FY15 Provider Manual Definitions



  1. Accepted Claim----A claim for DMH services that a Provider submitted to the Department of Healthcare and Family Services, within 180 days of the date of service that cleared all edits and was adjudicated for payment.
  2. Active Medicaid Individual---- An individual who has been determined by the Department to have an active enrollment status under Title XIX or Title XXI of the Social Security Act.
  3. Administrative Expense---- Administrative expense defined according to the instructions provided by the Department for the completion of the Consolidated Financial Report (CFR). This excludes any non-reimbursable expenses as defined in those instructions, but includes direct program administration costs plus management and general costs. Program administration costs are those expenses that are caused by activities not related to an individual case, but related to administration of the overall program. Examples include, but are not limited to:
    1. Accrued salaries and wages earned by all administrative, managerial, office, and clerical employees,
    2. Administrative staff payroll, taxes, fringe benefits, and Worker's Compensation Insurance,
    3. Other employee benefits for administrative and management staff,
    4. Administrative consultants,
    5. Telecommunications costs not assigned to program activities,
    6. The costs of administrative office supplies and expensed equipment, and
    7. Management and general expenses that are not part of any one program, but are caused by services to all programs run by an agency.
  4. Allowable expense----An expense by a provider associated with the provision of community mental health services as defined in 89 Ill. Admin. Code 509, Section 509.20a.
  5. Attachment---- That part of the Community Service Agreement that contains the contract provisions specific to the Division of Mental Health. The DHS/DMH attachment is referred to as "Attachment B". The Community Services Agreement Exhibits A-C include information on programs/services funded through the Attachment and reconciliation/closeout information for the funded services.
  6. Authorization--- The process by which a service is deemed to be reimbursable based on the application of medical necessity criteria pursuant to clinical review by utilization management clinicians employed by the Department or its agents.
  7. Billable Service---- A service described in either the 59 Ill. Admin Code 132 or the current Community Mental Health Service Definitions and Reimbursement Guide.
  8. Capacity Grant---- Funding for certain mental health programs or portions thereof that are not reimbursed on a fee-for- service basis. This funding is awarded as grants. The amounts of these grant awards are specified by program name on the accompanying Community Services Agreement Exhibits A-C and are expected to be reconciled by expenses as outlined in 89 Ill. Admin Code 511.
  9. Claim---- A statement of charges for mental health services that conforms to the requirements for billing prescribed by DHS/DMH and HFS for processing bills. A bill may apply to Medicaid or non-Medicaid services and to HFS eligible individuals, including Medicaid eligible, or to DHS/DMH eligible individuals.
  10. Clinical Review--- The review by a utilization management clinician of a consumer's current mental health status, functioning, and treatment needs to confirm the medical necessity of services for post payment review and quality improvement activities
  11. Consumer---- An individual who has received a DHS/DMH mental health treatment service or has participated in a DHS/DMH program.
  12. Contract Amount--- The sum of a Provider's non-Medicaid and Capacity Grant allocations for the fiscal year reflected on the Community Services Agreement Exhibits A-C
  13. Coordination of Benefits---- A systematic process of determining all parties liable for payment for a service to an individual and the amount of each party's liability.
  14. Department---- Reference to the Department of Human Services (DHS) or the Division of Mental Health (DHS/DMH) acting on behalf of the Department of Human Services or reference to any agent representing the Department or the Division in the execution of the terms of this contract.
  15. Department Approved Rate---- The rate associated with each billable service as specified in the current Community Mental Health Service Definitions and Reimbursement Guide.
  16. DHS/DMH---- Department of Human Services, Division of Mental Health.
  17. DHS/DMH Eligible Individual---- An individual who meets the eligibility criteria for DHS/DMH but who has not been determined to meet the eligibility requirement or be on active status for Programs administered by the Illinois Department of Healthcare and Family Services, including Title XIX or Title XXI, All Kids, and Veterans Care. This includes individuals who do not meet eligibility requirements under Title XIX or Title XXI, individuals who might meet those eligibility requirements but have not applied (or have not had their application approved), and individuals who may become active Medicaid individuals once they meet a Medicaid "spend-down" requirement.
