FFPOLICY AND PROCEDURE

POLICY STATEMENT:

The policy provides an overview of Buckeye’s utilization management approach for Peer Support Services.

PURPOSE:

This policy addresses the claim payment, eligibility, documentation and other requirements related to peer support for adults.

Peer support is an adjunct support rendered to an individual with a mental health disorder, substance use disorder, or co-occurring disorders. Peer support is not clinical care, rather it is support to and an adjunct to actual clinical care. The primary service for members with a behavioral health disorder must be clinical behavioral health treatment necessary to treat the member’s clinical diagnosis.

Peer support must be medically necessary and comply with Ohio Administrative Code (OAC) 5122-29-15 and Ohio Department of Medicaid (ODM) regulations. OAC and ODM regulations establish peer support requirements including what constitutes peer support, peer support specialist qualifications, supervision requirements, peer support training requirements, and medical record documentation requirements, among other requirements.

SCOPE:

This policy applies to all directors, officers, employees of Buckeye Health Plan, and external providers.

DEFINITIONS:

For the purposes of this policy, the following definitions apply:

(1) “Recovery” means the personal process of change in which an individual strives to improve their health and wellness, resiliency, and reach their full potential through self-directed actions.

(2) “Resiliency” means the ability to recover from setbacks, adapt well to change, and keep going in the face of adversity. It is the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress such as family and relationship problems, serious health problems, or workplace and financial stressors.

(3) “Wellness ” means a broad approach for things individuals can do at their own pace, in their own time, and within their own abilities, that can help them feel better and live longer.

POLICY:

Background:

Peer support services are services for individuals with a mental illness, intellectual or developmental disabilities, or substance use disorders and their caregivers and families.

Peer support services consist of activities that promote resiliency and recovery, self-determination, advocacy, well-being, and skill development. Peer support services are individualized, resiliency and recovery focused, and based on increasing knowledge and skills through a peer relationship that supports an individual’s or family’s ability to address needs, navigate systems and promote recovery, resiliency, and wellness. They promote family driven, youth guided, trauma informed care and cultural humility, encourage partnership with individuals and families, and advocate for informed choice.

Peer support services may include, but are not limited to:

(1) Ongoing exploration of recovery, resiliency, and wellness needs;

(2) Supporting individuals and their caregivers and families in achieving goals through increased knowledge, skills and connection as identified by the individual or family;

(3) Encouraging hope;

(4) Supporting the development of life skills;

(5) Developing and working toward achievement of individualized recovery, resiliency, and wellness goals;

(6) Modeling personal responsibility for resiliency, recovery and wellness;

(7) Teaching and coaching skills to effectively navigate systems to effectively and efficiently utilize services;

(8) Addressing skills or behaviors, through processes that assist an individual, caregiver, or family in eliminating barriers to achieving or maintaining recovery, resiliency, and wellness;

(9) Assisting with accessing and developing natural support systems;

(10) Promoting coordination and linkage among providers;

(11) Coordinating or assisting in crisis interventions and stabilization;

(12) Conducting outreach and community education;

(13) Attending and participating in team decision making or specific treatment team; or,

(14) Assisting individuals, caregivers, or families in the development of empowerment skills through advocacy and activities that mitigate discrimination and inspire hope.

Services should be provided in a culturally inclusive and competent manner which includes not practicing, condoning, facilitating, or collaborating in any form of discrimination based on ethnicity, race, gender, sexual orientation, age, religion, national origin, marital status, political belief, or mental or physical disability.

Peer support services are not site specific but shall be provided in locations that meet the needs of the individual, caregiver, or families.

Peer support services may be facilitated to individuals, families, or groups.

Peer support services shall be provided a person certified in accordance with in rule 5122-29-15.1 of the Administrative Code.

Peer support services providers shall report for any certified peer supporter employed by or volunteering with the provider to the Ohio department of mental health and addiction services any events that would disqualify the certified peer supporter pursuant to rule 5122-29-15.1 of the Administrative Code.

Rendering and Supervising Requirements OAC 5122.29.15.1:

Rendering

Certified peer recovery supporter:

(1) A “certified peer recovery supporter” (CPRS) is an individual, with direct lived experience, who has self-identified as being in recovery from a mental health or substance use disorder and has been certified pursuant to this rule.

(2) For CPRS certification the individual will be at least eighteen years of age at the time of certification.

