Reimbursement/Disbursement

It is not the Department's practice, or within its ability, to authorize or encourage the delivery of services beyond what the amount of funding contained in the contract can support. Therefore, if services are reported as contract services (using DARTS code DC) at anytime during the fiscal year, they are considered paid for by the amount of funding contained in the contract. Services that you do not want considered in this manner SHOULD NOT BE REPORTED TO DARTS. Providers are cautioned against the delivery of unfunded services as this practice may severely affect the delivery of quality clinical care and the organization's fiscal solvency.

Group Counseling

Level I and II services delivered as group counseling shall be reimbursed only for 16 patients per counseling group supported by Department funding (Medicaid or Contract).

Billings Linked to Level of Care

Billings should match the Level of Care for the patient. Outpatient care (Level I or II) cannot be billed on the same day as Residential care (Level III). Case management, psychiatric evaluation and medication monitoring may be billed on the same day for any patient in any Level of Care in accordance with stated contract conditions, eligibility, limits, or exceptions.

  • Level III Care - Patient Day - No more than one patient day shall be reimbursed for any recipient in a 24-hour period.
  • Day of Discharge or Transfer - Level III - Billing for the day of discharge or transfer is allowable if services are delivered on that day. However, in accordance with the billing provisions specified above, only services in one Level of Care may be billed per patient per day. For any patient transferred to another level of care within the same organization, only one type of billing for services rendered that day will be allowed. Additionally, when this occurs within the same organization, the Level of Care in which the patient spent the majority of time on the day of discharge should be billed. (A patient's day begins at 6:00 a.m. and continues for 24 hours.) Similarly, when a patient is discharged by one organization and transferred, via linkage agreement, to another organization for the same or a different level of care, only one organization may bill Medical Benefits, All Kids and Family Care for service delivered on that day, if applicable. However, if Medical Benefits, All Kids and Family Care were not billed, the referring and receiving organizations may both bill contract for any services rendered on the day of discharge.

Psychiatric Evaluation

Such services are limited to the provision of a psychiatric evaluation to determine whether the patient's primary condition is attributable to the effects of alcohol or drugs or to a diagnosed psychiatric or psychological disorder. Reimbursable psychiatric evaluations may be delivered to treatment patients where need for such service is documented in the patient's individualized treatment plan. Psychiatric evaluation shall be reimbursed at the established rate on a per encounter basis (one per day) to the psychiatrist.

Medication Monitoring

Medication monitoring, using the agency's physician, must be billed at the individual counseling rate for treatment patients. Psychotropic medication monitoring includes a review of the efficacy, dosage and side effects of any psychotropic medication used by the patient. This type of medication monitoring shall also be conducted by the agency's physician or psychiatrist and billed at the individual counseling rate.

Co-dependence/Collaterals

A co-dependent is a family member or significant other of an individual with an addiction related problem. DASA funding can be used for assessment of these individuals and alsofor Level I services if the assessment resulted in a diagnosis of co-dependent (DSM IV -V61.9).

A collateral is an individual who receives minimal service as a result of participation in someone else's addiction related treatment. These services are reported and billed as a treatment service for the patient. If a collateral is seen alone, it should be billed as an individual session. If any combination of patients and/or collaterals are seen together,each participant should be billed separately under the patient's unique identification number at the group rate. As a guideline, such service should average one contact per week. If need is demonstrated to exceed this average, these types of individuals should be treated as co-dependents.

CASE MANAGEMENT

Case Management is the delivery of services to patients in treatment that are designed to help them handle aspects of their lives that are not necessarily related to an addiction disorder but that might impact whether the patient remains in treatment or has successful treatment outcomes. Some examples of case management services are:

  • assistance with health needs 
  • assistance with transportation but not actual transportation of clients
  • assistance with child care
  • assistance with family situations, living conditions, school or work situations

Case management services are individualized for patients in treatment. They reflect particular needs identified in the assessment process and those developed within the treatment plan. Case management that meets the following criteria and is specified below as an eligible service can be reimbursed for a patient in any level of care:

  • The service is based upon an identified need, has an identified expected outcome documented in the assessment or the treatment plan.
  • The services are documented and integrated in the progress notes. Documentation must show date, time and duration and include a brief description of the service provided. The note must be signed by the person providing the service.
  • Another funding mechanism or funder is not paying for the case management service.

