The CSB supports DMAS’s proposal to expand TDO Program reimbursement for prescreening assessments administered to individuals who are not Medicaid-eligible. In particular, the CSB supports reimbursement when:

•  An individual is subject to an Emergency Custody Order;
•  An individual is not under an ECO, but the prescreening assessment results in the issuance of a Temporary Detention Order; and
•  A subsequent prescreening assessment is required as long as the individual remains under a TDO.

These changes appropriately recognize that CSBs are legally responsible for providing emergency services evaluations regardless of an individual’s insurance status and that clinically necessary prescreening may occur outside the initial ECO period. The expanded coverage should reduce uncompensated mandated services and support timely behavioral health crisis evaluations.

The CSB requests that DMAS address the following issues before finalizing the supplement.

 1. Clearly identify the required billing modifiers

The proposed language instructs providers to submit H2011 with the appropriate emergency-services team modifier but does not clearly specify the status modifier required for each newly covered prescreening circumstance.

 The current TDO Supplement directs providers to use modifier 32 when a prescreening is conducted under an ECO. Appendix G of the Mental Health Services Manual also distinguishes between modifier 32 for a prescreening under an ECO and modifier HK for a prescreening not conducted under an ECO.

DMAS should include a billing table specifying the complete modifier combination for each circumstance, including:

• A prescreening conducted under an ECO;
• A prescreening conducted without an ECO that results in a TDO;
• A subsequent prescreening conducted while the individual remains under a TDO;
• A prescreening conducted through telemedicine; and
• A prescreening involving more than one emergency-services team member.

The final supplement should expressly state whether modifier 32 remains required for ECO prescreening claims and identify the modifier required for subsequent assessments under a TDO. This information should not be left to provider interpretation.

 2. Define “subsequent prescreening assessment”

The proposed supplement allows reimbursement for subsequent prescreening assessments while a non-Medicaid-eligible individual remains under a TDO. This is an important addition, but the term “subsequent prescreening assessment” should be defined.

The final guidance should explain:

• What circumstances qualify as a subsequent prescreening assessment;
• Whether the assessment must be associated with a new or amended TDO;
• Whether reassessments due to a change in the individual’s clinical condition are covered;
• Whether an assessment related to a change in facility or disposition is covered;
• Whether more than one subsequent assessment may be reimbursed during the same TDO episode;
• Whether H2011 continues to be billed in 15-minute units for the actual time spent conducting the assessment; and
• What documentation must be maintained to support the claim.

Without clear parameters, CSBs and the TDO Program may interpret coverage differently, leading to inconsistent claims processing and avoidable denials.

 3. Clarify use of the CSB Emergency Custody Attestation Form

The CSB supports establishing an alternative form when law enforcement initiates emergency custody and a magistrate-issued ECO is unavailable. This recognizes that, under Virginia law, emergency custody can be initiated directly by law enforcement.

Additional instructions are needed regarding:

• The specific circumstances under which the form may substitute for an ECO;
• Whether the CSB must first attempt to obtain an ECO document from the magistrate;
• Which CSB staff members are authorized to sign the attestation;
• Whether electronic signatures are permitted;
• Whether information or confirmation from the initiating law-enforcement officer must be retained;
• How the required 10-digit patient account number must be created and whether it must remain unique across claims;
• Whether the form must be included with every claim associated with the emergency-custody episode; and
• Whether the completed form and claim may be submitted electronically.

The form also requests a Social Security number, driver’s license number, home address, and other identifying information that may not be known or readily available during a behavioral health emergency. The final instructions should allow the CSB to enter “unknown” or “not available” without causing the claim to be rejected.

 DMAS should also explain the claims-processing purpose for each requested identifier and limit required information to what is necessary to identify the individual and process the claim. Obtaining optional identifiers should not delay the prescreening assessment, the disposition process, or the submission of an otherwise valid claim.

 4. Clarify third-party liability requirements

The supplement should more clearly distinguish between uninsured individuals and those who are not Medicaid-eligible but have other health insurance.

DMAS should specify:

• Whether a CSB must bill commercial insurance before submitting a prescreening claim to the TDO Program;
• Whether an explanation of benefits or formal denial must accompany the claim;
• How the claim should be submitted when the commercial insurer does not recognize H2011 or does not cover involuntary prescreening services;
• Whether the TDO Program may reimburse deductibles, coinsurance or other unpaid balances; and
• What documentation is required when insurance information cannot be verified during an emergency episode.

Because prescreening assessments are mandated and time-sensitive, reimbursement should not depend on lengthy attempts to obtain payment from a carrier that does not cover the service.

 5. Clarify the removal of the 15-day IMD language

The CSB supports removing language that could be interpreted as imposing a 15-day clinical or benefit limit on an individual’s stay at an institution for mental health issues.

 The final supplement should clearly explain that the federal 15-day provision concerns federal managed-care capitation-payment rules and does not, by itself, establish a maximum medically necessary length of stay for the individual.

 6. Provide implementation guidance before enforcement

Before the revised supplement becomes effective, DMAS should provide:

• A provider bulletin summarizing the changes;
• A claims-processing table with sample claims and modifier combinations;
• Instructions and a completed example of the CSB Emergency Custody Attestation Form;
• Guidance on third-party liability documentation;
• A designated contact for TDO Program billing questions; and
• A reasonable implementation period for CSBs to update workflows, train emergency-services and billing staff, and modify electronic health record processes.

Claims submitted during the initial implementation period should not be denied solely because of unclear modifier, form, or documentation requirements that were not expressly addressed in the final guidance.