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2012 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 7. Screening, Brief Intervention, and Referral to Treatment (SBIRT) : 7.6 Documentation Requirements

7.6
Client record documentation must support medical necessity for the services provided and must be maintained and made readily available for review when requested by the Health and Human Services Commission (HHSC) or its designee. SBIRT documentation must include the following:
A written, client-centered plan for the delivery of medically necessary SBIRT. The plan must be completed at the time the client is admitted to the second session (referral). The plan must include the following:
The provider who performed the screening must document that a follow-up appointment was made for a subsequent session.
If inappropriate payments are identified on retrospective review for any provider, the payments will be recouped.

Texas Medicaid & Healthcare Partnership
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