Section 405IAC5-21.6-6. Clinical documentation requirements

   (a) To be reimbursable under this rule, the AMHH service must be supported by clinical documentation that is maintained in the member's clinical record.

  (b) The documentation required to support billing for an AMHH services must meet the following standards:

(1) Focus on recovery and habilitation.

(2) Emphasize member strengths.

(3) Reflect progress toward the habilitation goals reflected in the member's IICP.

(4) Be updated with every member encounter when billing is submitted for reimbursement.

(5) Be written and signed by the agency staff rendering services.

  (c) For a member participating in any AMHH service, the clinical documentation must contain the following information:

(1) The type of service being provided.

(2) The names and qualifications of the staff providing the service.

(3) The location or setting where the service was provided.

(4) The focus of the session or service delivered to or on behalf of the member.

(5) The member's symptoms, needs, goals, or issues addressed during the session.

(6) The duration of the service (actual time spent).

(7) Start and end time of the service.

(8) The member's IICP goal or goals being addressed during the session.

(9) The progress made toward meeting habilitation goals noted on the IICP.

(10) The date of service rendered, including month, day, and year.

  (d) The content of the documentation must support the amount of time billed.

  (e) For members participating in AMHH services in a group setting, documentation must be provided for each encounter and must include the following:

(1) The focus of the group or session.

(2) The member's level of activity in the group session.

(3) How the service:

(A) benefits the member; and

(B) assists the member in reaching the member's habilitation goals.

  (f) For AMHH services provided on behalf of the member without the member present, documentation must be provided for each encounter and must include the following information:

(1) The name or names of the person or persons attending the session and each person's relationship to the member.

(2) How the service:

(A) benefits the member; and

(B) assists the member in reaching the member's habilitation goals.

  (g) In addition to the requirements listed in this section, specific requirements for selected service types may be required and are reflected in other sections of this rule. (Office of the Secretary of Family and Social Services; 405 IAC 5-21.6-6; filed Dec 16, 2013, 9:11 a.m.: 20140115-IR-405130183FRA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA)