Community-Based Rehabilitation Services (CBRS) is a program ailable to adults who are recovering from a severe and persistent mental illness. This program promotes recovery, helps the enrollee integrate with his or her community, and provides services aimed at helping the enrollee improve his or her quality of life.
CBRS utilize credentialed psychosocial rehabilitation specialists to help enrollees develop the skills needed to increase their capacity to thrive in their home, work, school or in social environments. Services target skills that he been lost due to the symptoms of the enrollee’s behioral health condition.
CBRS vary in intensity, frequency and duration in order to help enrollees manage functional difficulties, or to otherwise realize recovery goals.
Some CBRS such as skills training and development require prior authorization, please refer to HCBSPAP300. Other services may no longer require prior authorization from in-network providers. Instead, Blue Cross of Idaho will conduct audits based on submitted claims. Criteria used to select cases for audit include, but are not limited to, the following:
High utilization (billing spanning more than 12 consecutive months) and/or frequency (billing more than six hours a week) Multiple agencies billing for servicesIf your case is selected for audit, we will send you written notification indicating the documentation required for review. The documentation requested may include, but is not limited to, the following:
Audit of Services Requested form Comprehensive diagnostic assessment Current treatment plan with time-limited, measurable goals and progress towards goals Rational/explanation for the audit triggers identified and any plans to address themWe will review the clinical documentation you submit using InterQual criteria supplemented by guidelines from the American Psychiatric Association, the American Psychological Association, the American Society of Addiction Medicine, and other well researched best practices.
If you are selected for an audit and do not submit the requested documentation to Blue Cross of Idaho, or if your treatment patterns fall outside the norms outlines in the above criteria and guidelines, your reimbursement rates may be affected in the future.
To qualify for CBRS, ALL of the following criteria must be met:
The enrollee has significant difficulty gaining and using the skills necessary to function adaptively in home and community settings. The enrollee also has significant difficulty getting or retaining the capability for independence, such as skills related to at least two of the following areas on either a continuous or an intermittent (at least once per year) basis: Vocational/educational Financial Social relationships/support Family Basic living skills Housing Community/legal Health/medical Within 10 calendar days of accessing services, the provider shall conduct and document the findings of a comprehensive diagnostic assessment. As part of the assessment, the provider shall assist the enrollee or the enrollee’s representative define the following: The enrollee's readiness for rehabilitation Activities needed to improve the enrollee's readiness such as motivational enhancement or learning activities The enrollee's overall rehabilitation goal The enrollee's present level of skills and knowledge relative to the rehabilitation goal and the skills and knowledge needed to achieve the enrollee's rehabilitation goal The enrollee's present resources, and the resources needed to achieve the enrollee's rehabilitation goal The evaluation of resources should include whether the enrollee has a primary care physician, and whether the enrollee has had a health history and physical examination within the last 12 months In the event the agency makes a determination that it cannot serve the enrollee, the agency must make appropriate referrals to other agencies to meet the enrollee's identified needs Within 10 calendar days of accessing services, the provider shall use the findings of the comprehensive diagnostic assessment to develop a rehabilitation plan in conjunction with the enrollee or the enrollee’s representative and the interdisciplinary team. The rehabilitation plan shall contain the following: Observable, measurable objectives aimed at helping the enrollee with achieving his/her rehabilitation goal The specific interventions for each skill/knowledge or resource objective The list of interventions should also include a provision to refer the enrollee to a primary care provider if the enrollee does not he a history and physical examination within the last 12 months, and to assist the enrollee with getting an annual examination thereafter; the person responsible for providing the intervention, and the amount, frequency and expected duration of servicelist of interventions should also include a provision to refer the enrollee to a primary care provider if the enrollee does not he a history and physical examination within the last 12 months, and to assist the enrollee with getting an annual examination thereafter; the person responsible for providing the intervention, and the amount, frequency and expected duration of service The enrollee or the enrollee’s representative’s signature as an attestation that the enrollee or the enrollee’s representative agrees with and participated in the development of the rehabilitation plan Theprovider, and whenever possible, the enrollee or the enrollee’s representative shall conduct an intermittent rehabilitation plan review as needed to incorporate progress, different goals, or change in service focus. The rehabilitation plan should be updated frequently enough to reflect changes in the enrollee’s condition, needs and preferences, and the period of time between reviews shall not exceed 90 calendar days. In the event that the enrollee has not engaged in services, the provider shall assist the enrollee or the enrollee’s representative with reevaluating the enrollee’s readiness for rehabilitation as well as the steps the enrollee or the enrollee’s representative wants to take to engage in services Inthe event that the enrollee has not benefitted from services, the provider shall assist the enrollee or the enrollee’s representative to determine whether the rehabilitation plan should be modified, or whether the enrollee could benefit from other services The review must include a reassessment of the enrollee's continued need for services.