§ 1155.32. Payment conditions for individual services.
(a) Payment will be made to a licensed IBHS agency for individual services if the following conditions are met:
(1) There is a written order for services based on a face-to-face interaction with the child, youth or young adult that meets the following:
(i) Written within 12 months prior to the initiation of IBHS.
(ii) Written by a licensed physician, licensed psychologist, certified registered nurse practitioner or other licensed professional whose scope of practice includes the diagnosis and treatment of behavioral health disorders and the prescribing of behavioral health services, including IBHS.
(iii) Includes a behavioral health disorder diagnosis listed in the most recent edition of the DSM or ICD.
(iv) Orders one or more IBHS for the child, youth or young adult and includes the following:
(A) The clinical information to support the medical necessity of the service ordered.
(B) The maximum number of hours of each service per month.
(C) The settings where services may be provided.
(D) The measurable improvements in the identified therapeutic needs that indicate when services may be reduced, changed or terminated.
(2) A face-to-face assessment has been completed by an individual qualified to provide behavior consultation services or mobile therapy services within 15 days of the initiation of individual services and prior to completing the ITP in accordance with § 5240.21 (relating to assessment) or a face-to-face assessment has been reviewed and updated within 12 months of the previous face-to-face assessment.
(3) The assessment and all updates have been signed by the staff person who completed the assessment.
(4) An ITP based upon the assessment and the written order for services has been completed within 30 days after the initiation of services in accordance with § 5240.22 (relating to individual treatment plan) or an ITP has been reviewed and updated within 6 months of the previous ITP.
(5) The ITP and all updates have been reviewed and signed by the youth, young adult, or parent or legal guardian of the child or youth, the staff person who completed the ITP and an individual who meets the qualifications of a clinical director in § 5240.12 (relating to staff qualifications).
(6) For continued individual services, a child, youth or young adult shall have an order written within 12 months of the initiation of the continued services that complies with subsection (a)(1)(ii)—(iv).
(b) Payment will be made to a licensed IBHS agency for individual services for up to 45 days after initiation of services, if an ITP has not yet been completed but there is a written order for services that complies with subsection (a)(1) and there is a treatment plan for the individual services provided.
Cross References This section cited in 55 Pa. Code § 1155.34 (relating to payment conditions for group services); 55 Pa. Code § 1155.35 (relating to payment conditions for EBT delivered through individual services, ABA services or group services); 55 Pa. Code § 1155.37 (relating to limitations); 55 Pa. Code § 5240.22 (relating to individual treatment plan); 55 Pa. Code § 5240.41 (relating to individual records); 55 Pa. Code § 5240.74 (relating to individual services initiation requirements); and 55 Pa. Code § 5240.96 (relating to individual treatment plan).
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