The following words and terms, when used in this subchapter,
have the following meanings unless the context clearly indicates otherwise.
(1) Adolescent--An individual who is at least 13 years
of age, but younger than 18 years of age.
(2) Adult--An individual who is 18 years of age or
(3) Assessment or reassessment--A systematic process
for determining an individual's need for any clinically necessary
medical, educational, social, or other services (e.g., taking client
history, gathering information from other sources, identifying the
needs of the individual, and completing related documentation).
(4) Business day--Any day except a Saturday, Sunday,
or legal holiday listed in the Texas Government Code, §662.021.
(5) Case manager--An employee who provides MH case
(6) Child--An individual who is at least three years
of age, but younger than 13 years of age.
(7) CFR--Code of Federal Regulations.
(8) Community based--A description of the location
where routine or intensive case management services are provided (i.e.,
in an individual's community).
(9) Community mental health center or CMHC--An entity
established in accordance with the Texas Health and Safety Code, §534.001,
as a community mental health center or a community mental health and
mental retardation center.
(10) Community resources--People or entities providing
services that address the identified needs of individuals receiving
MH case management services (e.g., providers of medical care, food,
clothing, child care, employment, or housing).
(11) Community services specialist or CSSP--A staff
member who, as of August 31, 2004:
(A) has received:
(i) a high school diploma; or
(ii) a high school equivalency certificate issued in
accordance with the law of the issuing state; and
(B) has had three continuous years of documented full-time
experience in the provision of MH case management services; and
(C) has demonstrated competency in the provision and
documentation of MH case management services in accordance with this
subchapter and the MH Case Management Billing
(12) Crisis--A situation in which:
(A) the individual presents an immediate danger to
self or others;
(B) the individual's mental or physical health is at
risk of serious deterioration; or
(C) an individual believes that he or she presents
an immediate danger to self or others or that his or her mental or
physical health is at risk of serious deterioration.
(13) Day--A calendar day, unless otherwise specified.
(14) Department--Department of State Health Services
(15) Designee--A person or entity named by the department
to act on its behalf.
(16) Dual relationship--A situation that occurs if
a case manager interacts with an individual in more than one capacity,
whether it be before, during, or after the professional, social, or
business relationship. Dual relationships can occur simultaneously
(17) Employee--A person who receives a W2 Wage and
Tax Statement from a provider.
(18) Individual--A person seeking or receiving MH case
(19) Institution for mental diseases or IMD--Based
on 42 CFR §435.1009, a hospital, nursing facility, or other institution
of more than 16 beds that is primarily engaged in providing psychiatric
diagnosis, treatment, or care of individuals with mental illness,
including medical attention, nursing care, and related services.
(20) Intensive case management--A focused effort to
coordinate community resources that assist a child or adolescent in
gaining access to necessary care and services appropriate to the child's
or adolescent's needs. The standards for providing intensive case
management services are set forth in §412.407 of this title (relating
to MH Case Management Services Standards).
(21) Intensive case management plan or plan--A written
document that is part of the medical record and is developed by a
case manager, in collaboration with the individual and the individual's
LAR or primary caregiver, that identifies services needed by the individual
and sets forth a plan for how the individual may gain access to the
(22) Legally authorized representative or LAR--A person
authorized by law to act on behalf of an individual with regard to
a matter described in this subchapter, including, but not limited
to, a parent, guardian, or managing conservator.
(23) Level of care or LOC--A designation given to the
department's standardized packages of mental health services, based
on the uniform assessment and the utilization management guidelines,
which specify the type, amount, and duration of MH case management
services to be provided to an individual.
