Section 2090.40   Reimbursable Services

a)         Level I:  (formerly Outpatient Services)

1)         Definition

The provision of treatment services as defined in 77 Ill. Adm. Code 2060.401(b).

2)         Reimbursement

Level I treatment services delivered to clients are Medicaid-reimbursable via the prospective rates in effect as of the date of service (89 Ill. Adm. Code 148.370).  Medicaid claims are submitted to the Department and shall meet the requirements of IDPA rules for alcoholism and substance abuse treatment programs (89 Ill. Adm. Code 148.340 through 148.370). The billable unit of service is a client hour defined as face-to-face counseling with a diagnosed client in an individual or group setting.  Reimbursement shall occur by a fee-for-service mechanism, using one client hour as the base unit of service, billable to the nearest quarter-hour.  No more than 25 hours may be reimbursed for an eligible adult client per benefit year.

b)         Level II:  (formerly Intensive Outpatient Services)

1)         Definition

The provision of treatment services as defined in 77 Ill. Adm. Code 2060.401(c).

2)         Reimbursement

Level II treatment services delivered to clients are Medicaid reimbursable via the prospective rates in effect as of the date of service (89 Ill. Adm. Code 148.370).   Medicaid claims are submitted to the Department, and shall meet the requirements of IDPA rules for alcoholism and substance abuse programs (89 Ill. Adm. Code 148.340 through 148.370).  The billable unit of service is a client hour defined as face-to-face counseling with a diagnosed client in an individual or group setting.  Reimbursement shall occur by a fee-for-service mechanism, using one client hour as the base unit of service billable to the nearest quarter-hour.    No more than 75 hours shall be reimbursed for an eligible adult client per benefit year.

c)         Level III:  (formerly Inpatient/Residential Services)

1)         Definition-Adolescent Residential Rehabilitation

The provision of treatment services as defined in 77 Ill. Adm. Code 2060.401(d).  Such treatment shall be for adolescents on a scheduled-only residential basis in a Medicaid enrolled hospital subacute setting, or to adolescents in a psychiatric facility or an inpatient program in a psychiatric facility, either of which is accredited by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181.

Adolescent residential rehabilitation must be delivered in accordance with an adolescent's individualized treatment plan recommended by a physician if in a hospital setting, and under the direction of a physician if in a psychiatric facility.

2)         Reimbursement

Adolescent residential rehabilitation treatment services delivered to clients are medicaid reimbursable via the prospective rates in effect as of the date of service (89 Ill. Adm. Code 148.370).  Medicaid claims are submitted to the Department and shall meet the requirements of IDPA rules for alcoholism and substance abuse treatment programs (89 Ill. Adm. Code 148.340 through 148.370). Reimbursement shall occur on a per diem basis.  Through June 30, 2003, no more than 120 days shall be reimbursed for an eligible client per benefit year.

3)         Definition-Day Treatment

The provision of treatment services as defined in 77 Ill. Adm. Code 2060.401(d).  The treatment shall be on a scheduled-only residential basis by a program licensed pursuant to 77 Ill. Adm. Code 2060 and certified as having 16 beds or fewer as specified in Section 2090.30 of this Part and excluding room and board, meals, night supervision of dormitory areas and other domiciliary support services.   Treatment services may be provided to adults and adolescents.

4)         Reimbursement

Day treatment services delivered to clients are Medicaid reimbursable via the prospective rates in effect as of the date of service (89 Ill. Adm. Code 148.370).  Day treatment services shall be reimbursed at a per diem rate.  No more than 30 days shall be reimbursed for an eligible adult client per benefit year.

5)         Definition - Medically Monitored Detoxification

The provision of detoxification services as defined in 77 Ill. Adm. Code 2060.405(a).  Such services shall occur in a Medicaid enrolled hospital subacute setting or in a residential program licensed pursuant to 77 Ill. Adm. Code 2060 and certified as having 16 beds or fewer as specified in Section 2090.30 of this Part, excluding room and board, meals, night supervision of dormitory areas and other domiciliary services.  The treatment shall be for individuals 18 years or older (individuals who are 17 years old may be included provided that their assessment includes justification based on behavior and life experience).

6)         Reimbursement

Medically monitored detoxification services delivered to clients are Medicaid reimbursable via the prospective rates in effect as of the date of service (89 Ill. Adm. Code 148.370).  Medicaid claims are submitted to the Department and shall meet the requirements of IDPA rules for alcoholism and substance abuse treatment programs (89 Ill. Adm. Code 148.340 through 148.370). Medically monitored detoxification shall be reimbursed at a per diem rate.  No more than nine days shall be reimbursed for each eligible adult patient per benefit year.

d)         Ancillary Psychiatric Diagnostic Services

1)         Ancillary psychiatric diagnostic services are limited psychiatric evaluations to determine whether the client's primary condition is attributable to the effects of alcohol or drugs or to a diagnosed psychiatric or psychological disorder.  Such an evaluation shall determine the client's primary condition and recommend appropriate treatment services.

2)         Reimbursable psychiatric evaluations are limited to a psychiatric evaluation/examination of a client and the exchange of information with the primary physician and other informants such as nurses, counseling staff, or family members and the preparation of a report including psychiatric history, mental status, and diagnosis.  This service shall be performed by a psychiatrist.

3)         Reimbursable psychiatric evaluations may be delivered to clients where the need for such services is documented in the client's individualized treatment plan.  Documentation of all such services shall be maintained in the client record.

4)         Ancillary diagnostic services delivered to clients are Medicaid-reimbursable on a per-encounter basis at the practitioner's usual and customary charge, not to exceed the prevailing rate as established by IDPA pursuant to 89 Ill. Adm. Code 140.400.

(Source:  Amended at 26 Ill. Reg. 12631, effective August 1, 2002)