Maryland
Department of Health and 
Mental Hygiene

Behavioral Health Administration
Maryland RecoveryNet
Forms
aND
Other Documentation
Supplement To The
Maryland RecoveryNEt
Provider Manual
Housing Providers

April 2015

BHA/Maryland RecoveryNet reserves the right to 
make changes to the Supplement and Provider Manual as needed.  	
Table of Contents

Maryland RecoveryNet

Service Provider Fee Schedule

Repayment Invoice

Critical Incident Report

Provider Proof of Service Delivery

Summary: Privacy Rule for HIPAA

Value Options Guide to Claims Submission

Maryland RecoveryNet Service Provider Fee Schedule
              3/1/2015

MDRN Fee Schedule for ValueOptions Effective 3-1-15					
CPT Code	Service Description	Billing Unit	Rate	Max Daily Unit/ Service Limit	Place of Service	
MDRN1	Half -Way House (clinical)	Daily	$60.00	30 day max*	55, 99	
MDRN2	Recovery/Supported Housing	Daily	$25.00	30 day max*	14, 99	
MDRN3	MDRN Intake interview	Unit	$100.00	I Unit	57, 99	
MDRN4	Care Coordination Check-ins	Unit	$15.00	24 Units	57, 99	
MDRN5	Transportation	 	individualized by provider	 	99	
MDRN6	Vital Documents	Unit (2 documents)	$50.00	2 Units	57, 99	
MDRN7	Gap Services-Transitional Services	Unit	$1.00	50 Units	57, 99	
MDRN8	Gap Service- clothing	Unit	$1.00	50 Units	57, 99	
MDRN9	Gap Services-Support Services	Unit	$1.00	150 Units	57, 99	
MDRN0	Gap Services-Medical	Unit	$1.00	250 Units*	57, 99	
MDR11	Peer Support Intake Interview	Unit	$75.00	1 Unit	11, 55, 57,99	
MDR12	Peer Support Encounter	Unit=15 min.	$12.00	16 units /mth max	11, 55, 57,99	
MDR13	Peer Support Leisure Activity	Unit	$25.00	4 Units	55, 57, 99	
MDR14	Peer Support Recovery Call	Unit	$5.00	5 Units/mth max	11, 99	
MDR15	Follow-up Questionnaire Gift Card	Unit	$20.00	1 Unit	11, 55, 57, 99	
MDR16	Six month follow-up survey/MDRN satisfaction survey	Unit	$130.00	1 Unit	11, 55, 57, 99	
 	Maximum payment per consumer = $4,500.00	* -- additional services must be authorized by the Regional Area Coordinator (RAC)	 	

 STATE OF MARYLAND 
DHMH 
Maryland Department of Health and Mental Hygiene
Behavioral Health Administration ● Spring Grove Hospital Center ● Voc Rehab Building 55 Wade Avenue ● Catonsville, Maryland  21228
Larry Hogan, Governor - Boyd Rutherford, Lt. Governor - Van Mitchell, Secretary 
                                          Gayle Jordan-Randolph, M.D., Deputy Secretary - Brian M. Hepburn, M.D., Executive Director

Maryland RecoveryNet Repayment Invoice 

Provider Name:						Contact:				

Location:												

The above listed provider is required to repay the Department of Health and Mental Hygiene for Maryland RecoveryNet-services that were not delivered or were incorrectly billed. 

M-Number #	Service Type	Date(s) of Service for repayment	Amount per unit	Total Amount for repayment	

					

Total amount for repayment:								$		

Please make the check payable to:	DHMH
Send check to: Behavioral Health Administration
		Attn: Fiscal Department
Vocational Rehabilitation Building
		55 Wade Ave.
		Catonsville, MD 21228
Please email patricia.konyeaso@maryland.gov  to confirm payment was sent.

For Official Use:
Date Invoice sent to Provider:				
Date Payment received:				
Deposit Date:						

 Maryland RecoveryNet – Critical Incident Report 

Please email form to Patricia.Konyeaso@maryland.gov  within 24 hours of becoming aware of the incident.
Today’s Date:  				 Date of Critical Incident:  				
Name/Title of Individual Completing Form:  							
Agency________________________________________________________________________
Address:  											
City:  						 State:  			 Zip:  			
Location Where Incident Occurred:
												
Please check if individual is NOT a Maryland RecoveryNet service recipient {    }
Individual involved in incident:
Name:  												
Date of Birth:  					 M-Number#:  				
	[  ]  Male           	[  ]  Female          [  ]  Transgendered
List any other involved party:
													
Nature of Incident:
	[  ]  Death (from any cause after entry into RecoveryNet services)
	       Cause of death:  									
	[  ]  Suicide Attempt
[  ]  Injury to self
[  ]  Injury to or assault on others
[  ]  Sexual/physical abuse or neglect, or allegation thereof
[  ]  Incarceration
[  ]  Inappropriate use of RecoveryNet funds
[  ]  Other (please specify:  								

Describe Incident:

												

Signature								Date

Name of Maryland RecoveryNet RAC__________________________________

Provider Proof of Service Delivery Documentation

Service Provider______________________________________________________________
Service Provider Signature										
Please fill out the information below and sign. Your signatures verify that the service that you were authorized to provide/receive thorough the RecoveryNet was delivered on the date indicated below by the service provider that you requested. 

