Hospital In-Reach Service Coordination (IRSC)

Overview

PrimeWest Health covers hospital in-reach service coordination (IRSC) to reduce instances of emergency department and other non-medically necessary health care utilization. Hospital IRSC brings together health care and community-based services for PrimeWest Health members for up to 60 days after hospital discharge. It includes helping the member navigate and coordinate services to address mental and chemical health; housing; transportation; employment; peer support services; and other health, social, and economic needs. Hospital IRSC also connects the member with existing covered services available to him/her, such as targeted or waiver case management or care coordination in a Health Care Home (HCH).

Eligible Providers

Hospitals may employ or contract with the following individual providers to provide hospital IRSC:

1. Clinical Nurse Specialist – Mental Health (CNS-MH)
2. Licensed Independent Clinical Social Worker (LICSW)
3. Licensed Marriage and Family Therapist (LMFT)
4. Licensed Professional Clinical Counselor (LPCC)
5. Licensed Psychologist (LP)
6. Mental health rehabilitative professional
7. Nurse practitioner (NP)
8. Physician
9. Physician assistant (PA)

Hospitals may also employ or contract for IRSC with a coordinator who is not one of the above-named provider types. This contracted coordinator must be supervised by one of the providers listed above and have, at minimum, a bachelor’s degree in social work, public health, corrections, or a related field.

Enrolled Community-Based Providers

MHCP-enrolled community-based providers need to sign and submit to MHCP a Community-based Providers for In-Reach Service Coordination (IRSC) – Applicant Assurance Statement (DHS-3898) so their records indicate they are IRSC program participants.

In-Reach Service Coordinators

Eligible in-reach service coordinators must hold a minimum of a bachelor’s degree in social work, public health, corrections, or a related field.

Eligible Members

Before performing the assessment, PrimeWest Health recommends that providers determine if the member is already receiving services that would make him/her ineligible for participation in in-reach care coordination.

Members receiving the following services are not eligible to participate:

1. Health care home services
2. Mental Health Targeted Case Management (MH-TCM) services
3. Health care delivery system (HCDS) demonstration project services

IRSC is available to members of any age with three or more emergency department visits in the previous four consecutive months.

The qualifying emergency department services and inpatient stays are not limited to a single hospital. Clinicians may use the Minnesota Information Transfer System (MN–ITS) Health Information Request (HIR) User Guide clinical tool to access a more complete medical history for PrimeWest Health members. The HIR User Guide clinical tool can help prevent duplication of services. If multiple providers deliver IRSC one or more days during a 60-day service period, PrimeWest Health will reimburse all providers for the initial assessment; however, only the provider whose claim is filed first with the state will be reimbursed for the follow-up continuing service.

Reimbursement Period

The 60-day service reimbursement period begins on either of the following:

1. On the date of the initial assessment for members identified in the emergency department
2. On the date of discharge from the hospital for members identified during hospitalization

Members enrolled in the following PrimeWest Health programs are eligible for hospital IRSC services:

Covered Services

PrimeWest Health covers hospital IRSC performed through a hospital ED. Covered services include coordination and navigation services and services rendered to connect eligible members with existing PrimeWest Health-covered services and community-based services and resources available.

The provider must perform an initial assessment of the member to evaluate the following:

1. Mental and chemical health needs
2. Housing needs
3. Transportation needs
4. Employment needs
5. Peer support services needs
6. Other health, social, and economic needs, including an assessment of other services that the member may be eligible for or receiving, such as targeted or waiver case management or care coordination in an HCH

Follow-up services after the initial assessment include navigation and coordination services to help the member access a continuum of services to reduce frequency of visits to a hospital ED for non-medically necessary health care utilization. These services may address the member’s needs determined in the initial assessment. Services may be provided in the member’s living environment or by phone.

Hospital IRSC:

1. May be provided for up to 60 days after the discharge date of the ED visit or inpatient hospital admitting event that results from an ED visit;
2. Is limited to two non-overlapping 60-day periods per calendar year, if there are a minimum of three ED visits or inpatient admitting events that resulted from an ED visit; and
3. Is limited to a total of 80 hours across one or both 60-day periods.

Non-Covered Services

The following services are not covered under hospital IRSC:

1. Services over 80 hours within a calendar year
2. More than two non-overlapping 60-day occurrences within a calendar year
3. Other existing covered services (for example, transportation, housing, mental health services, and chemical health services)

Billing

1. Use the electronic 837P Professional claim format.
2. Use procedure code T1016 with modifier U2 for the initial hospital IRSC assessment.
3. Use procedure code T1016 with modifier U2 and TS for follow-up hospital IRSC services.
4. Services are billable in 15-minute unit increments.
5. Use the hospital NPI as the billing provider.
6. Report the NPI of the treating professional; if the services are provided by an in-reach service coordinator, report the NPI of the supervising professional as the treating provider.

PW_11-18_494
Updated_11/09/2018