9 comments
The draft TDO Supplement should be revised to reflect Virginia’s evolving high-quality community crisis system, particularly the operational role of CRISIS NOW facilities aligned with SAMHSA’s highest fidelity National Guidelines for Crisis Care. Current restrictions appear to rely on outdated assumptions about where individuals under ECOs or TDOs can safely receive assessment and treatment, and may undermine efforts to reduce law enforcement burden, emergency room boarding, and pressure on state psychiatric hospitals.
The key recommendation is to base TDO-related limits on each facility’s demonstrated security and clinical capabilities, rather than applying blanket restrictions. Where a 23-hour program is not intended to hold an individual for the full TDO period, CSBs should plan transfer to an attached CSU bed when available or seek an alternate placement if needed. Medicaid and TDO rules should preserve enough flexibility for Crisis Now facilities to meet the community needs they were designed to address.
Connections Health Solutions appreciates the opportunity to submit these comments. Since November, 2025 Connections has been operating the Prince William County Crisis Receiving Center Complex filling critical gaps in behavioral health crisis care. The immediate impact we are seeing is reduced avoidable hospitalizations, alleviated strain on emergency departments, and improved efficiency across the healthcare, public safety, and criminal justice systems. We operate centers in five states nationwide, and we will be opening a second full-continuum center in partnership with Loudon County later this year. We bring proven experience and outcomes to Virginia’s evolving crisis system. The high level of demand we’re serving in Prince William County reflects both the gaps in the system—and the effectiveness of the model.
Rather than defaulting to hospital emergency departments, inpatient psychiatric units or jail, this center provides a safe, clinical alternative—aligned with SAMHSA’s highest fidelity National Guidelines for Crisis Care—to stabilize people quickly and connect them to ongoing community-based services.
Connections centers are an emergency response resource - open 24 hours a day, seven days a week accepting every individual who comes through the door—including people brought in by law enforcement and first responders—and it serves individuals experiencing the highest acuity mental health and substance use crises, including those who require Emergency Custody Orders and Temporary Detention Orders.
Basic Concern with DRAFT Revision of TDO Supplement
The original premise describing the appropriate location to provide services for an individual under and ECO or a TDO is both out of date and flawed. In order to take into account the rapidly changing landscape of the services available for individuals in crisis and reflect the ongoing capacity issues with the State Psychiatric Hospitals several changes are warranted in the draft:
If the restriction on placing someone who is on a TDO (TDO issued to the facility in question) is based upon the need for “security” and clinical capability – then the facility should be judged on that basis and the TDO “stipulation” attached to their licenses should reflect that.
If, however, the restriction is based on the fact that the 23-hour program is not intended to “house” someone for the 72 hour duration of a TDO then the CSB should note that placement will be made in the attached CSU as soon as a bed becomes available. If it is unlikely that a bed will be available in the specified amount of time, the CSB may choose to seek a different location.
While it within the purview of Medicaid to set limits on payment this seems to be contrary to the State’s intent to improve the functionality of the Community Crisis System. As we read these restrictions:
The original premise describing the appropriate location to provide services for an individual under and ECO or a TDO is both out of date and flawed. In order to take into account the rapidly changing landscape of the services available for individuals in crisis and reflect the ongoing capacity issues with the State Psychiatric Hospitals several changes are warranted in the draft:
If the restriction on placing someone who is on a TDO (TDO issued to the facility in question) is based upon the need for “security” and clinical capability – then the facility should be judged on that basis and the TDO “stipulation” attached to their licenses should reflect that.
If, however, the restriction is based on the fact that the 23-hour program is not intended to “house” someone for the 72 hour duration of a TDO then the CSB should note that placement will be made in the attached CSU as soon as a bed becomes available. If it is unlikely that a bed will be available in the specified amount of time, the CSB may choose to seek a different location.
While it within the purview of Medicaid to set limits on payment this seems to be contrary to the State’s intent to improve the functionality of the Community Crisis System. As we read these restrictions:
I would encourage further discussion regarding the role of 23-hour crisis receiving centers in serving individuals under a TDO, particularly when the crisis receiving center is co-located with a Crisis Stabilization Unit and has clinical staffing, infrastructure, and capacity to safely manage individuals at that level of acuity.
