13) 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.
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(14) Less Restrictive Alternative (LRA) Treatment Order: If a court determines that an Individual committed to an inpatient
Facility meets criteria for further treatment but finds that treatment in a less restrictive setting is a more appropriate
placement and is in the best interest of the Individual or others, an LRA order may be issued. The LRA order remands the
Individual to outpatient treatment by a Behavioral Health service provider in the community who is responsible for
monitoring and providing LRA treatment. The Individual must receive at least a minimum set of services and follow the
conditions outlined in the LRA order. The length of an LRA order is usually 90 or 180 days but in certain cases can be for
up to one year. (RCW 71.05.320). An LRA order may be extended by a court.
(15) Mental Health Care Provider: Means the individual with primary responsibility for implementing an individualized plan for
mental health rehabilitation services. Minimum qualifications are B.A. level in a related field, A.A. level with two years'
experience in the mental health or related fields. Additionally, this person would be supervised by a provider who meets
the definition of a mental health professional and be an Agency Affiliated Counselor.
(16) 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 reducing immediate risk of danger 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.
(17) 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 (YMCI). It is a
supplement to the Washington Provider Service Instruction Manual. It is available on Beacon's Washington website
(18) Peer Support Services: Means behavioral health services provided by Certified Peer Counselors. This service provides
scheduled activities that promote socialization, recovery, self -advocacy, development of natural supports, and
maintenance of community living skills. Individuals actively participate in decision-making and the operation of the
programmatic supports.
(19) Substance Use Disorder Professional (SUDP): An individual who is certified according to RCW 18.205.020 and the
certification requirements of WAC 246-811-030 to provide SUD services.
(20) Triage: The sorting and allocation of treatment to patients according to the urgency of their need for care.
(21) Withdrawal Management (previously known as detoxification): Care and treatment in a residential or hospital setting of
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;
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(AG — VO STD FACILITY) Page 30 of 72
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, Department of Corrections (DOC), jail -based
staff, First Responders, criminal justice system, 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 or prior criminal justice involvement.
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.
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
experiencing (normal, but often overwhelming) stress, concern, and exhaustion so that they are best equipped
to participate in the intervention, make decisions, and support their loved one.
d. Discussing and activating caregiver / natural support strengths and resources to identify how such strengths and
resources impact their ability to care for the individual's behavioral health needs.
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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).
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
Mental Health Clinical Specialist.
I. Confirm whether the Individual has a Crisis Alert on file and get access to any risk management / safety plans,
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, including access to
appropriate services along the behavioral health continuum of care.
o. For adults who are receiving Program for Assertive Community Treatment (PACT) or similar program, or youth
who are receiving Wraparound with Intensive Services (WISe) 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 management program,
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 provider (e.g. primary care,
PACT, residential, etc.).
(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
management.
b. MCIs shall be utilized whenever possible to provide the initial response in order to maximize the efficiency of
limited DCR resources by helping to ensure DCRs respond to cases specific to RCW 71.05 .
(7) If the Facility provides DCR services, core services include:
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a. Deliver Involuntary Treatment Act Services including all services and administrative functions required for the
evaluation for involuntary detention or involuntary 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.
The Facility will have a process in place to determine if an individual is impaired due to the presence of
substances in their 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 shall implement a plan to provide appropriate treatment services to the Individual, which
may include the development of Least Restrictive Alternatives (LRAs), or relapse prevention programs
reasonably calculated to reduce demand for involuntary detentions to E&T facilities and Secure
Withdrawal Management and Stabilization facilities.
iv. The Facility will monitor and track all individuals placed on Least Restrictive Alternatives (LRAs) and
Conditional Release (CR) in the county/region in accordance with RCW 71.05.320, RCW 71.05.340,
and RCW 71.05.585 respectively, and submit monthly updates to Beacon, using the template provided
by Beacon. Updates shall include information on LRA treatment from the treatment provider.
v. The Facility shall report to HCA and Beacon when it is determined an Individual meets detention criteria
under RCW 71.05.150, 71.05.1533 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.
vi. When the DCR determines an Individual meets detention criteria, the investigation has been completed
and when no bed is available, the DCR shall submit 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;
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.
vii. When a DCR submits a No Bed Report due to the lack of an involuntary treatment bed, a face-to-face
re -assessment is conducted each day by the DCR or Mental 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) 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 MHP 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 and providers unless: (1) there
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are significant safety issues identified, documented, and reported to Beacon; and / or (2) the requesting
stakeholder or provider 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 issues pertaining to adults,
children, and families.
d. The Facility's community response time will be no longer than 2 hours or as mandated by WAC and RCW.
e. The Facility will seek less restrictive alternatives for all individuals served, with effort made to maintain an
individual in their community, and voluntary placement when a higher level of care is clinically indicated. The
Facility may provide crisis and community stabilization 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
counseling, skill building, case management, check -ins by phone or in person and other supportive services
including engagement with family and significant others for support.
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
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,
mediation, 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 understanding (MOU) documenting the
provision of applicable crisis services (Mobile Crisis Intervention, Designated Crisis Responder) with applicable key
partner organizations including but not limited to school districts, child welfare, law enforcement, emergency services,
hospitals, providers, etc.
(9) Partner with Beacon to organize and facilitate community forum(s), on an agreed upon frequency, for the purposes of
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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Exhibit 113-TA17
Mental Health Program Provisions
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. In accordance with WAC 246-341, provide mental health services, residential services (licensed under WAC
246-337), and crisis stabilization services. Provide services to individuals on a least restrictive alternative (LRA)
or conditional release (CR) in accordance with RCW 71.05.
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.
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
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spenddown.
(2) The Facility shall provide medically necessary mental health services to Eligible Individuals. Facility shall provide 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 receives a referral for a non -Medicaid LRA ordered service, the referral must be prioritized. Staff will coordinate
and collaborate with superior courts, contractors providing services to persons released on assisted outpatient treatment
orders, and other stakeholders within their region. Updates must be provided as required in the LRA.
(6) If Facility is providing Outpatient Mental Health Services, they must be provided by staff with appropriate credentials as
defined by WAC 246-341-0515.
