10.09.34.04

.04 Limitations.

A. To be eligible for therapeutic behavioral services the:

(1) Recipient shall be younger than 21 years old and enrolled in the Program;

(2) Recipient shall be assessed as having behaviors or symptoms related to a mental health diagnosis that places the individual's current living arrangement at risk and creates a risk for a more restrictive placement, or prevents transition to a less restrictive placement;

(3) Recipient's behaviors or symptoms shall be safely and effectively treated in the community; and

(4) Recipient's parent, guardian, or individual who customarily provides care shall be present during the provision of all therapeutic behavioral services to participate in the behavioral plan, unless there are clinical goals specifically addressed in the behavior plan that need to be achieved requiring that the parent, guardian, or individual who customarily provides care not be present.

B. Therapeutic behavioral services shall meet the definition of rehabilitation services.

C. Therapeutic behavioral services shall be:

(1) Decreased proportionally when indicated by the recipient's progress;

(2) Discontinued when the targeted outcomes have been reached; or

(3) Reassessed for new targeted outcomes if progress on the current outcomes is not being achieved.

D. A therapeutic behavioral service provider may not bill the Program for:

(1) Services that are:

(a) Provided in:

(i) An intermediate care facility;

(ii) An institution for mental disease;

(iii) A hospital; or

(iv) A crisis residential program;

(b) Habilitative, custodial, or activities of daily living;

(c) Not authorized by the Department or its designee;

(d) Provided by a therapeutic behavioral aide who is a member of the recipient's immediate family or who resides in the recipient's home;

(e) Not medically necessary;

(f) Beyond the provider's scope of practice;

(g) Not performed under the supervision of a licensed health care provider;

(h) Rendered but not appropriately documented;

(i) Part of another service paid for by the State; or

(j) Rendered by mail, telephone, or otherwise not one-to-one, in person;

(2) Services that duplicate the care and custody provided by another State agency pursuant to a court order or a voluntary placement agreement;

(3) Respite services;

(4) Seclusion or restrictive techniques;

(5) Completion of forms or reports;

(6) Broken or missed appointments; or

(7) Travel to and from site of service.