  18. Early Periodic Screening, Diagnosis, and Treatment (EPSDT) ---- The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program is the nation's largest preventive child health initiative. It is a comprehensive child health program that provides initial and periodic examinations and medically necessary follow-up care. For more information, consult the Illinois Department of Healthcare and Family Services Handbook for Providers of Healthy Kids Services.
  19. Evidence Based Practice--- A mental and behavioral health intervention for which systematic empirical research has provided evidence of statistically significant effectiveness as treatment for specific problems.
  20. Family Driven Care---In Child and Adolescent Services, Family Driven means that families have a primary decision making role in the care of their own children as well as the policies and procedures governing care for all children in their community, state, tribe, territory and nation. Additional information can be obtained at the following website; http://www.samhsa.gov/children/core-values.asp
  21. Fee-for-Service---- Funding mechanisms by which the payments are made on the basis of a rate, unit cost, or allowable cost incurred and are based on a statement or claim as required by the Department. Payments made as a fee-for-service are not subject to the Illinois Grant Funds Recovery Act (30 ILCS 705). Payment is made contingent on the Provider's delivery of services, as documented in an accepted claim.
  22. Fiscal Year--- The twelve-month period from July 1 through June 30. FY and fiscal year have the same meaning. When used with a specific year the year may be expressed as a full year (Ex: 2013) or by using the last two digits of the fiscal year. (Ex: 13).
  23. Grant---- A funding mechanism by which a program of services and activities receives all or part of the funding in advance of the actual delivery of services. This includes prorated prospective payments and payments made by the Department on an estimated basis or any other basis when the Department does not know the actual amount earned by the Provider. This does not include advance payments made under the authority of Section 9.05 of the State Finance Act (30 ILCS 105/9.05. All funds paid as a grant are subject to the Illinois Grant Funds Recovery Act (30 ILCS 705) and subject to reconciliation under 89 Ill. Adm. Code 511, section 511.10.
  24. Grant Activity Report---- The reporting or report submitted to the Department of a program of services and activities funded as a capacity grant program. This report must conform to the requirements specified by DHS/DMH, and for efficiency, DHS/DMH may utilize its management information system for such reporting. However, grant activity reporting or reports are not considered as a bill for FY 2013.
  25. Household---- A household includes all persons related legally or as a relative who occupy a housing unit and who are financially responsible for other members of the household. Financially responsible means the individual can be claimed as a dependent on a tax return. A housing unit is a house, an apartment, a mobile home, a group of rooms, or a single room that is occupied (or if vacant, is intended for occupancy) as separate living quarters. Separate living quarters are those in which the occupants live and eat separately from any other persons in the building and which have direct access from the outside of the building or through a common hall. The occupants may be a single family, one person living alone, two or more related families living together, or any other group of persons related legally or as a relative who share living arrangements. People not living in households are classified as living in group quarters.
  26. Household Income--- The gross amount of income a household receives evidenced by pay stubs, tax returns or other documents submitted to the provider or reported to the provider by the consumer, their guardian or family member
  27. Housing Coordinator----The Division of Mental Health Housing Coordinator - Coordinates all matters related to Permanent Supportive Housing (PSH) development, as well as all matters that relate to housing options that DMH currently funds. Relates to all public entities local, state, and federal, as well as private to facilitate the expansion of permanent supportive housing on a statewide level. Coordinates any necessary activities and forums with any and all stakeholders to further the development of permanent supportive housing options in Illinois.
  28. HFS (Medicaid) Eligible Individual---- An individual who meets the eligibility requirement and is on active status for Programs administered by the Illinois Department of Healthcare and Family Services, including Title XIX or Title XXI, All Kids, Veterans' Care, Healthcare Benefits for Persons with Disabilities, and the Integrated Care Program.
  29. Integrated Care Project---- The program under which the Department Of Healthcare and Family Services (HFS) has contracted with two Health Maintenance Organizations to provide the full spectrum of Medicaid Covered Services, including Mental Health and Substance Abuse services, through an integrated care delivery system to Older Adults and Adults with Disabilities who are eligible for Medicaid but are not eligible for Medicare. The Integrated Care Program will operate in DuPage, Kane, Kankakee, Lake, Will, and suburban (areas with zip codes that do not begin with "606") Cook counties.
