Section 132

Section 132.145 General Provisions

A provider shall comply with the following:

a) A provider shall, at a minimum, directly provide mental health assessment, ITP development, review, modification (see Section 132.148(c)) and at least one additional Part 132 mental health service. Directly provided means that the QMHP and LPHA who signed the mental health assessment and ITP are employed by or contractual employees of the provider. The public payer may waive the requirement of at least one additional Part 132 mental health service if it deems that such waiver increases the availability of mental health services to Medicaid-eligible clients.

b) A provider may subcontract for services authorized by this Part. All subcontractors must be certified to participate in the Illinois Medical Assistance program and enrolled as a provider with HFS. There shall be a written agreement between the provider and the subcontractor that defines their contractual agreement and assures the subcontractor's compliance with applicable service provisions of Subpart C. All subcontracts must be approved by and on file with the State agency and, when applicable, the public payer. For purposes of this subsection, a contractual employee or an individual on contract is not considered to be a subcontractor.

c) Unless specified otherwise, services under this Part shall be provided to clients with a diagnosis of mental illness as defined in Section 132.25 and whose level of role functioning, in the absence of treatment or medication, is impaired. The provision of mental health services is expected to result in an improvement or prevention of regression in the client's existing condition.

d) Consent

1) Prior to the initiation of mental health services, the provider shall obtain written or oral consent from the client and the client's parent or guardian, as applicable.

2) Consent must be given by the parent or guardian for a child under 12 years of age, except a child 12 through 17 years of age can consent to treatment for 5 outpatient sessions of no more than 45 minutes in duration.

3) If the client is determined to be in need of crisis intervention services, or if the assessment is court ordered for the client, consent is not required.

4) Legally competent adults who participate in treatment services are deemed to have consented.

5) Oral consent shall also be documented in the record.

e) An LPHA shall provide the clinical direction and recommend medically necessary services as documented by his or her dated signature on the mental health assessment and ITP. The public payer, or his or her designee, may provide additional clinical direction in determining whether services are medically necessary. If the public payer or its designee and the LPHA do not concur on medical necessity, an appeal may be initiated in writing or by phone in accordance with the Service Authorization Protocol located on the DHS website at http://www.dhs.state.il.us/page.aspx?item=33244.

f) When discharging a client from services, the provider shall ensure the continuity and coordination of services as provided in the client's ITP. The provider shall:

1) Communicate, consistent with the requirements of Section 132.142, relevant treatment and service information prior to or at the time that the client is transferred to a receiving program of the provider or is terminated from service and referred to a program operated by another service provider, if the client, or parent or guardian, as appropriate, provides written authorization; and

2) Document in the client's record the referrals to other human service providers and follow-up efforts to link the clients to services.

g) Services provided under this Part are subject to the provisions of an executed contract between the provider and the public payer. The public payer is not required to reimburse services under this Part not enumerated in the contract.

(Source: Amended at 32 Ill. Reg. 9981, effective July 1, 2008)