If a facility is equipped to manage the needs commonly associated with individuals under a TDO, including the ability to safely respond to significant behavioral escalation and utilize seclusion, physical restraint, or medication for behavioral emergencies when clinically indicated, it should be permitted to provide care while an individual awaits an appropriate inpatient bed. This could include transition to the facility's attached CSU when a bed becomes available or transfer to another appropriate facility elsewhere in the Commonwealth.
The alternative is often not a more therapeutic or safer level of care. It is an emergency department. Individuals may spend prolonged periods in an ED awaiting psychiatric placement, frequently remaining under law-enforcement custody and, at times, in restraints, while receiving limited psychiatric treatment during that wait. Emergency departments serve an essential role in addressing medical emergencies, but they are generally not designed or staffed to provide the same level of specialized behavioral health crisis intervention available within a crisis receiving center.
Virginia has invested significantly in developing a crisis continuum intended to provide individuals experiencing behavioral health emergencies with care in the most appropriate and least restrictive setting possible. A blanket exclusion of individuals under TDOs from otherwise capable crisis receiving centers risks working against that goal.
I would encourage DBHDS to consider a model based on facility capability and clinical appropriateness rather than TDO status alone. Where a crisis receiving center and attached CSU can demonstrate the staffing, safety infrastructure, clinical capabilities, and regulatory requirements necessary to manage this population, those facilities should have the flexibility to serve individuals under a TDO while they await definitive placement.
Ultimately, the question should be: Where can this individual safely receive the most appropriate psychiatric care while awaiting placement? When a behavioral health crisis facility is equipped to provide that care, requiring the individual to remain in an emergency department simply because of their legal status may not produce the safest or most clinically appropriate outcome.
I would encourage further discussion regarding billing practices for TDOs and ECOs. The updated TDO supplement manual now includes any non Medicaid eligible individual to be covered under the TDO/ECO program. Per the updates:
"For Prescreening Assessments:
Claims for CSB prescreening assessments conducted through emergency services may be submitted to the TDO Program for:
All prescreening assessments are billed under the H2011 HCPCS code and the appropriate team modifier. See Appendix G of the Mental Health Services Manual for additional details. DBHDS Virginia Crisis Connect requirements apply but providers are not required to submit a registration form to the TDO Program."
According to Appendix G in the Mental Health Services Manual, currently preadmission screening require a registration and are listed under the Mobile Crisis Services. Allowable billing is 8 hours within 72 hours. If additional hours are needed, per Appendix G, "If additional time is needed, including time on the last day of the registration that exceeds the 72 consecutive hours from the time of admission, providers must submit a new registration form."
While the ECO period lasts 8 hours, it is rare that an individual is assessed and a bed is located within the 8 hour time period and they are placed in a facility under a TDO. Often Emergency Services is providing care coordination through the duration of the 72 hour TDO period as a billable service, and may need additional hours past the 72 hours if the individual needs a bedside hearing and is still receiving care coordination and placement efforts well beyond the 8 hour ECO and 72 hour TDO bed placement period. Clarification for ability to bill the ECO/TDO fund for time spent for the ECO, TDO, and subsequent prescreens completed while the individual is under a TDO is essential. It is recognized that a registration will not be required but clarification as to reference of billing practices per Appendix G as to additional hours allowable to bill services. Clarification as well for billable services that span multiple days, due to execution and completion of ECO/TDO over several days due to the nature of 24/7/365 Emergency Services service delivery.
I would strongly encourage further discussion regarding the potential for 23 Hour Crisis Centers to accept individuals under an ECO or TDO, particularly when those individuals would share space with voluntary individuals.
One of the fundamental purposes of a Crisis Center is to provide a safe, calm, therapeutic environment where individuals can voluntarily seek support, de-escalate, and ideally prevent a crisis from progressing to a higher level of care. Introducing individuals who are involuntarily detained and may require a significantly higher level of supervision and intervention has the potential to change that environment.
The needs of voluntary individuals seeking support and those requiring involuntary detention can be dramatically different. We should be cautious about creating an environment in which meeting the needs of one population unintentionally compromises the therapeutic experience, sense of safety, or willingness to seek services of another. Many individuals choose Crisis Center services specifically because they offer an alternative to the acuity and environment of an emergency department or inpatient setting. If the Crisis Center begins to resemble those environments, we risk losing one of the very things that makes this level of care effective.
We see a similar principle with Crisis Stabilization Units. For some individuals, a CSU provides a more therapeutic and less overwhelming alternative to a higher-acuity inpatient environment. There are individuals who will voluntarily accept treatment in a CSU specifically because they feel safer there but would not go voluntarily to a psychiatric hospital. We should preserve that same intentionality across the crisis continuum rather than making every level of care serve every level of acuity.
There are also significant operational considerations. Our current Crisis Center infrastructure and staffing model were designed around voluntary crisis services. Managing individuals under an ECO or TDO may require different staffing, including continuous or 1:1 supervision, enhanced safety measures, and other resources that many Crisis Centers were not designed or funded to provide; not to mention that we already serve ECO’s at the CIT Assessment Center and TDO’s at the CSU at our CSRC location.
Additionally, an ECO involves law enforcement custody. For many of the individuals we serve, the presence of law enforcement can itself be distressing or triggering. Bringing that dynamic into a space intentionally designed to feel safe, voluntary, and welcoming deserves careful consideration.
Ultimately, my concern is about protecting the integrity and purpose of Crisis Center services. Voluntary individuals should be able to access the environment we have represented to them: a safe, calm, therapeutic place to seek help before their situation escalates. We should be very cautious about implementing changes that could unintentionally discourage lower-acuity individuals from seeking help early or make them feel less safe once they arrive.
The CSB supports DMAS’s proposal to expand TDO Program reimbursement for prescreening assessments administered to individuals who are not Medicaid-eligible. In particular, the CSB supports reimbursement when:
These changes appropriately recognize that CSBs are legally responsible for providing emergency services evaluations regardless of an individual’s insurance status and that clinically necessary prescreening may occur outside the initial ECO period. The expanded coverage should reduce uncompensated mandated services and support timely behavioral health crisis evaluations.
The CSB requests that DMAS address the following issues before finalizing the supplement.
1. Clearly identify the required billing modifiers
The proposed language instructs providers to submit H2011 with the appropriate emergency-services team modifier but does not clearly specify the status modifier required for each newly covered prescreening circumstance.
The current TDO Supplement directs providers to use modifier 32 when a prescreening is conducted under an ECO. Appendix G of the Mental Health Services Manual also distinguishes between modifier 32 for a prescreening under an ECO and modifier HK for a prescreening not conducted under an ECO.
DMAS should include a billing table specifying the complete modifier combination for each circumstance, including:
The final supplement should expressly state whether modifier 32 remains required for ECO prescreening claims and identify the modifier required for subsequent assessments under a TDO. This information should not be left to provider interpretation.
2. Define “subsequent prescreening assessment”
The proposed supplement allows reimbursement for subsequent prescreening assessments while a non-Medicaid-eligible individual remains under a TDO. This is an important addition, but the term “subsequent prescreening assessment” should be defined.
The final guidance should explain:
Without clear parameters, CSBs and the TDO Program may interpret coverage differently, leading to inconsistent claims processing and avoidable denials.
3. Clarify use of the CSB Emergency Custody Attestation Form
The CSB supports establishing an alternative form when law enforcement initiates emergency custody and a magistrate-issued ECO is unavailable. This recognizes that, under Virginia law, emergency custody can be initiated directly by law enforcement.
Additional instructions are needed regarding:
The form also requests a Social Security number, driver’s license number, home address, and other identifying information that may not be known or readily available during a behavioral health emergency. The final instructions should allow the CSB to enter “unknown” or “not available” without causing the claim to be rejected.
DMAS should also explain the claims-processing purpose for each requested identifier and limit required information to what is necessary to identify the individual and process the claim. Obtaining optional identifiers should not delay the prescreening assessment, the disposition process, or the submission of an otherwise valid claim.
4. Clarify third-party liability requirements
The supplement should more clearly distinguish between uninsured individuals and those who are not Medicaid-eligible but have other health insurance.
DMAS should specify:
Because prescreening assessments are mandated and time-sensitive, reimbursement should not depend on lengthy attempts to obtain payment from a carrier that does not cover the service.
5. Clarify the removal of the 15-day IMD language
The CSB supports removing language that could be interpreted as imposing a 15-day clinical or benefit limit on an individual’s stay at an institution for mental health issues.
The final supplement should clearly explain that the federal 15-day provision concerns federal managed-care capitation-payment rules and does not, by itself, establish a maximum medically necessary length of stay for the individual.
6. Provide implementation guidance before enforcement
Before the revised supplement becomes effective, DMAS should provide:
Claims submitted during the initial implementation period should not be denied solely because of unclear modifier, form, or documentation requirements that were not expressly addressed in the final guidance.
Address continuity of 23-hour crisis stabilization services
The proposed Supplement continues to reimburse 23-hour crisis stabilization through the TDO Program during an ECO but not after the individual becomes subject to a TDO. While this may create a discontinuity in care, we believe the issue warrants further evaluation before broadly extending reimbursement.
Virginia’s psychiatric bed shortages make 23-hour crisis services an important diversion option. However, not all 23-hour settings are designed to safely manage individuals under a TDO. Some operate in open environments with recliners in close proximity and may lack secured egress, continuous observation, enhanced staffing, or other safety features associated with higher-acuity psychiatric care.
National models indicate that some high-acuity psychiatric emergency programs can safely serve involuntary patients when appropriate staffing, monitoring, security, and clinical infrastructure are in place. The key issue, therefore, is not merely whether a person under a TDO may remain in a 23-hour setting, but which individuals can be safely served, in which settings, and under what conditions.
We recommend that DMAS and DBHDS further evaluate the clinical, safety, operational, capacity, and reimbursement implications before implementing a statewide change. This review should include patient outcomes, safety events, effects on 23-hour bed availability, impacts on inpatient and emergency department utilization, facility capabilities, and the potential for reimbursement policy to unintentionally influence level-of-care decisions.
A reasonable path forward may be to establish clear clinical and facility criteria or to consider a limited pilot to continue 23-hour reimbursement after an ECO converts to a TDO. This would allow Virginia to balance continuity of care and psychiatric bed capacity with patient safety, risk management, and appropriate level-of-care decisions.
The Eastern Shore Community Services Board (ESCSB) does not support the VACSB's position on this issue. DMAS should not pay for TDOs for patients who are NOT receiving acute inpatient level of care that a TDO indicate is warranted. The ESCSB's understanding of this proposal is that TDO Patients are being "placed" in a 23-hour Crisis Recovery Center (CRC)recliner, instead of being placed in an actual inpatient TDO bed. A 23-hour CRC facility is by definition a voluntary facility. CRC patients have the capacity to volunteer and have been assessed to be at a sub-acute level of care, otherwise they would have been assessed to meet the regulatory criteria for acute in-patient care wither voluntary or under a TDO. At the very minimum a TDO patient is placed against their will either by refusing or by lacking the capacity to make an informed decision. Thus, requiring in-patient psychiatric care.
Submitted by John Konkel, LPC Emergency Services and CIT Coordinator, ESCSB
CSBs that operate facilities with co-located crisis services, such as Crisis Receiving Centers (CRCs), Crisis Stabilization Units (CSUs), and Crisis Intervention Team Assessment Centers (CITACs), should be allowed to manage the populations of individuals receiving services within those facilities according to the individuals level of care needs, the building specifications, workflows, and program-specific policies and procedures. In order to support these operations, DMAS should provide flexibility in reimbursing services for individuals under ECOs and TDOs based on their presence within the facility broadly, rather than limiting reimbursement based on the specific program area in which the individual is located.