Certified youth peer supporter:

(1) A certified youth peer supporter (CYPS) is an individual who self-identifies as having lived experience with the behavioral health care system and other child or youth serving systems and has been certified by the state pursuant to this rule.

(2) For CYPS the individual will be at least eighteen years of age but no older than thirty years of age at the time of certification.

Certified family peer supporter:

(1) A certified family peer supporter (CFPS) is an individual who has self-identified as the caregiver of a person with behavioral health challenges who has successfully navigated service systems for at least one year on behalf of the person and has been certified pursuant to this rule.

(2) For CFPS certification the individual will be at least twenty-one years of age at the time of certification.

Supervising

Certified peer supporters will be supervised by an individual who either:

(1) Has experience delivering peer services in behavioral health over a cumulative period of two years, has completed the sixteen hours of online learning administered or designated by the department, and has completed the four-hour supervising peers training administered or designated by the department; or,

(2) Is a clinician with one of the following licenses, and has completed the sixteen hours of online learning administered or designated by the department and has completed the four-hour supervising peers training administered or designated by the department:

(a) Licensed social worker;

(b) Licensed independent social worker;

(c) Licensed professional counselor;

(d) Licensed chemical dependency counselor II;

(e) Licensed chemical dependency counselor III;

(f) Licensed professional clinical counselor;

(g) Licensed independent chemical dependency counselor;

(h) Licensed marriage and family therapist;

(i) Licensed independent marriage and family therapist;

(j) Psychologist; or,

(k) Psychiatrist.

PROCEDURE:

1. Peer support should be supplemental to actual clinical services and should not be used to replace clinically based programming, i.e. outpatient psychotherapy, intensive outpatient program (IOP), partial hospitalization, or residential treatment.

2. Peer support should be individualized and member-centric to meet the member’s needs as specified in the member’s plan of care.

3. Members receiving peer support should meet the requirements of ASAM Adult Level 1 Outpatient Criteria if for a member with a substance use disorder (SUD), InterQual Outpatient Criteria for a member with a mental health disorder, or OAC requirements for services.

4. Components of peer support must include:

a. Social and emotional support provided by persons having a mental health, substance use or co-occurring disorder to others with a similar disorder, in order to bring about a desired social or personal change.

b. Common activities:

i. Promote self advocacy and empowerment;

ii. Connecting people to resources and work;

iii. Goal Setting;

iv. Outreach and engagement to treatment;

v. Recovery coaching; and

c. Support is structured and scheduled, non-clinical but involves therapeutic activities that promote socialization, recovery, self-advocacy, preservation and enhancement of community.

5. The amount of peer support provided should decrease over time as a treatment goal is for the member to demonstrates self-management skills.

6. Peer support should not exceed 24 units (6 hours) per member per week and extend beyond 26 weeks per member per calendar year.

a. Services delivered above these limits are subject to utilization review and require a prior authorization.

7. If a provider submits a claim for peer support that exceeds either amount referenced above (6 hours per week for a member or 26 weeks per calendar year for a member):

a. Buckeye will deny the claim; and

b. The provider must:

i. Submit medical records in accordance with Buckeye’s prior authorization process to demonstrate that additional peer support is medically necessary and appropriate based on the member’s diagnosis; and

ii. Submit documentation such as the member’s plan of care and progress notes to demonstrate that the additional amount complies with plan of care and health record regulatory requirements established in OAC 5122-29-15.

8. A claim for peer support that exceeds 6 hours per week for a member or 26 weeks per calendar year for a member must:

a. Clearly indicate why additional peer support are medically necessary to enable the member to achieve the specific goals specified in the member’s plan of care;

b. Clearly indicate how the additional peer support will directly contribute to the Member achieving the goals specified in the member’s plan of care; and

c. Clearly indicate why peer support rather than other services are medically necessary to enable the member to achieve the specific goals specified in the member’s plan of care.

9. If the provider does not submit medical records and documentation requested within 30 days of the request, the claim will remain denied.

10. If the provider submits medical records and documentation within 30 days of the request, and the medical records demonstrate that the additional peer support was medically necessary and appropriate based on the member’s diagnosis and meets the regulatory requirements, Buckeye will adjust the claim for payment (provided that CMS, NCCI, and other standing coding guidelines are met).

11. If the provider submits medical records and documentation that do not demonstrate that additional peer support was medically necessary and appropriate based on the member’s diagnosis or does not demonstrate that regulatory requirements were met, the claim will remain denied.

Coding Implications

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.