(24) Life domains--Areas of life in which a child or
adolescent has unmet needs, including, but not limited to safety,
health, emotional, psychological, social, educational, cultural, and
(25) Medically necessary--A clinical determination
made by an LPHA that services:
(A) are reasonable and necessary for the treatment
of a mental health disorder or to improve, maintain, or prevent deterioration
of functioning resulting from such a disorder;
(B) are provided in accordance with accepted standards
of practice in behavioral health care;
(C) are furnished in the most appropriate and least
restrictive setting in which services can be safely provided;
(D) are at the most appropriate level or amount of
service that can be safely provided; and
(E) could not have been omitted without adversely affecting
the individual's mental and/or physical health or the quality of care
(26) Mental health (MH) case management services--Activities
that assist an individual in gaining and coordinating access to necessary
care and services appropriate to the individual's needs. Case management
activities include assessment, recovery planning, referral and linkage,
and monitoring and follow up. Activities may be provided as routine
case management or intensive case management.
(27) Monitoring and follow-up--Activities and contacts
that are necessary to ensure that referrals and linkages are effectively
implemented and adequately addressing the needs of the individual.
The activities and contacts may be with the individual, LAR, primary
caregiver, family members, providers, or other people and entities
to determine whether services are being furnished, the adequacy of
those services, and changes in the needs or status of the individual.
(28) Primary caregiver--A person 18 years of age or
(A) has actual care, control, and possession of a child
or adolescent; or
(B) has assumed responsibility for providing shelter
and care for an adult.
(29) Provider--A community mental health center that
has a contract with the department to provide general revenue-funded
MH case management services, Medicaid-funded MH case management services,
(30) Qualified mental health professional-community
services or QMHP-CS--A staff member who meets the definition of a
QMHP-CS set forth in Subchapter G of this chapter (relating to Mental
Health Community Services Standards).
(31) Recovery--A process of change through which individuals
improve their health and wellness, live a self-directed life, and
strive to reach their full potential.
(32) Recovery plan or treatment plan--A written plan
developed with the individual and, as required, the LAR and a QMHP-CS
that specifies the individual's recovery goals, objectives, and strategies/interventions
in conjunction with the uniform assessment that guides the recovery
process and fosters resiliency as further described in §412.322(e)
of this title (relating to Provider Responsibilities for Treatment
Planning and Service Authorization) concerning content and timeframe
of treatment plan.
(33) Recovery planning--A systematic process for ensuring
the individual's active participation and allowing the LAR, and the
primary caregiver and others to develop goals and identify a course
of action to respond to the clinically assessed needs. The assessed
needs may address medical, social, educational, and other services
needed by the individual.
(34) Referral and linkage--Activities that help link
an individual with medical, social, and educational providers, and
with other programs and services that are capable of providing needed
services (e.g., referrals to providers for needed services and scheduling
(35) Routine case management--Services that assist
an individual in gaining and coordinating access to necessary care
and services appropriate to the individual's needs. The standards
for providing routine case management services are set forth in §412.407
of this title.
(36) Site based--The location where routine case management
services are usually provided (i.e., the case manager's place of business).
(37) Staff member--Provider personnel, including a
full-time and part-time employee, contractor, or intern, but excluding
(38) Strengths based--The concept used in service delivery
that identifies, builds on, and enhances the capabilities, knowledge,
skills, and assets of the child, adolescent, LAR, or primary caregiver,
and family, their community, and other team members. The focus is
on increasing functional strengths and assets rather than on the elimination
(39) TAC--Texas Administrative Code.
(40) Uniform assessment--An assessment adopted by the
department that is used for recommending an appropriate level of care
(41) Utilization management guidelines--Guidelines
developed by the department that establish the type, amount, and duration
of MH case management services for each LOC.
(42) Wraparound process planning or other department-approved
model--A strengths-based course of action involving a child or an
adolescent and family, including any additional people identified
by the child or adolescent, LAR, primary caregiver, and family, that
results in a unique set of community services and natural supports
that are individualized for the child or adolescent to achieve a positive
set of identified outcomes.
Source Note: The provisions of this §412.403 adopted to be effective February 14, 2013, 38 TexReg 647