Certification and Reimbursement of Mental Health Rehabilitation Service Providers

HAWAII ADMINISTRATIVE RULES TITLE 11 DEPARTMENT OF HEALTH CHAPTER 172 CERTIFICATION AND REIMBURSEMENT OF MENTAL HEALTH REHABILITATION SERVICES PROVIDERS

Subchapter 1 General Provisions

§11-172-01 Scope §11-172-02 Definitions

Subchapter 2 Provider Certification Process

§11-172-03 Certification required §11-172-04 Filing of a provider application §11-172-05 Application forms §11-172-06 Number of copies filed §11-172-07 When to file an application: new Provider §11-172-08 When to file an application: existing provider §11-172-09 Complete application required §11-172-10 Determination of completeness §11-172-11 Notification of completeness §11-172-12 Review period §11-172-13 Service standards §11-172-14 On-site survey §11-172-15 Decision on a certificate application §11-172-16 Failure to act within the required time §11-172-17 Determination of non-compliance §11-172-18 Plan of correction §11-172-19 Acceptance of plan of correction §11-172-20 Granting or continuation of certificate following implementation of plan of correction. §11-172-21 Denial of certificate §11-172-22 Appeal of denial §11-172-23 Term of certification §11-172-24 Unannounced on-site surveys §11-172-25 Certificate not transferable §11-172-26 Notification of changes by provider §11-172-27 Revocation of certificate §11-172-28 Appeal of revocation §11-172-29 Termination of certification

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Subchapter 3 Reimbursement of Providers

§11-172-30 Contract for services §11-172-31 Reimbursement for providers §11-172-32 Medical assistance reimbursement §11-172-33 Utilization management information and data

Subchapter 4 Miscellaneous Provisions

§11-172-34 Free choice of provider §11-172-35 Severability

Historical note: These rules are promulgated pursuant to the memorandum of agreement, dated November 29, 2002, between the Department of Human Services and the Department of Health, whereby the Department of Health agrees to “Develop and promulgate Hawaii Administrative Rules regarding the Adult Mental Health Division (AMHD) process for determining Provider Agencies’ participation in the Community Mental Health Program.”

SUBCHAPTER 1

GENERAL PROVISIONS

§11-172-01 Scope. The rules in this chapter govern procedures before the department of health for the certification and reimbursement of mental health rehabilitation services providers. [Eff Aug 06 2005] (Auth: HRS § 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS §§ 321-1, 334-9)

§11-172-02 Definitions. As used in this chapter: “Agency’ means a for profit or not-for-profit organization that provides mental health rehabilitation services as defined herein. “Applicant’ means an agency that is applying for initial certification or re-certification under this chapter. “Assertive community treatment services” means assertive community treatment service as defined in section 17-1737-44.1.

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“Biopsychosocial rehabilitation services” means biopsychosocial rehabilitative programs as defined in section 17-1737-44.1. “Certificate” means a document issued by the department attesting that a mental health rehabilitation services provider is in compliance with Hawaii state laws and this chapter. “Community Mental health rehabilitation services” or “CMHRS” means services that are intended for the maximum reduction of mental disability and restoration of an individual to his or her best possible functional level. The services shall be: (1) Recommended by a psychiatrist, psychologist, advance practice registered nurse (APRN) in behavioral health, or licensed clinical social worker in behavioral health; (2) Rendered by licensed practitioners and qualified mental health professionals, or agency staff, under the supervision of a qualified mental health professional; and (3) Rendered by mental health rehabilitation services agencies certified under this chapter. “Crisis management services” means crisis management service as defined in section 17-1737-44.1. “Crisis residential services” means crisis residential service as defined in section 17-1737-44.1. “Department” means the department of health, State of Hawaii. “Director” means the director of health. “Individual” means a person who receives any of the services defined in this chapter. “Intensive outpatient hospital services” means intensive outpatient hospital. services as defined in section 17-1737-44.1. “License” means a license issued by the State certifying the compliance with all existing state laws and rules relative to the operation of a facility or service. “Licensed clinical social worker” means a person who is a licensed clinical social worker pursuant to chapter 467E, HRS. “provider” means an agency certified under this chapter to provide mental health rehabilitation services. “Qualified mental health professional” or “QMHP” means: (1) A psychiatrist licensed to practice medicine in the State of Hawaii in accordance with chapter 453, HRS, and who is certified or is eligible to be certified in

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psychiatry by the American Board of Psychiatry or Neurology; (2) A psychologist licensed in accordance with chapter 465, HRS; (3) A licensed clinical social worker in behavioral health or licensed in accordance with chapter 467E, HRS; (4) An advanced practice registered nurse (APRN) in behavioral health licensed in accordance with chapter 457, HRS and qualified as provided under section 17-1737- 12 (3) (5) Any other person as determined by the department of human services. “State” means the State of Hawaii. “Therapeutic living supports services” means therapeutic living supports s ices as defined in section 17-1737-44.1. [Eff Aug 06 2005] (Auth: HRS § 321-1, 334- 9; 42 C.F.R. § 431.10) (Imp: HRS §§ 321-1, 334-9)

SUBCHAPTER 2

PROVIDER CERTIFICATION PROCESS

§11-172-03 Certification required. Each applicant who seeks to one or more of the following services: assertive community treatment services; biopsychosocial rehabilitation services; crisis management services; crisis residential services; intensive outpatient hospital services; or therapeutic living support services (hereinafter community mental health rehabilitation services or “CMHRS”) shall obtain certification pursuant to this chapter. [Eff Aug 06 2005] (Auth: HRS § 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1,334-9)

§11-172-04 Filing of a provider application. Each applicant seeking initial certification or provider seeking re-certification under this chapter shall file an application with the department. The application shall be filed on the form prescribed and furnished by the department. The department shall not accept for filing any application that is not submitted on the correct form. [Eff AUG 06 2005] (Auth: HRS § 321-1, 334-9; 42 C.F.R. § 431.10)(Imp: HRS § 321-1, 334-9)

§11-172-05 Application forms. The application form prescribed by the department may vary according to the type of service being proposed in the application. The department may revise or amend the application forms from

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time to time. An application form may require the applicant to provide any information that is reasonably necessary for an informed review of the application, and the applicant shall provide the information in the form and manner that the department may prescribe. The department may require the applicant to provide supporting document, information submitted in the application. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-06 Number of copies filed. Unless the department directs otherwise, the applicant shall file with the department the original and one copy of the application and supporting documentation. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-07 When to file an application: new provider. An applicant who is not yet certified by the department may file an application at any time, or as directed by the department. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-08 When to file an application: existing provider. A provider who is already certified by the department, and who is seeking renewal of a certificate, shall file an application at least ninety days prior to the expiration of its existing certificate. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-09 Complete application required. The department requires a complete application for review. The filing of an application with the department does not by itself mean that the application is complete. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-10 Determination of completeness (a) An application is complete when the department determines that the application is properly filled out and includes all necessary information. (b) The department shall determine if the application is complete within ten business days after the application is filed. If the application is incomplete, the department shall notify the applicant of the actions or additional information required to complete the application. The

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applicant shall have thirty calendar days in which to complete the application. Thirty days shall be computed from the date when the department provides notification to the applicant. (c) If the applicant fails to complete the application within the thirty days, the department shall dismiss the application without prejudice. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-l1 Notification of completeness. When the department determines that the application is complete, it shall provide written notification to the applicant of the beginning of the review period. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-12 Review period. To the extent practicable, the period for department review of the application shall not exceed ninety calendar days from the date of notification of completeness to the date when the department issues its decision on the application. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-13 Service standards. The applicant shall submit documentation demonstrating that it complies with the department service standards established in the application form. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-14 On-site survey. The department may conduct an on-site survey of an applicant for initial certification or renewal of certification. The applicant shall provide access to all records necessary to verify compliance with certification standards, and the department may conduct interviews with staff and any other individual with the applicant’s permission. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-15. Decision on a certificate application. (a) Unless the application for a certificate has been withdrawn or dismissed, the department shall make its decision on the application within the required time. The decision may be: (1) An approval; (2) A disapproval; or

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(3) A determination of noncompliance pursuant to Section 11-172-16. (b) On the date that the department makes its decision,, it shall send the decision to the applicant by certified mail, return receipt requested, and delivered’ to addressee only. (c) If the department approves the certificate application the form of the certificate may be in the form of a letter of approval, and shall include the effective dates of the certificate. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-16 Failure to act within the required time. A certificate shall not be issued or denied solely because the department failed to issue a decision within the required time. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-17 Determination of noncompliance. If the department determines that an existing provider applying for re-certification fails to comply with the certification requirements, it may, within thirty days after the conclusion of the on-site survey, provide a written statement of non-compliance. The statement of non compliance shall describe the areas of non-compliance, suggest action needed to bring the applicant’s operation into compliance with the requirements of this chapter, and set forth a timetable for the applicant to submit a written plan of correction. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-18 Plan of correction. The applicant shall submit a written plan of correction which shall describe the actions to be taken and specify a timetable for correcting the areas of non-compliance with the certification requirements. The applicant shall submit the written plan to the department within thirty days after receipt of the written statement of non-compliance from the department. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-19 Acceptance of plan of correction. The department shall notify the applicant or provider if the plan of correction is acceptable within thirty days after receipt of the plan of correction. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