(7) 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
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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
I. Services require authorization by Beacon Care Managers
(8) 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
(9) 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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(10) 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
(11) 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.
(12) 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.
(13) Facility will make its best, good -faith effort to schedule Prescriber and other Provider appointments within seven (7)
calendar days of an Individual's discharge.
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IV. Reporting Requirements are detailed in Exhibit B-25
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Exhibit B -8.A17
Washington State Health Care Authority Specific Provisions
In addition to the obligations set forth elsewhere in this Agreement, Beacon and Facility agree to comply with the following
requirements with respect to Covered Services rendered to Eligible Individuals subject to Beacon's contract with the Washington
Health Care Authority. In the event of any conflict between the provisions of the Agreement and this Exhibit B-8, the provisions of
this Exhibit control as related to Washington State Health Care Authority Specific Provisions. Capitalized terms used but not defined
in this Exhibit B-8 shall have the meanings set forth in the Agreement.
I: Hold Harmless.
(1) Facility hereby agrees that in no event, including, but not limited to nonpayment by Beacon, or Payor, Beacon's insolvency
or the insolvency of Payor, or breach of this contract will Facility bill, charge, collect a deposit from, seek compensation,
remuneration, or reimbursement from, or have any recourse against an Eligible Individual or person acting on their behalf,
other than Beacon or Payor, for Covered Services provided 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
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 services promised in this contract
to Eligible Individuals for the duration of the period for which payments were made or until the Eligible Individual'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.
(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 existing or hereafter 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 directly or indirectly from Beacon or
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 an 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 be given reasonable notice of not 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, Facility may terminate the
Agreement without penalty if Facility does not agree with the changes, subject to the requirements in Article VIII
of the Agreement
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b. A material amendment to the Agreement may be rejected by Facility. The rejection will not affect the terms of
the existing Agreement. A material amendment has the same meaning as in RCW 48.39.005.
(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 informing Eligible Individuals of 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 penalize Facility
or its Practitioners otherwise practicing in 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 Facility to bind Beacon or Payor to pay
for any service.
(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 includes
prohibiting 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 authorities any act or practice
by Beacon that jeopardizes an 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 their patient, for the following:
a. The individual's health status, medical care, or treatment options, including any alternative treatment that
may be self-administered,
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, including the right 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 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 a private purchaser of a Plan or as a participant
in publicly financed programs of health care services. This requirement does not apply to circumstances when the
Facility should not render services due to limitations arising from lack of training, experience, skill, or licensing
restrictions
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VI. Dispute Resolution.
(1) Notwithstanding those provisions in Article X of the Agreement, the parties are not required to engage in binding arbitration;
however, parties agree to otherwise follow the dispute resolution process prior to judicial remedies. Facility has thirty days
after the action giving rise to a dispute to complain and 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, 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 thirty (30) days of
receipt. For purposes of this Section VII, Clean Claim means a claim that has no defect or impropriety, including
any 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 by Beacon and ninety-
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 shall pay 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 percent (1 %) 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 submitting an 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 denial.
f. Beacon's Provider Dispute Resolution (PDR) Process can be utilized for claims that deny 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 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 any
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duplicate coverage to Beacon;
b. Ensure that services and benefits available under this Contract shall be secondary to all other coverage
c. Attempt to recover any third -party resources available to individuals, including pursuit of FFS Medicaid funds
provided for AVAN Individuals who 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-going basis and remain
accountable and responsible for compliance 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) The Facility shall maintain Policy and Procedures that demonstrate compliance with contractual requirements.
(2) Comply with all applicable state and federal laws, rules, and regulations related to services rendered to Eligible individuals,
and applicable requirements of the Beacon and Washington State Health Care Authority Contract.
(3) Comply with Beacon's Program Integrity requirements and HCA approved Program Integrity policies and procedures.
(4) 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
thereafter.
a. Facility agrees to immediately disclose to Beacon Health Options any exclusion or other event which makes
them ineligible to perform work related directly or indirectly to Federal health care programs.
b. Facility will submit a completed monthly attestation regarding exclusionary checks to Beacon Health Options no
later than the 1 Oth of each month.
c. Facility will make evidence of monthly checks available upon request.
(5) 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;
(6) Participate in Beacon required or HCA sponsored Quality Improvement activities.
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(7) Keep records necessary to adequately document services provided in a manner consistent with state and federal laws
and regulations.
(8) 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;
(9) Submit all reports and clinical information required by Beacon and/or Payors that may be required by Contract(s) and to
ensure the quality, appropriateness and timeliness of contracted services;
(10) 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. Audit/Access to Records.
(1) Facility shall comply with all applicable required audits including authority to conduct a Facility inspection, 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 records.
c. The Facility must provide access to its premises and the records requested to any state or federal agency 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 relating to the ability of the Facility to
deliver health care services that meet the 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 necessary to perform
the audit.
(6) The billing audit rights granted to Beacon and the Payors are reciprocal so that Facility may audit the denial of its claims.
XI. Miscellaneous.
(1) Compliance with law. Beacon and Facility shall comply with all applicable Washington laws governing this Agreement
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and the provision of Covered Services 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 necessary for consistency with the
applicable Washington law.
(2) Conflicts or inconsistencies. In the event of any conflict or inconsistency between 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; provided
however, that if Beacon and Facility are capable of complying with both the requirements of such other section and this
Exhibit B-8, nothing herein shall be construed as waiving the obligations of Beacon or Facility under such other section.
XII. Additional Provisions Required of the Washington State Health Care Authority (HCA)I.
(1) Facility shall not subcontract services identified in this contract without the express permission of Beacon Health Options.
Beacon will respond in a timely manner to subcontracting requests and clearly communicate feedback about potential
subcontractor(s) and subcontract language. In the event subcontracting is approved, all requirements contained in this
contract must be included in any subcontract (45 CFR 92.35).
(2) The Facility shall inform, post, and guarantee that each Individual has the following rights in compliance with WAC 246-
341-0600:
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 (including the
option of no treatment).
d. To participate in decisions regarding their behavioral health care, including the right to refuse treatment and to
express preferences about future treatment decisions.
e. To be treated with respect and with due consideration for their dignity and privacy.
f. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or
retaliation.
g. To request and receive a copy of their medical records, and to request that they be amended or corrected, as
specified in 45 C.F.R. Part 164.
h. To be free to exercise their rights and to ensure that to do so does not adversely affect the way the Facility treats
the Individual.