Name 							   ___________      
Date of Service:____________ Service Type:  ____Housing        ___Employment     ___Peer/Recovery Coaching
Client signature						 						

Name 							   ___________      
Date of Service:____________ Service Type:  ____Housing        ___Employment    ___Peer/Recovery Coaching
Client signature						 						

Name 							   ___________      
Date of Service:____________ Service Type:  ____Housing        ___Employment   ___Peer/Recovery Coaching
Client signature						 						

Name 							   ___________      
Date of Service:____________ Service Type:  ____Housing        ___Employment   ___Peer/Recovery Coaching
Client signature						 						

Name 							   ___________      
Date of Service:___________  Service Type:  ____Housing        ___Employment   ___Peer/Recovery Coaching
Client signature						 						

Name 							   ___________      
Date of Service:___________ Service Type:  ____Housing        ___Employment   ___Peer/Recovery Coaching
Client signature						 						

Name 							   ___________      
Date of Service:__________  Service Type:  ____Housing        ___Employment   ___Peer/Recovery Coaching
Client signature						 						
Provider Note: this form must be signed (must be legible) by the service recipient for each day you are requesting reimbursement. This document must be kept on the service site and made available on request by the RAC or DHMH staff. The Provider proof of service delivery documentation will be requested at time of audit and forms must be kept by the provider for five years.

Summary: Privacy Rule for Health Insurance Portability and Accountability Act (HIPAA)
Published as 45 CFR parts 160 and 164 and effective in 2003, this Act protects the privacy of Protected Health Information (PHI) that is:
1.	Transmitted by electronic media;
2.	Maintained in any medium described in the definition of electronic media: or
3.	Transmitted or maintained in any other form or medium.

As defined by HIPAA, Protected Health Information is any information, including demographic information, collected from an individual, that is:
1.	Created or received by a healthcare provider, health plan, employer, or healthcare clearinghouse;
2.	Related to the past, present, or future physical or mental health or condition of an individual; the provision of healthcare to an individual; or the past, present, or future payment for the provision of healthcare to an individual; and which is
3.	Able to identify the individual, or with respect to which, there is reasonable basis to believe that the information can be used to identify the individual.

Business associate as defined by HIPAA (45 CFR section 160.103), is a person who, on behalf of the covered entity or provider or of an organized healthcare arrangement in which the covered entity participates, but other than in the capacity of a member of the workforce of such covered entity or arrangement, performs, or assists in the performance of:

1.	A function or activity involving the use or disclosure of individually identifiable health information, including claims processing or administration, data analysis, processing or administration, utilization review, quality assurance, billing, benefit management, practice management, and re-pricing; or
2.	Any other function or activity regulated by this subchapter; or providers, other than in the capacity of a member of the workforce of such covered entity, legal, actuarial, accounting, consulting, consulting, data aggregation, management, administrative, accreditation, or financial services to or for such covered entity, or to or for an organized healthcare arrangement in which the covered entity participates, where the provision of the service involves the disclosure of individually identifiable health information from such covered entity or arrangement, or from another business associate of such covered entity or arrangement, to the person.

All providers who qualify as covered entities must comply with the provisions of the Privacy Rule of HIPAA. A covered entity is defined as a healthcare provider, a health plan, or a clearing house who transmits any health information in electronic form in connection with a transaction covered by this subchapter (section 160.103 of 45 CFR part 160). If this provider is a covered entity, then HIPAA requires the appropriate policies and procedures to be in place to comply with the HIPAA Privacy Rule. HIPAA requires such policies and procedures to include, but not be limited to, the following topics: Notice of Privacy Practices, Amendment of Protected Health Information (PHI), Recipient Access to PHI, Accounting of Disclosures, Workforce Training, Verification, Authorization for Disclosures of PHI, HIPAA Complaint Process, Marketing (if applicable), Research (if applicable), Audit and Monitoring or HIPAA compliance, and Business Associates Agreements with those companies providing goods and services which require the disclosure of PHI, etc.
Where existing confidentiality protections provided by CFR part 2, related to the release of alcohol and drug abuse records, are greater than HIPAA, then the department anticipates that the provider will consider any such provision of 42 CFR part 2 as the guiding language.