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§11-172-20 Granting or continuation of certificate following implementation of plan of correction The department may grant or continue a certificate after it verifies that the app1ican has complied with its written plan of correction and meets all the certification requirements. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-21 Denial of certificate. The department may deny any application for initial certification or re certification for any of the following reasons: (1) The applicant or provider is not licensed to do business in the State of Hawaii; (2) The applicant or provider does not meet the service-specific standards detailed in the application form and instructions; (3) Previous felonies committed by any of the applicant’s or provider’s management personnel; (4) Previous revocation of medicaid or medicare certification or professional license of the applicant, provider, or their respective staff; (5) The applicant or provider lacks sufficient organizational and fiscal infrastructure; (6) The applicant or provider has received a written statement of non-compliance pursuant to section 11-172-16 and has failed to submit a written plan of correction within the time specified in section 11-172-17; (7) The provider is in violation of the terms of the AMHD contract and has not corrected the violation within the time specified by AMHD; or (8) The applicant or provider has been terminated as an AMHD provider. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§l1-172-22 Appeal of denial. Any applicant or provider denied certification under this chapter may appeal to the Adult Mental Health Division in accordance with its policies and procedures. If not satisfied with the final Adult Mental Health Division decision, the applicant or provider may appeal in writing to the director pursuant to the department’s rules of practice and procedure. If no request for an appeal is received by the director within forty-five days of the mailing of the written decision to the respondent the decision shall become final. [Eff AUG 06 2005] (Auth: HRS §§ 321-196) (Imp: HRS § 321-193)

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§11-172-23 Term of certification. Certification shall be granted for a period of time to be determined by the department, but not to exceed three years from the date of the department’s decision under section 11-172-14, subject to the applicant or provider’s continuous compliance with certification requirements. Certification shall remain in effect unless it expires, or is renewed or revoked. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-24 Unannounced on-site surveys. The department may conduct on-site surveys of an applicant or provider at any time without prior notice. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-25 Certificate not transferable. A certificate shall be issued only to the applicant named in the application. The certificate may not be sold, assigned, leased, donated, or otherwise transferred to any other applicant or provider. [Eff AUG 06 2005] (Auth: HRS §§ 321- 1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-26 Notification of changes by provider. The provider shall notify the department immediately of any changes in its operation that affect the provider’s continued compliance with these requirements, including changes in ownership, control, service, affiliation, or referral arrangements. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-27 Revocation of certificate. The department may revoke a certificate at any time if it determines that the provider has failed to comply with any certification requirement. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-28 Appeal of revocation. Any provider whose certificate is revoked under this chapter may appeal in accordance with Adult Mental Health Division policies and procedures. If the provider is not satisfied with the final decision of the Adult Mental Health Division, the provider may appeal the decision in writing to the director pursuant to the department of health’s rules of practice and procedure. If no request for an appeal is received by the director within forty— five days of the mailing of the

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written decision to the respondent the decision shall become final. [Eff AUG 06 2005] (Auth: HRS §§ 321-196) (Imp: HRS § 321-193)

§11-172-29 Termination of certification. Certification shall be considered terminated and invalid after its expiration date if the provider fails to apply for renewal of certification prior to the expiration. date of the certificate, voluntarily relinquishes certification or goes out of business. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

SUBCHAPTER 3

REIMBURSEMENT OF PROVIDERS

§11-172-30. Contract for services. The department may enter into contracts with providers certified under this chapter. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-31 Reimbursement for providers. Providers submitting claims for medical assistance reimbursement shall be reimbursed for services as provided in section 17- 1737-44.1(f). Providers shall submit their claims to the department. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-32 Medical assistance reimbursement. Medical assistance reimbursement to providers shall only be made for individuals eligible for medical assistance and who are medically determined to need community mental health rehabilitation services. These services must be recommended by a physician or other licensed practitioner to promote the maximum reduction or restoration, or both, of an individual to the individual’s best possible functional level relevant to the individual’s diagnosis of mental illness, or mental illness and abuse of drugs or alcohol. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-33 Utilization management information and data. Providers shall submit information and data regarding appropriateness of CMHRS provided, lengths of stay, and quality of CMHRS provided to the department. Upon request, the applicant or provider shall deliver to the department the requested information. The department shall develop and

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give to the applicant or provider forms for providing this information, and shall review the information to determine compliance with department policies and requirements. The department may establish policies and procedures for conducting reviews under this section. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

SUBCHAPTER 4

MISCELLANEOUS PROVISIONS

§11-172-34 Free choice of provider. All individuals receiving mental health rehabilitation services under this chapter shall be entitled to choose their providers, subject to availability, from among those certified under this chapter. [Eff AUG 06 2005] (Auth: HRS §§ 321-1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

§11-172-35 Severability. If any provision of this chapter or application thereof to any agency or circumstance is held invalid, the application of the remainder of the chapter to other agencies or circumstances shall not be affected. [Eff AUG 06 2005] (Auth: HRS §§ 321- 1, 334-9; 42 C.F.R. § 431.10) (Imp: HRS § 321-1, 334-9)

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DEPARTMENT OF HEALTH

Chapter 11-172, Hawaii Administrative rules, on the Summary Page dated JUL 7, 2005, was adopted on JUL 7 2005, following a public hearing held on February 17, 2005, after public notice was given in the Honolulu Star Bulletin on January 9, 2005.

The adoption of chapter 11-172 shall take effect ten days after filing with the Office of the Lieutenant Governor. Signed by Chiyome L. Fukino, Director Department of Health

APPROVED: Signed by Linda Lingle Governor State of Hawaii Dated: JUL 26 2005 APPROVED AS TO FORM:

Signed by Deputy Attorney General

_________________________ Filed

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