(3) 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. Patient consent is required for telemedicine per RCW 48.43.735. Failure to obtain consent could result in
disciplinary action against the provider.
c. Complying with the provisions of the Natural Death Act (Chapter 70.122 RCW) and state rules concerning
Advance Directives (WAC 182-501-0125); and,
d. When appropriate, informing Individuals of their right to make anatomical gifts (Chapter 68.64 RCW).
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(4) Facility shall use the Integrated Co-Occurring Disorder Screening Tool (GAIN-SS found at https://www.hca.wa.gov/billers-
providers-partners/behavioral-health-recover r�l� ain-ss) for all services except DCR services, and shall train staff that will
be using the tool(s) to address the screening and assessment process, the tool, and quadrant placement. Failure to
implement and maintain the process may result in corrective action.
(5) Ensure that all services and activities provided under this Contract shall be designed and delivered in a manner
sensitive to the needs of the diverse population.
(6) Initiate actions to develop or improve access, retention, and cultural relevance of treatment, relapse prevention or
other appropriate services, for ethnic minorities and other diverse populations in need of services under this Contract
as identified in their needs assessment.
(7) Participate in training when requested by the HCA. Exceptions must be in writing and include a plan for how the
required information shall be provided to staff.
(8) Provide interpreter services free of change for Individuals with a preferred language other than English. This includes
the provision of interpreters for Individuals who are Deaf, DeafBlind, or Hard of Hearing. This includes oral interpretation
Sign Language (SL), and the use of Auxiliary Aids and Services as defined in (42 C.F.R. § 438.10(d)(4)).
(9) The following provisions are required by (i) federal statutes and regulations applicable to medical assistance programs for
the indigent, (ii) state statutes and regulations applicable to medical assistance programs for the indigent, or (iii) 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 to
such statutes, regulations, and agreements. Further, any purported modifications to these provisions inconsistent with
such statutes, regulations, and agreements shall be null and void.
(10) Facility shall provide reasonable access to facilities and financial and medical records for duly authorized representatives
of the CMS, HCA, Department of Social & Health Services ("DSHS") or the Department of Health & Human Services
("DHHS") for audit purposes and immediate access for Medicaid fraud investigators.
(11) Facility shall investigate and disclose to Beacon and HCA immediately upon becoming aware of any person in their
employment who has been convicted of a criminal offense related to that person's involvement in any program under
Medicare, Medicaid, or Title XX of the Social Security Act since the inception of those programs.
(12) Facility shall require nondiscrimination in employment and Individual services.
(13) Facility shall conduct criminal background checks and maintain related policies and procedures and personnel files
consistent with requirements in RCW 43.43 and, WAC 246-341.
(14) Facility shall completely and accurately report encounter data to Beacon. Facility shall have the capacity to submit all
required data to enable Beacon to meet the requirements in the Encounter Data Transaction Guide published by HCA.
(15) Facility shall comply with Beacon's fraud and abuse policies and procedures.
(16) Facility shall not assign this Agreement without Beacon's written agreement,
(17) Facility shall comply with any term or condition of Beacon's contracts with HCA that is applicable to the services to be
performed by Facility.
(18) 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.
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(19) 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 harmless
HCA and its employees against all injuries, deaths, losses, damages, claims, suits, liabilities, judgments, 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.
(20) If, at any time, Beacon determines that Facility is deficient in the performance of its obligations under the Agreement,
Beacon may require Facility to develop and submit a Corrective Action Plan (CAP) that is designed to correct such
deficiency.
a. Beacon shall approve, disapprove, or require modifications to the corrective action plan based on its reasonable
judgment as to whether the corrective action plan will correct the deficiency.
b. Facility shall, upon approval of Beacon, immediately implement the corrective action plan, as approved or
modified by Beacon.
c. Facility's failure to implement any corrective action plan may, in the sole discretion of Beacon, be considered
breach of the Agreement, subject to any and all contractual remedies including termination of the Agreement
with or without notice.
(21) 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 not inhibit enrollees with
disabilities from obtaining Covered Services.
(22) Facility shall comply with all Program Integrity provisions as documented in Beacon's Provider Manual and asset forth by
42 CFR 438.608 and Beacon's contracts with HCA.
(23) With the exception of crisis services, Facility shall ensure that all persons receiving services under this Agreement are
screened for financial eligibility. Specifically, Facility shall:
a. Capture sufficient demographic, financial, and other information to support eligibility decisions and reporting
requirements.
b. Check Medicaid eligibility, including conducing a benefit inquiry in the ProviderOne system, prior to each service
delivery.
c. Conduct an inquiry regarding each Eligible Individual' s continued financial eligibility no less than once each
month.
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 must meet: (i) the
financial eligibility criteria; and (ii) the clinical or program eligibility criteria for the service . For services in which
medical necessity criteria applies, all services must be medically necessary.
g. Funding for services where medical necessity does not apply can only be used under the follow circumstances:
i. Based on available resources
1. Service type(s) allowable by fund source
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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. Financial eligibility criteria for non -crisis behavioral health services are as follows:
i. Does not qualify for Medicaid.
ii. Gross monthly income (adjusted for family size) that does not exceed 220% of the Federal Poverty
Guidelines,
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 SLID or mental health crisis services due to inability to access non -crisis
behavioral health services
4. Have more than 5 visits over 6 months to the emergency department, withdrawal
management facility, or the sobering center due to a SUD
(24) Facility may offer a sliding scale fee schedule to Individuals who are not eligible for Medicaid coverage that takes into
consideration an Individual's circumstances and ability to pay. If the Facility selects to develop a fee schedule, the fee
schedule must comply with the following and must be reviewed 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 sliding fee schedule;
d. Protect Individual's privacy in assessing fees;
e. Maintain records to account for each Individual's visit and any charges incurred;
f. Charge Individuals at or below 100 percent of Federal Poverty Level (FPL) a nominal fee or no fee at all. The
Federal Poverty Guidelines can be found at https://aspe.hhs.gov/poverty-guidelines.
g. Develop at least three (3) incremental amounts on the sliding fee scale for Individuals between 101 to 220
percent FPL.
h. Facility will reduce the amount billed to Beacon by any sliding fee schedule amounts collected from Eligible
Individuals.