Examples of Case Management Activities

  • Inter/intra provider record review.
  • Internal and/or external multi-disciplinary clinical staffing.
  • Telephone calls, letters and other attempts to engage family members or significant others in the patient's treatment.
  • Telephone calls, letters, home visits to patients to keep them engaged in treatment.
  • Assistance with budgeting, meal planning and housekeeping.
  • Letters, telephone calls, meetings with employers on behalf of a patient.
  • Assist patients and their families in obtaining Medicaid, Social Security, cash grants, WIC, Link Cards and other entitlements that they may need.
  • Assist patients and their families in obtaining medical, dental, mental health, educational, recreational, vocational and social services as specified in the treatmentplan.

EARLY INTERVENTION

Early Intervention is the ASAM Level of Care 0.5 and is an organized service delivered in a wide variety of settings for individuals who sub-clinical or pre-treatment services for individuals who have at least one risk area related to primary use and/or possession of alcohol or drugs but do not have a diagnosis of abuse or dependence. Examples of risk areas are as follows:

  • Repeated absences, suspensions or terminations from work or school environments
  • Gang involvement
  • Criminal Justice Involvement
  • Absence from family or home, homelessness, or for youth, running away or placement in alternative living environments or schools
  • Abuse of or addiction to alcohol or drugs by a family member or significant other
  • Extreme or prolonged exposure to severe stressor, e.g., loss of home through flood or fire, death of significant other

Early Intervention services can be provided in an individual or group setting but must be documented in a client record by time, date and duration.

COMMUNITY INTERVENTION

Community Intervention is service that occurs within the community rather than in a treatment setting. These services focus on the community and its residents and include crisis intervention, case finding to identify individuals in need of service including in-reach and outreach to targeted populations or individuals not admitted to treatment. Outreach is the encouragement, engagement or re-engagement of at risk individual(s) into treatment through community institutions such as churches, schools and medical facilities (as defined by the community) or through Illinois Department of Human Services consultation. In-reach is the education of community institutions or state agencies and social service sstaff regarding the screening and referral of at risk individuals to treatment programs forthe purpose of a clinical assessment.

Anticipated outcomes of community intervention include an increased awareness,"community ownership" and connectedness between the service system and community institutions. Service visibility will increase. Access to services will increase for all populations but particularly for those earlier in their "problem use" as the general public becomes more aware of alcohol and drug use symptoms and treatment resources. Examples of community intervention activities are as follows:

  • Crisis Intervention consisting of brief contacts to determine appropriate interventions and/or services
  • In-reach activities such as meetings with local DHS or DCFS office staff to discuss screenings and referrals
  • Outreach activities designed to educate community stake holders and increase referrals for treatment
  • Consultations with referral sources
  • Training, if specific funding for participation in or the delivery of this type of activityis contained within the contract
  • Client/Patient Transportation for case management or treatment activity identified through assessment or in the treatment plan.

Billing Methadone Patients

All Methadone patients must have an open demographic record in DARTS. Billable services are then calculated in DARTS based upon submissions to the Pharmacy Log. If the patient does not have an open demographic record in DARTS, services will not calculate.

Methadone services are covered by the case rate which pays weekly as specified in the contract. The case rate pays for dispensing, at least one individual counseling session per month, toxicology and medical services as well as any other service required by State and Federal regulations. Assessment and medication monitoring can be billed in addition to the case rate.

Providers cannot bill additional Level I services to a Methadone patient using DASA contract funds, regardless of where the patient is receiving Methadone.

If a patient on Methadone requires Level II or III care, the provider of that service can bill and receive reimbursement even if they or another provider is receiving the case rate for outpatient Methadone services. In these instances, the Methadone specific services that are considered part of the case rate must be delivered in addition to the Level II and III care. Any provider who has Medicaid certification for Level I care may also provide additional clinically appropriate individual and group counseling for a Methadone patient who is Medicaid eligible.