  30. Illinois Mental Health Collaborative for Access and Choice (Collaborative)----The DHS/DMH name for the functions, services, and processes performed by the DHS/DMH Administrative Service Organization.
  31. Medicaid Eligible---See HFS Eligible Individual
  32. Medicaid Service---- Any service defined under the Medicaid Community Mental Health Services Program in 59 Ill. Admin Code 132.
  33. Mental Health Service Site - A physical location, designated by an address and linked to a particular DMH-contracted Mental Health Provider, from which this provider delivers a DMH funded mental health service and has all of the following characteristics:
    • Each service site may have only one address;
    • Each service site must have a unique address (no two sites may share the same address);
    • The site must be owned, leased, or otherwise controlled by a DMH funded mental health provider;
    • The site must have staff employed by or under contract with the DMH funded mental health provider;
    • A DMH funded mental health provider may have multiple service sites.
      Certified Mental Health Service Site - A Mental Health Service Site as defined above that has been certified as defined by 59 IL Adm. 132 ("Rule 132") as determined by the Department of Human Services (DHS) or the Department of Children and Family Services (DCFS) or their respective agents designated for this purpose. A Mental Health Service Site may be certified only if the DMH Mental Health Provider with which the site is associated is also certified. A DMH provider may provide both Medicaid and non-Medicaid services for which they are certified/ approved at a certified site.
  34. Non-Medicaid Contract Amount---- The portion of the Provider's Contract Amount for the Provider's billings for non-Medicaid services or for Medicaid services provided to non-Medicaid recipients.
  35. Non-Medicaid Service---- Any service defined in the Community Mental Health Service Definitions and Reimbursement Guide as Non-Medicaid (DHS only) service.
  36. Permanent Supportive Housing (PSH)----Integrated permanent housing (typically rental apartments or units with a self-contained bathroom and kitchenette) linked with flexible community-based mental health services that are available to the tenant/consumer as needed, but not mandated as a condition of occupancy. The PSH model is based on a philosophy that supports consumer choice and empowerment, rights and responsibilities of tenancy, and appropriate, flexible, accessible and available support services.
  37. Program---- A defined set of one or more mental health activities or services that are grouped to achieve objectives for a particular population or mental health system need. The distinction of a program is not in the individual activities or services, which are not exclusive and may be included in more than one program, but in the combination of the activities.
  38. Program Manual---- A resource manual that by reference is part of the Community Service Agreement. It contains further explanation of the DMH specific guidelines, requirements, and contract provisions in Attachment B when warranted.
  39. Provider---- A community-based agency or entity, including community hospitals, delivering direct mental health services to individuals through a Community Service Agreement with DHS/DMH.
  40. Provider Database---- A collection by DHS/DMH or its agent containing key pieces of information to describe aspects of the Provider's organization and its operations.
  41. Provider Manual----A policy and procedure document produced by DHS/DMH providing a source of readily available information regarding administrative functions, services and process including consumer enrollment, service delivery requirements, service authorizations, monitoring, billing administration, forms and other valuable information in executing the provider's business arrangement with DHS/DMH.
  42. Purchase of Service----See "Fee-for-Service"
  43. Reconciliation (of Grant Payments)---- The process by which DHS grant payments to Providers for the fiscal year are compared to the Provider's expenses for the year or the number or amount of services and activities delivered during the fiscal year. This process is described in 89 Ill. Admin. Code 511.
  44. Resident--- A individual with a home address in the State of Illinois, including individuals who are considered "homeless" but spending their nights in Illinois.
  45. SASS ---- The Screening Assessment and Support Services program of intensive mental health services delivered by an agency to provide pre-admission, crisis stabilization, and follow-up services to children with mental illnesses or emotional disorders who are at risk for psychiatric hospitalization.
  46. Service---- Treatment events or products as contracted for through this agreement.
  47. Third Party Payments----Payments from Medicare, other government entities, private insurance and other payers liable for payment for services for an individual (excluding payments from the individual or their family) for specific services for an identified individual. Not included are payments (such as grants) to the Provider that are not designated for services to a specific individual.