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(25) 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 (M HAD) policy and procedure that respects
an 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 technical assistance to those
who express an interest in developing and maintaining a mental health advance directive
c. Maintain current copies of any mental health advance directive in the individual's utilization records.
d. Inform individuals that complaints concerning noncompliance with a mental health advance directive should be
referred to the Washington State Department of Health by calling 1-360-236-2620 or by following the written
instructions contained in the mental health benefit booklet.
(26) The Facility shall implement a Grievance process that complies with WAC 182-538C-110. The Facility shall:
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, the quality of care or services provided, and aspects of
interpersonal relationships such as rudeness of a provider or employee, or failure to respect the Individual's
rights regardless of whether remedial action is requested. Grievance includes an Individual's right to dispute an
extension of time proposed by the Contractor to make an authorization decision.
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 Hearing, or a
Grievance for individuals if similar services are immediately available in the service area.
(27) The Facility shall ensure that the offer hours of operation for individuals served under this contract with Beacon are no
less than the hours of operation offered to any other individual.
(28) If the Facility is a faith -based organization (FBO), it shall meet the requirements 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 reasonable time frame when requested by
the recipient of services. The FBO shall report to the Contractor all referrals made to alternative 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 any 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
(29) Critical Incident Reporting.
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a. Facility shall comply with all critical incidents reporting in accordance with WAC 246-341. All critical incidents
shall be reported within 1 business day of becoming aware of the incident.
(30) For providers in twenty-four (24) hour settings, a requirement to provide discharge planning services which shall, at a
minimum:
a. Coordinate a community-based discharge plan for each individual served under this Agreement beginning at
intake in order to procure the best available recovery plan and environment for the individual. Discharge planning
shall apply to all individuals regardless of length of stay or whether they complete treatment.
b. Coordinate exchange of assessment, admission, treatment progress, and continuing care information 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 or employment
services, and courts which specify aftercare expectations and services, including procedure for involvement of
referents in treatment activities.
d. Coordinate, as needed, with Department of Behavioral Health and Rehabilitation (DBHR) prevention services,
vocational services, housing services and supports, and other community resources and services that may be
appropriate, including the Division of Children and Family Services, the Community Services Division including
Community Service Offices (CSOs), Tribal 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 and
financial 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 and its compliance
with the terms of the Agreement.
d. Inform Provider of the results of any performance evaluations and of any dissatisfaction with Provider's
performance, and reserve the 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 authorized by law
(e.g., which has been vacated by a court of law, or for which authority has been withdrawn, or which is the subject
of a legislative repeal), Facility must do no work on that part after the effective date of the loss of program
authority. If Facility works on a program or activity no longer authorized by law after the date the legal authority
for the work ends, Facility will not be paid for that work. If Facility was paid in advance to work on a no -longer -
authorized program or activity and under the terms of this Contract the work was to be performed after the date
the legal authority ended, the payment for that work must be returned. However, if Facility worked on a program
or activity prior to the date legal authority ended for that program or activity, and the state included the cost of
performing that work in its payments to Facility, Facility may keep the payment for that work even 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 recovery plan that ensures timely reinstitution of the
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Individual information system following total loss of the primary system or a substantial loss of functionality. The plan shall
include the following:
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 numbers
d. Procedures for effective communication, application inventory and business recovery priorities, and hardware
and software vendor lists
e. Documentation of updated system and operations and a process for frequent back up of systems and data
f. Off-site storage of system and data backups and ability to recover data and systems from 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 indicating there is an up to date business continuity disaster plan in
place. Certification must be received by December 31 of each contract year to
SeaconWAdASO@beaconhealthoptions.com.
(35) If a Facility receives FBG funds, an annual fiscal review will be conducted regardless of reimbursement methodology. The
Facility shall provide Beacon with requested documentation to comply with fiscal review requirements. Requested
documents may include, but are not limited to, the following:
a. An accounting of FBG expenditures by revenue source.
b. Confirmation that no expenditures were made for items prohibited by this Contract.
c. Confirmation that expenditures were made only for the purposes stated in this Contract, and for services that
were actually provided.
d. FBG 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 marijuana or
treatment 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 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 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 a constituent
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thereof that is otherwise a banned substance under federal law.
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,
including any amendments, modifications or supplements thereto. All services shall be provided in accordance with these
documents and legal authorities:
a. Beacon's contracts, program agreements, exhibits, amendments, and any other agreements with the
Washington State Health Care Authority;
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 Manual and any
applicable BARS Supplemental Instructions;
d. State laws and regulations including the Revised Code of Washington and the Washington Administrative Code;
e. Beacon External Policies and Procedures, including Beacon's Provider Handbook and Washington State ASO
Provider Handbook: Supplemental Appendix;
f. CPT Manual, HCPC Manual, and Washington State Service Encounter Reporting 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:
a. This Agreement may be terminated by either party for any reason upon ninety (90) days written notice to the
other party.
b. Any Exhibit may be suspended or terminated by Beacon immediately upon written notice if:
i. Facility is disqualified, terminated, suspended, debarred, or otherwise excluded from or ineligible for
participation under the program or any other state or federal government-sponsored health program;
or
ii. 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
sharing information with the public as required by federal, state or local law.
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Exhibit 8-10.A17
Mental Health Block Grant Program Provisions
This Exhibit contains additional provisions applicable to Covered Services rendered to Eligible Individuals (as defined below)
covered under Mental Health Block Grant (MHBG) 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-10 and subject to the provisions set out in Exhibit B-10, the provisions of this Exhibit control as related to services rendered
to individuals receiving Mental Health Block Grant (MHBG) Program services.
I: General Provisions.
(1) Whenever in this Exhibit B-10 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. Follow all rules and regulations of CFDA 93.958 for provision of services for the Block Grants for Community
Mental Health (MHBG) program.
