Section 405IAC5-21.7-9. Coverage requirements and limits

   (a) In order for a service provider to be reimbursed for providing a CMHW service to an eligible member, the service must be provided in the manner established by this section.

  (b) In order to be eligible for reimbursement, a covered CMHW service shall meet the following criteria:

(1) Be documented on the member's office-approved plan of care.

(2) Be supported by the member's level of need, as documented in the most recent assessment of the member.

(3) Be provided by an office-certified CMHW service provider meeting all required service-specific qualifications and standards.

(4) Be provided within the scope and limitations for the service as approved by the office.

  (c) A CMHW service shall be deemed noncovered and shall not be eligible for reimbursement if the service meets any of the following criteria:

(1) The service is provided to the member at the same time as another service that is the same in nature and scope, regardless of funding source, including federal, state, local, and private entities.

(2) The service is provided as a diversionary, leisurely, or recreational activity that is not a component of respite care service.

(3) The service is provided in a manner that is not within the scope or limitations of the CMHW service.

(4) The service is not documented as a covered or authorized service on the participant's office-approved plan of care.

(5) Provision of the service is not supported by the office-approved documentation standards in the member's clinical record.

(6) The service is provided by a service provider other than the service provider documented on the member's plan of care.

(7) The service provided exceeds the limits approved by the office, including the quantity, limit, duration, or frequency of the service.

(8) The service is listed in this rule as a noncovered service or is otherwise excluded from coverage.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-9; filed Dec 18, 2013, 11:13 a.m.: 20140115-IR-405130211FRA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA)