Illinois Department of Human Services
Division of Developmental Disabilities
This Information Bulletin provides guidance on the process for implementing, delivering and billing Behavior Intervention and Treatment (56U) for individuals enrolled in the Home and Community Based Support (HCBS) Waiver for Adults with Developmental Disabilities "Adult Waiver", Support Waiver for Children and Young Adults with Developmental Disabilities "Children's Support Waiver", Residential Waiver for Children and Young Adults with Developmental Disabilities "Children's Residential Waiver" and non-waiver funded services and supports.
Behavior Intervention and Treatment is used when an individual needs support in improving their daily lives, reaching goals important to them or support to change behaviors that are unsafe, undesirable, or unhealthy. This process should include the individual, guardian, if applicable, parent(s), Independent Service Coordinator, service providers including the individual's Direct Support Professional (DSP) and anyone else who the individual chooses to include. The goal of this service is to improve the individual's life, wellbeing, and satisfaction. Behavior intervention should be based on the individual's skills, talents and strengths and use positive interventions.
Process to Become a Provider:
To become an approved provider of 56U services, a provider must follow the instructions on the Division of Developmental Disabilities (DDD) website . Additionally, the provider must receive approval from the Division and become an enrolled Medicaid provider with the DDD through the IMPACT Provider Enrollment system prior to being able to provide or bill for Behavior Intervention and Treatment services. For questions about provider enrollment, please contact Janene VanBebber at Janene.email@example.com.
Developing a Behavior Support Plan (BSP):
All behaviors are a form of communication. Even behaviors which may be considered undesired are a form of communication. The 56U provider must try to understand what the behavior might be communicating prior to implementing a BSP
- BSP should be based on a functional assessment of the target behavior(s) of the individual. If interventions are used, they should be positive and start with the least restrictive measures possible. If an individual is prescribed psychotropic medication, a BSP may be required. For example, a BSP would not be required for a maintenance medication for a diagnosis that does not present any targeted behaviors in need of modification. This would usually be an individual who is considered in remission from a mental illness diagnosis with the use of psychotropic mediation. For individuals with mental illness diagnoses, who continue to have symptoms, a BSP is still required to assist with adaptive functioning.
- BSP that uses restrictive measures is also required to be approved by the provider's Human Rights Committee (HRC). BSPs with proactive strategies are only required to be reviewed by the Behavior Management Committees. All required documentation for a BSP is subject to review by the Division.
- The BSP should include a description of the individual the plan is supporting. The description should include the individual's likes and dislikes as well as what motivates the individual. Avoid using jargon, when possible, which could lead to confusion.
- The BSP should be explained to the individual in a way they understand.
- The 56U provider must have a conversation with the individual about the services in which they are involved, even when the individual has a guardian. The individual should be aware of the development of the plan and be an active participant in the process. They should be consulted when making changes to the plan.
- The individual's record should contain documentation of informed consent and the efforts made to inform and educate the individual on the contents of the BSP. This can be accomplished with a signature page in the BSP.
- Prior to developing a BSP, attempts should be made and documented to determine if a medical issue is causing a behavior that is unsafe, undesirable, or unhealthy. This can be accomplished with a statement in the BSP stating it was done.
- Common and serious side-effects of psychotropic medications should be documented in the BSP. Common and serious side-effects must also be explained to the individual and staff. It is the responsibility of the residential provider to facilitate the communication (verbal, written or otherwise) between the prescriber and the individual, staff and unpaid caregivers.
Environmental & Situational Assessment
- Behaviors can also be the result or reaction to the individual's environment, activities and/or events which precede the behavior. Some behaviors can have an antecedent which may occur for a longer than expected time prior to the target behavior occurring. It is important to collect and record environmental and situational data for a specified period-of-time preceding the occurrence of the target behavior(s). Environmental and situational data could include place, time, noises, smells, lighting conditions, activity of the individual, identification of other people in the area and what activities or actions were occurring preceding the target behavior. See if there is a pattern for antecedents which might trigger the target behavior.
- Target behaviors should be explained to the individual in a way he or she understands.
- Each target behavior must be objectively defined.
- The BSP should use concrete language so there is no ambiguity or confusion about the target behavior.
- Each target behavior should have a corresponding intervention.
- Proactive measures should be developed to aid in preventing psychiatric admissions if an individual has a history of requiring admission to psychiatric facilities.
- Interventions should be explained to the individuals in a way he or she understands.
- There should be clear instructions that use concrete language on how to implement interventions.
- Staff must be properly trained on all interventions specified in a BSP.
- Interventions should be strength based, positive and proactive.
- Intervention effectiveness should be evaluated at least on a quarterly basis or more frequently as needed.
- Intervention effectiveness should be determined by reviewing behavior data collection, interviews with staff and unpaid caregivers, and speaking with the individual.
- All restrictive interventions that are implemented at a DDD funded residential setting or DDD funded Community Day Services (CDS) site must be reviewed at the Human Rights Committee (HRC) annually.
- If the individual lives in a DDD-funded setting, progress must be documented in the Behavior Management Committee (BMC) notes for all interventions. The progress for restrictive interventions is required to be reported to the HRC.
- All providers implementing a BSP must collect data to support the use of any restrictive intervention. Best practices indicate that data collection should be in place to monitor any target behavior prior to implementing a BSP. Staff must be oriented and trained on data collection for the target behavior. During a BQM review, providers must be prepared to provide data for target behaviors.
- All staff who work with the individual must be trained on the individual's BSP. Providers should document when the training occurred. This training should occur at least annually or whenever there is a change to the BSP.
- The initial training of staff on an individual's BSP should occur in person by someone who knows the individual and is knowledgeable of the BSP.
Behavior Management Committee and Human Rights Committee:
- All BSPs that use restrictive measures while the individual is in a DDD-funded residential setting or a DDD funded CDS setting must be reviewed by the BMC and HRC at their respective sites.
- All BSPs with restrictive interventions must be reviewed by the HRC.
- All BSPs must be reviewed by the BMC.
- If a restrictive measure is implemented, the BSP must clearly document the target behavior that justifies the inclusion of the right's restriction. All restrictive measures should be balanced by positive procedures designed to build or teach skills to reduce the need for the restriction. Additionally, there must be a timeline and plan to minimize or fade the restriction as the target behavior is reduced.
- If an emergency rights restriction must be implemented for the safety of the individual, this must be documented in the HRC notes as well as in the provider's behavior notes. Emergency rights restrictions include but are not limited to:
- Locks on refrigerators
- Locks on cabinets
- Restricting access to food
- Restricting unsupervised access to the internet
- Psychotropic medications are considered a rights restriction and should be documented in the BSP if a BSP is required.
During the initial months of developing a BSP, billable time may be spent completing direct observations and engagement with the individual, as well as indirect services such as: writing the BSP, researching appropriate interventions and training staff. All 56U providers should meet in person with the individual on a regular basis determined by the individual's needs. If this is not possible, providers should document the barriers to in-person meetings.
When possible, 56U providers should work in conjunction with the prescribing provider for individuals who take psychotropic medication. Demonstrating frequency and intensity of maladaptive behaviors is very important when assessing the efficacy of psychotropic medications. Data collection should be provided to the prescribing provider as needed.
Coupling 56U services with counseling or therapy is often beneficial and may be more effective than behavioral analytic services alone. Where appropriate, individuals should be offered counseling, therapy and/or provided resources for services. This can be done through community providers or through the Waiver. For more information on Counseling and Psychotherapy Waiver Services, please see the Waiver Manual. Coordinating and securing these services is the responsibility of the residential provider.
Direct service is defined by the provider working in-person with the individual.
Indirect service is defined by activities the provider does to benefit the individual that do not involve the provider specifically interacting with the individual. Indirect services that are billable may include writing BSPs, researching interventions, consulting with school staff, training the day program and residential staff who provide services for the individual, engaging in data collection, data analysis, data reporting, and participating in team meetings that relate to the individual. Indirect services may be billed while an individual is at a CDS.
Each billable event requires a clinical narrative documenting the specific therapy service provided as well as the specific date, start and stop time the service was rendered. The 56U provider must maintain documentation that reflects a brief description of the session's focus and periodic reviews of progress towards established treatment goals.
Billable time includes direct and indirect service. In all cases, the service must be provided by an appropriately credentialed person who is an approved Medicaid provider enrolled with DDD and the IMPACT system to provide the service.
A behavior consultant can bill for services when supervising someone who is in training to become a behavior consultant as long as the behavior consultant is present and participating in the treatment session. The trainee's time is not billable.
Behavior Intervention and Treatment can be provided to individuals who are authorized for DDD-funded services and who may be temporarily being served in a nursing facility (NF), hospital, etc. as long as the temporary provider (NF, hospital, etc.) approves that the therapy service can be provided in their location, the service is being provided and supporting documentation is maintained. Location of the service must be part of the supporting documentation.
The approved Behavior Intervention and Treatment provider must bill under their own social security number or TIN as recognized by the Internal Revenue Service and as enrolled as a Medicaid provider through the IMPACT system.
The DDD Medicaid Waiver Unit is required to conduct Post Payment Reviews annually. One of the required reviews is the review of claims from providers who claimed services totaling more than 12 hours on a single day.
Billable time should be billed as accurately as possible to the actual time services were provided. Billable time may be rounded to the nearest 15-minute increment, though a provider may not bill for more time than was spent providing an intervention. After the first 15 minutes of service, a provider should round up or down to the nearest 15 minutes (7 minutes or less round down, more than 7 minutes should be rounded up). A provider must indicate the date, start and stop times for each individual service provided in their billing notes. Since 56U is an individual service, a provider can only bill for one (1) individual during any billing or when rounding to a 15-minute time-period.
Note that services should not be billed prior to:
- The service being added to the Personal Plan.
- The 56U provider has been selected and approved by individual/guardian.
- The provider (which can be a designee of the 56U provider organization) has signed the Provider Page of the Personal Plan.
Travel time to and from a location, while not providing a behavior analytic service, is not billable.
Direct services may not be delivered under the waiver during the typical school day relative to the age of the individual or during times when educational services are being provided. Planning for school services and training of school staff may not be included or billed.
Direct services may not be billed at the same time as Community Day Services unless the provider is observing the target behavior(s) while the individual is participating at the day program. Medicaid rules prohibit the billing of both Behavior Intervention (56U) and any day program bill codes to be billed at the same time for direct services.
During a Post Payment Review or other financial audits conducted by DDD, the Division first identifies instances where billing practices may be questionable. Division staff do an initial review using billing submitted through the ROCS billing system. Division staff will then send a letter to the provider requesting documentation supporting an audit trail of their billing for the services. Once documentation is received, Division staff review for compliance. If compliant, Division staff notify the provider of their acceptable billing. If non-compliant, Division staff take one of two courses of action. If noncompliance is low, the Division contacts the provider to notify them of the non-compliant practices so it isn't repeated, and the provider must correct the non-compliant billing. If noncompliance is high and potentially fraudulent, the Division works with the Department of Healthcare and Family Services (HFS), Office of Inspector General (OIG) to determine what action should be taken. In most cases, the findings are sent to the Illinois State Police Medicaid Fraud Control Unit (ISP MFCU) for further investigation.
For guidance on 56U rates and maximum units per fiscal year, please visit the DDD Rate Table
For more information, please see III. Waiver Services - Professional Services