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-10, Eligible Individual means any non -Medicaid individual eligible to
receive services through the MHBG Program offered by the Washington State Health Care Authority and for MHBG
services not covered by Medicaid, any Medicaid individual.
(4) Mental Health Block Grant (MHBG): Means those funds granted by the Secretary of the Department of Health and Human
Services (DHHS), through the Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services
Administration (SAMHSA), to states to establish or expand an organized community-based 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 of those MHBG services further described
within this Exhibit B-10 which are reimbursable pursuant to the contract between Beacon and the Washington State Health
Care Authority.
III. Services. Facility agrees to:
(1) Facility may use block grant funds to help Individuals satisfy cost-sharing requirements for MHBG-authorized mental
health 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;
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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 resiliency for SED children in accordance with
federal and state requirements.
(4) Ensure that MHBG funds are used only for services to individuals who are not enrolled in Medicaid or for services that are
not covered by Medicaid as described in the following table:
Benefits
Services
Use MHBG Funds
Use Medicaid
Individual is not a Medicaid
recipient
An Allowable Type
y yp
Yes
No
Individual is a Medicaid
Allowed under Medicaid
No
Yes
recipient
Individual is a Medicaid
Not Allowed under
recipient
Medicaid
Yes
No
(5) MHBG 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 to any services being
provided.
(6) Participate in annual peer review by individuals with expertise in the field of mental health treatment when requested by
HCA (42 U.S.C. 300x-53 (a) and 45 C.R.R. 96.136, MHBG Service Provisions).
(7) Send a representative to the regional Behavioral Health Advisory Board (BHAB) meetings to report on program data and
results,
IV. Reporting Requirements are detailed in Exhibit B-25
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Addendum to Exhibit B -10.A17
Behavioral Health Community-based Outreach and Engagement
This Addendum contains additional provisions applicable to administration of the Behavioral Health Community-based
Outreach and Engagement under Exhibit B-10.
Objective:
Engage Peer Support Specialists to provide Behavioral Health Community-based Outreach and Engagement to identified
clients in support of positive recovery outcomes. Behavioral Health Community-based Outreach and Engagement will include
peer support, support for education activities, resource referral, sharing their lived experience with behavioral health issues
and recovery 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 behavioral health
staff.
3) Provide peer support, support for education activities, resource referral, share lived experience with behavioral health
issues and recovery principles.
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. They will travel with the Grant County Safe
Syringe program.
Reporting Requirements are detailed in Exhibit B-25.
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Exhibit B -11 -Al 7
Substance Use Disorder Program Provisions
This Exhibit contains additional provisions applicable to Covered Services rendered to Eligible Individuals (as defined below)
covered under Substance Use Disorder (SUD) 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-11 and subject to the provisions set out in Exhibit B-11, the provisions of this Exhibit control as related to services rendered to
individuals receiving SUD Program services.
I: General Provisions.
(1) Whenever in this Exhibit B-11 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 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 Substance Abuse Prevention
and Treatment Block Grant (SABG) program when funding is used.
c. Facility shall provide alcohol and drug treatment services per RCW 70.96A as described in the Services below.
d. If applicable, Facility shall provide alcohol and drug treatment services pursuant to the Dedicated Cannabis
Account DCA program provisions as promulgated by the Washington State Health Care Authority when that
funding is used.
i. DCA funds shall be used to fund SUD treatment services for youth living at or below 220 percent of the
federal poverty level, without insurance coverage or who are seeking services independent of their
parent/guardian;
ii. DCA funds may be used for development, implementation, maintenance, and evaluation of programs
that support intervention, 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 or
CJTA eligible patients. Specifically, Facility shall:
ii. Provide services to individuals with an addiction or a substance abuse problem that, if not treated,
would result in addiction, against whom a prosecuting attorney in Washington State has filed charges.
iii. In accordance with RCW 2.30.040, counties are required to provide a dollar -for -dollar participation
match for CJTA funded services for Individuals who are under the supervision of a therapeutic court.
1. No more than 10 percent of the total CJTA funds can be used for the following treatment
support services combined:
a. Transportation; and
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b. Child Care Services.
iv. The Facility, under the provisions of this contract and in accordance with RCS 71.24.580(9), will abide
by the following guidelines 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 any medication
approved the by the FDA for the treatment 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 FDA for the treatment of SUD, as
a condition of individual being admitted into the program, continuing in the program, or
graduating from the program; with the understanding that decisions concerning medication
adjustment are made solely between the Individual and their prescribing providers.
4. Coordinates care with agencies that are able to provide or facilitate the induction of any
medication approved by the FDA for the treatment of SUD.
v. 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 the process 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 Guidelines (ASAM Guidelines): Means a professional society
dedicated to increasing access and improving the quality addiction treatment. ASAM Guidelines are 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 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 using techniques such as evidence -
based motivational interviewing, and 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 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; have passed a
Washington State background check; 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 by the state for expenditure on: a) SUD
treatment and treatment support services for offenders with a SUD that, if not treated, would result in addiction, against
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)..
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(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 by Historical 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 and group
counseling, education, and related activities including room and board in a 24 -hour -a -day supervised Facility in
accordance with WAC 246-341 (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. (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.
(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
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in accordance with WAC 246-341. 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
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 to provide
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 abstinence (assisting 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 to persons
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 -administration 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 WAC 246-341. (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 thirteen (13) through seventeen (17). Specific programs may assign a different age
range for youth.
(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:
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(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;
ii. The total dollars paid out for cost-sharing; and
iii. 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 current regional SABG Project Plan and obtain approval from the Account Partnership Director
before submission of a cost reimbursement invoice.
