GENERAL INFORMATION

Community Support Services (CSS) are a variety of behavioral health rehabilitative services that are used to reduce the functional disability of a person diagnosed with a mental health and/or a substance use disorder (SUD), as defined by the current edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD) who meet medical necessity criteria. The goal of CSS is to reduce disabilities and restore maximum functioning that can lead to living a more independent life. 

The types of Community Support Services offered include:

• Psychosocial Rehabilitation Services (PRS).
• Modification (B-MOD).
• Support (FS).
• Child Care (TCC)/ Therapeutic Foster Care (TFC).
• Integration Services (CIS).
• Support Services (PSS).

BEHAVIOR MODIFICATION (B-MOD):

This face-to-face service is provided to children and adolescents ages 0 to 2 to conduct in vivo redirection and modeling of appropriate behaviors to enhance their functioning within the home or community. Shadowing (following and observation) a beneficiary in any setting is not reimbursable under Medicaid. B-MOD is intended to be time-limited, and the intensity of services offered should reflect the scope of impairment. Services are more intensive and frequent at the beginning of treatment and are expected to decrease over time as the beneficiary’s skills develop. Services are based upon a finding of medical necessity, shall be directly related to the beneficiary’s diagnostic and clinical needs, and are expected to achieve the specific rehabilitative goals specified in the beneficiary’s IPOC. The goal of B-MOD is to alter patterns of behavior that are inappropriate or undesirable of the child or the adolescent. B-MOD involves the utilization of regularly scheduled interventions designed to optimize emotional and behavioral functioning in the natural environment through the application of clinically planned techniques that promote the development of healthy coping skills, adaptive interactions with others, and appropriate responses to environmental stimuli. B-MOD provides the beneficiary the opportunity to alter existing behaviors, acquire new behaviors, and function more effectively within his or her environment. Interventions are planned in such a way that they are constantly supporting, guiding, and reinforcing the beneficiary’s ability to learn life skills. B-MOD involves identifying precipitating factors that cause a behavior. New, more appropriate behaviors are identified, developed, and strengthened through modeling and shaping. Intervention strategies that require direct involvement with the beneficiary must be used to develop, shape, model, reinforce and strengthen the new behaviors. B-MOD techniques allow professionals to build the desired behavior in steps and reward those behaviors that come progressively closer to the goal and allow the beneficiary the opportunity to observe the professional performing the desired behavior. Successful delivery of B-MOD should result in the display of desirable behaviors that have been infrequently or never displayed by the beneficiary. These desirable responses must be reflected in progress notes and show increasing frequency for ongoing B-MOD authorization.

COMMUNITY INTEGRATION SERVICES:
Community Integration Services (CIS) are face-to-face services to assist adult members 18 years or older diagnosed with serious and persistent mental health (SPMI) disorder(s) or co-occurring mental health and substance use disorders (SUDs) in  improving community living competencies,  social and interpersonal competencies, personal adjustment competencies, cognitive and adult role competencies, and prevocational activities. CIS requires that a member be actively involved in the development and management of his/her overall rehabilitation, including planned goals, objectives and intervention activities included on the Individual Plan of Care (IPOC). The member who is meaningfully involved in CIS programs should be able to articulate his/her individual goals and objectives, and to identify ways in which his/her current activities are intended to assist him/her in achieving those goals and objectives and further his/her own recovery. There must be a collaborative and supportive relationship between the providers, member, and family (if family is involved) to work on IPOC goal achievement.

PSYCHOSOCIAL REHABILITATION SERVICES (PRS):
The purpose of this face-to-face service is to enhance, restore and/or strengthen the skills needed to promote and sustain independence and stability within the member’s living, learning, social, and work environments. PRS is a skill-building service, not a form of psychotherapy or counseling. PRS is intended to be time limited. The intensity and frequency of services offered should reflect the scope of impairment. Services are generally more intensive and frequent at the beginning of treatment and are expected to decrease as the member’s skills develop. Services are based on medical necessity, shall be directly related to the member’s diagnostic and clinical needs, and are expected to achieve the specific rehabilitative goals specified in the member’s IPOC

FAMILY SUPPORT (FS):
The service is provided to children and adolescents ages 0 to 21. The purpose of this face-to-face service is to enable the family or caregiver (parent, guardian, custodian, or persons serving in a caregiver role) to serve as an engaged member of the member’s treatment team and to develop and/or improve the ability of the family or caregiver(s) to appropriately care for the member. FS is intended to be time-limited, and the intensity of services offered should reflect the scope of impairment. Services are generally more intensive and frequent at the beginning of treatment and are expected to decrease over time as the member’s and family/caregiver’s skills develop. Services are based upon a finding of medical necessity, must be directly related to the member’s diagnostic and clinical needs, and are expected to achieve the rehabilitative goals specified in the member’s IPOC. 

FS is intended to: 

• Equip families with coping skills to independently manage challenges and crisis situations related to the member’s behavioral health and/or SUD.

• Educate families/caregivers to advocate effectively for the member in their care.

• Provide families/caregivers with information and skills necessary to allow them to be an integral and active part of the member’s treatment team.

• Model skills for the family/caregiver.  FS is a service with the primary purpose of treating the member’s behavioral health and/or SUD. FS does not include case management activities, nor does it include respite care or childcare services of any kind.

