In the case of co-therapists providing group psychotherapy, the provider who bills for the service for a specific member is responsible for maintaining records and signing entries for that member. Facsimile signatures will be considered valid by DHHS if in accordance with mental health licensing standards. Separate clinical records must be maintained for all members receiving group psychotherapy services. The records must not identify any other member or confidential information of another member. For crisis services, the progress note must describe the intervention, the nature of the problem requiring intervention, and how the goal of stabilization will be attempted, in lieu of an ITP. 65.09 POLICIES AND PROCEDURES (cont.) The clinical record shall also specifically include written information or reports on all medication reviews, medical consultations, psychometric testing, and collateral contacts made on behalf of the member (name, relationship to member, etc.). Documentation of cases where a member requires more than two (2) hours of outpatient services per week to prevent hospitalization must be included in the file. This documentation must be signed by the supervising clinician. D. Discharge/Closing Summary A closing summary shall be signed, credentialed and dated and included in the clinical record at the time of discharge. This will include a summary of the treatment, to include any after care or support services recommended and outcome in relation to the ITP. E. Quality Assurance Periodic review of cases to assure quality and appropriateness of care will be conducted in accordance with the quality assurance (QA) protocols established by DHHS. Reviews will be in writing, signed and dated by the reviewers, and included in the member’s record, or kept in a separate and distinct file parallel to the member’s record. 65.09-5 Program Integrity (PI) Unit Program Integrity Unit requirements apply as defined in the MaineCare Benefits Chapter I, Administrative Policies and Procedures”. Manual, “General
In the case of co-therapists providing group psychotherapy, the provider who bills for the service for a specific member is responsible for maintaining records and signing entries for that member. Facsimile signatures will be considered valid by DHHS if in accordance with mental health licensing standards. Separate clinical records must be maintained for all members receiving group psychotherapy services. The records must not identify any other member or confidential information of another member. For crisis services, the progress note must describe the intervention, the nature of the problem requiring intervention, and how the goal of stabilization will be attempted, in lieu of an ITP. 65.09 POLICIES AND PROCEDURES (cont.) The clinical record shall also specifically include written information or reports on all medication reviews, medical consultations, psychometric testing, and collateral contacts made on behalf of the member (name, relationship to member, etc.). Documentation of cases where a member requires more than two (2) hours of outpatient services per week to prevent hospitalization must be included in the file. This documentation must be signed by the supervising clinician. D. Discharge/Closing Summary A closing summary shall be signed, credentialed and dated and included in the clinical record at the time of discharge. This will include a summary of the treatment, to include any after care or support services recommended and outcome in relation to the ITP. E. Quality Assurance Periodic review of cases to assure quality and appropriateness of care will be conducted in accordance with the quality assurance (QA) protocols established by DHHS. Reviews will be in writing, signed and dated by the reviewers, and included in the member’s record, or kept in a separate and distinct file parallel to the member’s record. 65.09-5 Program Integrity (PI) Unit Program Integrity Unit requirements apply as defined in the MaineCare Benefits Manual, Chapter I, “General Administrative Policies and Procedures”.
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