Allowable Services Table
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CJTA-Drug Court:
SABG: 1st priority
1st Priority for
DCA: 1st priority
for non -offender
GFS: Default
Service
qualifying
for youth or
adults or services
funding after all
nonviolent
perinatal women
not covered by
others
offender
DCA
Brief Intervention (Any Level,
x
X
X
X
Assessment not Required
Acute Withdrawal Management
x
X
X
X
ASAM Level 3.7WM
Sub -Acute Withdrawal
Management (ASAM Level
X
X
X
X
3.2WM
Outpatient Treatment (ASAM
X
X
X
X
Level 1
Intensive Outpatient Treatment
X
X
X
X
ASAM Level 2.1
Brief Outpatient Treatment
x
X
X
X
ASAM Level 1
Opioid Substitution Treatment
X
X
X
X
ASAM Level 1
Case Management (ASAM Levels
x
X
X
X
1.2
Intensive Inpatient Residential
x
X
X
X
Treatment ASAM Level 3.5
Long-term Care Residential
x
X
X
X
Treatment ASAM Level 3.3
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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
c. Must accept admissions 24hrs/7 days per week.
d. Must have written admission and discharge criteria.
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CJTA-Drug Court:
SABG:1st priority
1st Priority for
DCA: 1st priority
for non -offender
GFS: Default
Service
qualifying
for youth or
adults or services
funding after all
nonviolent
perinatal women
not covered by
others
offender
DCA
Recovery House Residential
X
X
X
X
Treatment (ASAM Level 3.1
Assessment
X*
X
X
X
Engagement and Referral
X
X
X
Alcohol/Drug Information School
X
X
X
ADIS
Interim Services
X
X
X
X
Outreach and Engagement at
$40/hour. Time shall be
X
X
X
X
calculated in 15 minute units.
Crisis Services
X
X
Sobering Services
X
X
X
Involuntary Commitment
X
X
X
Investigations and Treatment
Therapeutic Interventions for
X
X
X
Children
Transportation
X
X
X
X
Childcare Services provided by
X
X
X
X
licensed childcare providers
PPW Housing Support Services
X
X
X
Family Hardship
x
Recovery Support Services
X
X
X
X
Continuing Education
X
X
Urinalysis
X
X
X
X
Employment services and job
X
X
X
training
Relapse prevention
X
X
X
X
Family/marriage education
X
X
X
Peer-to-peer services, mentoring
X
X
X
X
and coaching
Self-help and support groups
X
X
X
Housing support services (rent
X
X
X
and/or deposits
Life skills
X
X
X
Education
X
X
X
Parent education and child
X
X
X
development
Naloxone
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
c. Must accept admissions 24hrs/7 days per week.
d. Must have written admission and discharge criteria.
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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 three (3) years'
experience treating substance 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 by 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 afull range of treatment programming 7 days per week.
f. Must provide individualized treatment plans.
g. Must provide emergency psychiatric/medical services on-site or by contract.
h. Must require and/or encourage family involvement in treatment.
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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) Facility will make its best, good -faith effort to schedule Prescriber and other Provider appointments within seven (7)
calendar days of an Individual's discharge.
(7) Conduct an inquiry regarding each patient's continued financial eligibility no less than one time per month.
(8) Document the evidence of each financial screening in individual patient records.
(9) 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 -day period to the same person and an
intake has not been provided, the Facility 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 treatment.
(10) For SABG funded services, the Facility shall ensure the following:
a. As a Facility receiving funding under the Block Grant and providing services required by CFR Title 45, Section
96.959, Facility shall make every effort, including the establishment of systems for eligibility determination, billing,
and collection, to:
i. 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 include any State compensation program, other public assistance program for medical
expenses, grant programs, private health insurance, or any other benefit program; and
ii. Secure payments from individuals for services in accordance with their ability to pay.
b. Meet the needs of priority populations, in priority order below, as identified in the SABG or by HCA, including but
not limited to:
iii. Pregnant individuals injecting drugs.
iv. Pregnant individuals with SLID.
v. Women with dependent children.
vi. Individuals who are injecting drugs or substances.
vii. The following additional priority populations, in no particular order:
1. Postpartum women (up to one year, regardless of pregnancy outcome).
2. Patients transitioning from residential care to outpatient care.
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3. Youth.
4. Offenders as defined in RCW 70.96.350.
c. Within available resources, ensure that SABG services are not denied to any Eligible Individual regardless of:
viii. The individual's drug(s) of choice.
ix. The fact that the individual is taking FDA approved medically -prescribed medications.
x. The fact that the individual is using over the counter nicotine cessation medications or actively
participating in a nicotine replacement therapy regimen
d. Deliver SABG services as described in the regional SABG Project Plan for the current fiscal year approved by
Beacon and the Health Care Authority.
e. Ensure that SABG funds are used only for services to individuals who are not enrolled in Medicaid orfor services
that are not covered by Medicaid as described in the following table:
Benefits
Services
Use SABG Funds
Use Medicaid
Individual is not a Medicaid
An Allowable Type
y yp
Yes
No
recipient
Individual is a Medicaid
Allowed under Medicaid
No
Yes
recipient
Individual is a Medicaid
Not Allowed under
recipient
Medicaid
Yes
No
f. Have protocols for maintaining waiting lists and providing interim services for SABG priority population
individuals, as defined in this Contract, who are eligible to receive services but for whom SUD treatment services
are not available due to limitations in provider capacity or available resources.
xi. 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 phone
number
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.
g. Ensure interim services are provided by for pregnant and parenting women and intravenous drug users.
h. Interim services shall be made available within forty-eight (48) hours of seeking treatment for pregnant and
parenting women and intravenous drug users.
xii. Admission to treatment services for the intravenous drug user shall be provided within fourteen (14)
days after the patient makes the request, regardless of funding source.
xiii. If there is no treatment capacity within fourteen (14) days of the initial patient request, the Facility shall
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have up to one hundred twenty (120) days, after the date of such request, to admit the patient into
treatment. Interim services must be documented in the system platform designated by the HCA and
include, ata minimum:
1. Counseling on the effects of alcohol and drug use on the fetus for the pregnant patient.
2. Prenatal care for the pregnant patient.
3.Human immunodeficiency virus (HIV) and tuberculosis (TB) education.
4. HIV or TB treatment services if necessary for an intravenous drug user.
5. The interim service documentation requirement is specifically for the admission of priority
populations with any funding source; and any patient being served with SABG Block Grant
funds.
i. A pregnant woman who is unable to access residential treatment due to lack of capacity and is in need of
detoxification, can be referred to a Chemical Using Pregnant (CUP) program for admission, typically within
twenty-four (24) hours.
j. Facility shall notify Beacon, in writing, when the Facility is at ninety (90) percent capacity and 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 the
SABG Capacity Management Form.