PEER SUPPORT SERVICES (PSS):
The purpose of this face-to-face service is to assist member’s recovery from mental health and/or substance abuse disorders by sharing similar lived experience and recovery.  The qualified peer support specialist gives advice and guidance, provides insight, shares information on services and empowers the member to make healthy decisions. The unique relationship between the peer support specialist and the member fosters understanding and trust in members who otherwise would be alienated from treatment. The member’s IPOC determines the focus of PSS.  Service interventions include the following: 

• Self-help activities that cultivate the member’s ability to make informed and independent choices. Activities help the member develop a network for information and support from others who have been through similar experiences. 

• Self-improvement planning and facilitating specific, realistic activities leading to increased self-worth and improved self-concepts. 

• Assistance with substance use reduction or elimination provides support for self-help, self-improvement, skill development, and social networking to promote healthy choices, decisions, and skills regarding SUDs or mental illness and recovery. 

• System advocacy assists members in making telephone calls and composing letters about issues related to SUDs, or mental illness or recovery. 

• Individual advocacy discusses concerns about medications or diagnoses with a Physician or nurse at the member’s requests. Further, it helps members arrange the necessary treatment when requested, guiding them toward a proactive role in their own treatment. 

• Crisis support assists members with the development of a crisis plan.

THERAPEUTIC CHILD SERVICES (TCC):
The purpose of this face-to-face service is to assist children under the age of six (6) with severe emotional and/or behavioral disturbances, and to promote or enhance appropriate developmental functioning which fosters social, emotional, and self-regulatory behavioral competence. Services incorporate a combination of psychotherapy and skill building.

TCC is a child-focused, family-centered intervention which targets the relationship between the child and the parent (or primary caregiver). Grounded in attachment theory, services are relationship-based, developmentally appropriate and trauma informed. Services must be evidence-based and include either Trauma Focused Cognitive-Behavioral Therapy (TF-CBT) or Parent-Child Interactive Therapy (PCIT). TCC provides a continuum of individual, family and group services that meet the needs of children with severe emotional and/or behavioral disturbances. The service is family-focused, with the intention of keeping the child in his or her home and community. The TCC must have documentation of staff certification to provide the evidence-based treatment being utilized as well as a documented plan for fidelity monitoring. TCC Services must be rendered in a South Carolina Department of Social Services (SCDSS) licensed or approved daycare facility that affords an adequate therapeutic environment and that protects the child’s rights to privacy and confidentiality.

Therapeutic Foster Care (TFC):

The purpose of this residential, face-to-face service is to enhance, restore and/or strengthen the skills needed to promote and sustain independence and stability within the member’s living, learning, social, and vocational environments. Therapeutic Foster Care (TFC) services are based on medical necessity, shall be directly related to the member’s diagnostic and clinical needs, and are expected to support the achievement of the specific rehabilitative goals specified in the member’s Individual Plan of Care (IPOC).

Policy: All members must meet medical necessity criteria to be eligible for treatment services. A physician or LPHA must certify that the member meets the medical necessity criteria for each service.  Each service must be listed on IPOC. The Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUSCASII) shall be used by private agencies to establish pre-admission criteria for Community Support Services.

Medical Necessity means the need for treatment services is necessary to diagnose, treat, cure, or prevent an illness, or participation in services is reasonably expected to relieve pain, improve and preserve health, or be essential to life. Services are not primarily for the benefit of the Provider and/or for the convenience of the member/family, caretaker or provider. Services and treatment shall be rendered in a cost effective and in the least restrictive setting required by the member’s condition. Services and treatment shall be consistent with generally accepted professional standards of practice and shall not be experimental or investigational in nature.

Medical Necessity shall be substantiated by records. The fact that a physician or LPHA prescribed a service does not deem it medically necessary.

For specific Medical Necessity criteria for each services described above, refer to the appropriate SCDHHS manual:

Licensed Independent Practitioners Rehabilitative Services Manual
Community Mental Health Services Manual
Local Education Agencies Services Provider Manual
Rehabilitative Behavioral Health Services Manual
RHC Services Provider Manual
Provider Administrative and Billing Manual

References:

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision

2. Coding Source: Healthy Connections Medicaid Provider Manual, “Rehabilitative Behavioral Health Services”

3. South Carolina Department of Health and Human Services. Rehabilitative Behavioral health Services Provider Manual

4. Anthony, W. A., & Farkas, M. D. (2009) Primer on the Psychiatric Rehabilitation Process. https://cpr.bu.edu/wp-content/uploads/2011/11/Primer-on-the-PsychiatricRehabilitation-Process.pdf

5. Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUSCASII)**

6. Rudyard & Propst. (1997) Stages in Realizing the International Diffusion of a Single Way of Working: The Clubhouse Model. http://www.fountainhouse.org/sites/default/files/ftp/articles/stages-the-clubhousemodel.pdf.**

Definitions

1. IPOC: an individualized comprehensive plan of care developed in collaboration with the member, significant other(s), parent, guardian, primary caregiver, other State agencies and staff, or service providers that outlines the service delivery needed to meet the identified needs and improve the functioning of the member.
2. SPMI: Serious and Persistent Mental Illness is a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within current edition of the Diagnostic Statistical Manual of Mental Disorders (DSM) that has resulted in functional impairment which substantially interferes with or limits one or more major life activities.
3. LPHA:  Licensed Practitioner of the Healing Arts an individual who, within the scope of state law, has the ability and appropriate state licensure to independently make a clinical assessment, certify a diagnosis and recommend treatment for individuals with a mental illness.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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