TMPPM 2010 > Behavioral Health, Rehabilitation, and Case Management Services Handbook > Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), and Licensed Professional Counselor (LPC) > Services/Benefits, Limitations, and Prior Authorization > Prior Authorization > Initial Prior Authorization Request for Encounters/Visits beyond the 30-Encounter/Visit Limit

5.2.1 Prior Authorization

5.2.1.1 Initial Prior Authorization Request for Encounters/Visits beyond the 30-Encounter/Visit Limit

Each Medicaid client is limited to 30 encounters/visits per calendar year. It is anticipated that this limitation, which allows for 6 months of weekly therapy or 12 months of biweekly therapy, is adequate for 75 to 80 percent of clients. Clinicians should plan therapy with this limit in mind. However, it may be medically necessary for some clients to receive extended encounters/visits. In these situations, prior authorization is required.

A provider who sees a client regularly and who anticipates that the client will require encounters/visits beyond the 30-encounter/visit limit must submit the request for prior authorization before the client's 25th encounter/visit.

It is recognized that a client may change providers in the middle of the year, and the new provider may not be able to obtain complete information on the client. In these instances, prior authorization may be made before rendering services when the request is accompanied by an explanation as to why the provider was not able to submit the prior authorization request by the client's 25th encounter/visit.

After the 30 encounter/visit annual limitation has been met, prior authorization will be considered in increments of up to 10 additional encounters/visits per request. All requests for prior authorization of extensions beyond the 30 initial encounter/visit annual limit must be submitted on a completed "Outpatient Psychotherapy/Counseling Form," which must include the following:

•Client name and Medicaid number, date of birth, age, and sex

•Provider name and identifier

•A complete diagnosis as listed in the current edition of the DSM-IV-TR

•History of substance abuse

•Current medications

•Current living condition

•Clinical update, including specific symptoms and response to past treatment, treatment plan (measurable short term goals for the extension, specific therapeutic interventions to be used in therapy, measurable expected outcomes of therapy, length of treatment anticipated, and planned frequency of encounters/visits)

•Number, type of services requested, and the dates based on the frequency of encounters and/or visits that the services will be provided

•Date on which the current treatment is to begin

•Indication of court-ordered or Department of Family and Protective Services (DFPS)-directed services, when appropriate

Refer to: Form BH.1, "Outpatient Psychotherapy/Counseling Form" in Section 11, "Forms" in this handbook.

Note: All areas of the request form must be completed with the information required by the form. If additional room is needed for a particular section of the form, providers may state "see attached," in that section and attach the additional pages to the form. The attachment must contain the specific information required in that section of the form.

A prior authorization request for initial extended encounters/visits must be submitted no sooner than 30 days before the date of service being requested, so that the most current information is provided.

Prior authorization requests will be reviewed by HHSC or its designee's Medical Director. The number of encounters/visits that are prior authorized will depend upon the patient's symptoms and response to past treatment. If the client requires additional extensions, the provider must submit a new request for prior authorization at the end of each extension period. The additional request(s) must include the following new documentation concerning the patient's current conditions.