I. 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
to any services being provided
m. Participate in annual peer review by individuals with expertise in the field of drug abuse treatment when
requested by HCA (42 U.S.C. 300x-53 (a) and 45 C.R.R. 96.136)
n. Send a representative to the regional Behavioral Health Advisory Board (BHAB) meetings to report on program
data and results.
o. Facility shall ensure compliance with tuberculosis screening, testing and referral, in accordance with (42 USC
300x -24(a) and 45 CFR 96.127), in the following manner:
xiv. Coordinating with other public entities to make tuberculosis services available to each Eligible Individual
receiving SABG-funded SUD treatment.
xv. The services will include tuberculosis counseling, testing, and providing for or referring infected with
tuberculosis for appropriate medical evaluation and treatment.
xvi. 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 to
another provider of tuberculosis services.
xvii. Contract for case management activities to ensure the Eligible Individuals receive tuberculosis services.
(11) Charitable Choice Requirements of 42 CFR Part 54 are followed and Faith -Based Organizations (FBO) are provided
opportunities to compete with traditional alcohol/drug abuse treatment providers for funding.
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p. Contracted FBOs are required to meet the requirements of 42 C.F.R. Part 54 as follows:
xviii. Eligible Individuals requesting or receiving SUD services shall be provided with a choice of SUD
treatment providers.
xix. The FBO shall facilitate a referral to an alternative Facility within a reasonable time frame when
requested by the recipient of service
xx. The FBO shall report to Beacon all referrals made to alternative providers.
xxi. The FBO shall provide Eligible Individuals with a notice of their rights.
xxii. The FBO provides Eligible Individuals with a summary of services that includes any religious activities.
xxiii. Funds received from the FBO must be segregated in a manner consistent with federal Regulations.
xxiv. No funds may be expended for religious activities.
(12) Prior Authorization is required for all residential services.
(13) Facility may provide the following services, as authorized by Beacon, using funds from the Designated Cannabis Account
when that funding is used:
q. Substance Use Disorder Outpatient youth treatment utilizing individual, group and family treatment modalities
r. Assessment
s. Residential Treatment Services — Youth
(14) When CJTA funding is used, Facility shall have participated in the development and implementation of any local 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).
(15) When CJTA funding is used for treatment in the jail:
t. CJTA funding used for this purpose may not supplant any locally funded programs within a city, county, or tribal
jail.
u. SUD treatment service provided in jail may include, but are not limited to the following:
xxv. Engaging Individuals in SUD treatment
xxvi. Referral to SUD services;
xxvii. Administration of Medications for the treatment of SUDs including Opioid Use Disorder to include the
following
xxviii. Screening for medications for SUDs
xxii. Cost of medications for SUDs
xxx. Administration of medications for SUDs
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v. Coordinating care;
w. Continuity of Care; and
x. Transition planning
IV. Reporting Requirements are detailed in Exhibit B-25.
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Exhibit B -25.A17
Reporting Provisions
This Exhibit contains additional provisions applicable to reporting on Covered Services 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-25 and subject to the provisions set out in Exhibit B-25, the provisions of this Exhibit control as related to reporting
on services rendered to individuals receiving Covered Services.
General Provisions.
(1) Whenever in this Exhibit B-18 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.
II: Global Reporting Requirements
(1) HCA reporting templates are located at: https://www.hca.wa.gov/billers-providers-partners/programs-and-
services/model-managed-care-contracts.
(2) Provision of required reports is a condition for payment.
(3) If applicable, a copy of the transportation log will be included with monthly invoices.
(4) Facility will use Beacon's Provider Connects portal to register Eligible Individuals for services to ensure they are
assigned a unique ID. Registrations must include, but are not limited to, appropriate start date and fund assignment for
encounters/claims reporting. For those with Medicaid, the individual's Provider One ID must be provided so proper
allocation of cost can be distinguished for the Payor.
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 that complies with HCA Service
Encounter Reporting Instructions (SERI) Guide, HCA Encounter Data Reporting Guide (EDRG), and Behavioral Health
Supplemental Data (BHSD) transactions that comply with the most current Behavioral Health Data System (BHDS) Guide.
Behavioral Health Supplemental Transactions related to services provided to Individuals must be submitted within thirty
(30) calendar days from the date of service or event,
a. Data quality will be measured for each individual transaction as outlined in the BHDS Guide. Error ratios that
exceed 1 percent for each separate transaction may result in corrective actions up to and including sanctions.
b. Data quality error corrections must be made within 2 weeks of notification.
(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: BeaconWAASO(a.beacon healthoptions. com. The name of the report should be
included in the email subject line.
(6) Facility will submit a completed monthly attestation regarding exclusionary checks to Beacon Health Options no later than
the 10th of each month.
(7) Facility must provide claims and/or encounter codes to Beacon for reporting to the Washington State Health Care Authority
in accordance with the Rate Schedules in this Contract. For all fund codes except Federal Block Grant (FBG), claims
submitted for health care payments, also known as the Fee for Service (FFS) payment type, must be submitted within
current Washington State Health Care Authority timely filing requirements or they will be denied for timely filing. For FBG
fund codes, claims must be submitted by July 10 for the prior fiscal year (July 1— June 30). For MHBG COVID and SABG
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COVID fund codes, claims must be submitted by March 24 for dates of service prior to March 14. Encounters submitted
for health care reporting purposes, also known as the Prepaid payment type, must be submitted to Beacon monthly for
the previous month. Claims and encounter submissions are used to reconcile services provided and directly impact future
rate setting and/or funding available in the RSA. Failure to submit claims and/or encounters for services rendered as
outlined in your 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 providing services outlined in Exhibit B-4 Crisis Proqram Provisions, the following additional reporting
requirements apply.
(1) when reporting encounters, the fund code and, for those 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 but not limited to, core
demographics, date of contact, referral reason, intervention provided, outcome, follow up services 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) by the 20th day of
the month.
