• The required documentation for retrospective review must meet the general requirements below and must also meet service specific documentation requirements as indicated in the OBHS manual.
    •  
    • Must be individualized to the beneficiary and specific to the services provided, duplicated notes are not allowed
    •  
    • The date and actual time the services were provided
    •  
    • Original signature, name and credentials of the person, who authorized the services
    •  
    • Original signature, name and credentials of the person, who provided the services, if different from authorizing professional
    •  
    • The setting in which the services were provided.  For all settings other than the provider’s enrolled sites, the name and physical address of the place of service must be included
    •  
    • The relationship of the services to the treatment regimen described in the Treatment Plan
    •  
    • Updates describing the patient’s progress
    •  
    • For services that require contact with anyone other than the beneficiary, evidence of conformance with
    • HIPAA regulations, including presence in documentation of Specific Authorizations, is required
  •  
  • Review is based on tier determination per Independent Assessment. 

 

  • If the claim indicates a crisis intervention, and this is the only service provided to the beneficiary, the mental health diagnosis is not required.

 

  • For reviews where no Independent Assessment has been completed, or when an Independent Assessment resulted in a Tier 1 determination, the following documents are required:
    •  
    • Provider note
    •  
    • Mental health diagnosis – must have mental health diagnosis as the first service provided (90791)
    •  
    • PCP referral, if applicable

 

  • For reviews where an Independent Assessment was completed with a  Tier 2 or Tier 3 determination, the following documents are required:
    •  
    • Provider note
    •  
    • Mental health diagnosis (90791)
    •  
    • Treatment plan covering the claim service date 
    •  
    • A Psychiatric Assessment covering the claim service date (90792)