(5) Facility shall administer a client satisfaction survey upon completion of services and provide an annual report with an
analysis of survey results and recommendations to Beacon. At minimum, the analysis shall include: number of surveys
completed, percentage of completed surveys relative to clients served, results of surveys, comparison of results overtime,
trends found in population and actions taken or to be taken by crisis provider to improve client satisfaction. Annual report
is due by January 10 for the previous calendar year.
(6) Facility will provide a quarterly report of progress towards execution and/or maintenance of inter -agency
agreements/MOUs including the following information: organizations with executed agreements and maintenance
status, organizations in discussion and status of discussions, organizations not yet approached and plans for
engagement. Reports are due by the 20th day of the month following the end of the quarter.
(7) Facility shall report dashboard data monthly to Beacon to fulfill reporting requirements to key stakeholders and the HCA,
including but not limited to, the elements outlined in the following Crisis Dashboard Reporting Elements tables when those
services are provided by the Facility:
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.
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Crisis Dashboard Reporting Elements
Data
Reported by
Key
IP = 1n Person
TH = Telehealth
MCI (Adult/Youth)
Responses that do
not require a DCR
DCR
Referral Source
Regional Crisis Line
X
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)
Total number referrals received
x
x
Response Time
For Initial Dispatch (average minutes)
x
x
From Request to Face -to -Face Arrival (average minutes)
x
x
encounters in initial 2 -person response
x
Emergent (respond within 2 hours)
x
x
Emergent Performance Incentive (respond within 90 minutes)
x
Urgent (as scheduled within 24 hours), defined as:
x
x
By next judicial day for someone in secure setting
Definitions provided for information only,
subcategory reporting of Urgent response
times not currently required.
No more than 6 hours post medical clearance: ER observation,
refused voluntary treatment
Brought by Peace Officer, up to 12 hours post medical clearance:
crisis stabilization, E&T, hospital ED, triage, secure detox, SUD
Within 3 hours must be assessed; determination within 12 hours of
notice
Up to 12 hours to evaluate minors (13 + years old) brought to E&T,
hospital ER, secure detox
Location of Intervention
Community
x
x
ER/Hospital
x
Jail or Juvenile Detention
x
Other (provide details)
x
x
Placement
# Unavailable bed reports
x
# Single Bed Certs
x
# Out of County Placements
x
Outcomes
Phone Consult Only: Inappropriate Referral
x
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Data
Reported by
Key
IP = In Person
TH = Telehealth
MCI (Adult/Youth)
Responses that do
not require a DCR
DCR
Phone Consult Only: Refused Service/Declined IP Response (individual
or family)
x
Refer to Community Stabilization (TH or IP)
x
Refer to DCR (TH or IP)
x
Resolved (TH or IP): # result in Referral to 7 -day Crisis CM Services
x
Resolved (TH or IP): % seen in 7 day CM follow-up
x
Resolved (TH or IP): Follow-up contact made within 24 hours
x
Resolved (TH or IP): Seen by follow-up PCP/OP in 7 days
x
# Face -to -Face crisis contacts (TH or OP)
x
diverted from Higher Level of Care (HLOC)
x
with unplanned contact/return to crisis system
x
x
Results in Referral to OP Treatment
x
Results in Referral to Voluntary IP Treatment
x
Results in Detention under ITA: MH Detention
x
Results in Detention under ITA: Referral to AOT, LRA, CR
x
Results in Detention under ITA: SUD Detention (Ricky's Law)
x
Referred to Law Enforcement
x
Unable to Contact / Refused Service
x
x
Other or No Further Steps
x
Total number of ITA Investigations
x
Total number of ITA Investigations Conducted via TH
x
Total number unique individuals served
x
x
Court. Hearing outcomes
# 14 -day hearing outcomes
x
# 90 -day hearing outcomes
x
# 180 -day hearing outcomes
x
# LRA/CR in place
x
Individuals monitored during reporting period
x
Individual unique ID #
x
Type of Service Provided
x
Start and End dates
x
Treatment Provider and Phone #
x
Health insurance coverage
x
# LRA/CR revoked
x
IV: If Facility is providing services outlined in Exhibit B-7 Mental Health Program Provisions, the following additional reporting
requirements apply.
(1) If Facility is providing Crisis Triage/Stabilization services, report monthly on the number of admissions, average length of
stay, number diverted to other resources/services, and number of denials for each location due by the 10th of the following
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month.
V: If Facility is providing services outlined in Exhibit B-10 Mental Health Block Grant Proqram Provisions, the following
additional reporting requirements apply.
(1) Using the template provided by Beacon, the Facility shall submit a MHBG Monthly Service Report by the 20th of each
month:
(2) Using the template provided by Beacon, the Contractor shall submit an MHBG Annual Progress Report by July 1.
(3) Any other reports deemed necessary by Beacon to meet its reporting requirements pursuant to the terms of its agreement
with the Washington State Health Care Authority and deemed necessary by Beacon to ensure quality of care and services
provided to Eligible Individuals.
(4) If Facility is providing services outlined in an Addenda listed below, the following additional reporting requirements apply.
b. Addendum to Exhibit B-10 Behavioral Health Community-based Outreach & Engagement
i. Report monthly data, by the 10 of the following month, regarding the unique 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 the quarter describing the
activities, outcomes, barriers, and lessons learned.
VI: If Facility is providing services outlined in Exhibit B-11 Substance Use Disorder Program Provisions, the following
additional reporting requirements apply.
(1) If Facility is providing Outreach and Engagement services as detailed in the Allowable Services Table, a detailed
accounting must be included with the invoice for these hourly services. Detail shall include location, date, topic, and
number of attendees for community education events and/or a de -identified spreadsheet of encounters to document
outreach and engagement to individuals using the template provided by Beacon.
(2) On a quarterly basis, on the 20th of the month following the close of the quarter, Facility shall submit the SABG Capacity
Management Form..
(3) Using the template provided by Beacon, the Facility shall submit a SABG Monthly Service Report by the 20th of each
month
(4) Using the template provided by Beacon, the Facility shall submit an SABG Annual Progress Report by July 1.
(5) Any other reports deemed necessary by Beacon to meet its reporting requirements pursuant to the terms of its agreement with
the Washington State Health Care Authority and deemed necessary by Beacon to ensure quality of care and services provided
to Eligible Individuals.
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