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7.4.2 Prior Authorization Requirements after the Annual Encounter/Visit Limitations Has Been Met
All outpatient behavioral health services for all provider types approved to deliver outpatient services will require prior authorization with the exception of the following:
• CDTF services
•County Indigent Health Care Program (CIHCP) services
•FQHC and rural health clinic (RHC) services
•Laboratory and radiology services
•MHMR services
•Pharmacological regimen oversight (procedure code M0064) and pharmacological management (procedure code 90862)
•SHARS behavioral health rehabilitation services
•One psychiatric diagnostic interview (procedure code 90801 or 90802) per year, per client, per provider (same provider)
Prior authorization will be considered in increments of up to ten services per request once the annual encounter/visit limitation has been met. If the client changes providers during the year and the new provider is unable to obtain complete information on the client, prior authorization may be made when the request is accompanied by an explanation as to why the provider was not able to submit the prior authorization request by the 25th encounter/visit and before rendering services. This information must be submitted in addition to the usual medical necessity information.
Prior authorization will not be granted to providers who have been seeing a client and have a well established relationship or from the start of the calendar year and who have not requested prior authorization before the 25th encounter/visit.
All requests for prior authorization with the exception of psychological and neuropsychological testing must include a completed Outpatient Psychotherapy/Counseling Request Form dated and signed by the performing provider with the following information:
•Client name, 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 responses 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 the planned frequency of encounters/visits)
•Number of services requested for each type of therapy and the dates based on the frequency of encounters/visits that the services will be provided
•The date on which current treatment is to begin
•A indication of court-ordered or DFPS-directed services
The Outpatient Psychotherapy/Counseling Request Form may be mailed to the TMHP Special Medical Prior Authorization Department at:
Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization Department
12357-B Riata Trace Parkway, Suite 150
Austin, TX 78727
The form may also be faxed to 1-512-514-4214 or submitted online on the TMHP website at www.tmhp.com.
All of the required areas on the request form must be completed. 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.
The request must be signed and received no later than the start date listed on the request form and no earlier than 30 days prior to the start date listed on the form.
To avoid unnecessary denials, the provider must provide correct and complete information, including accurate documentation of medical necessity for the services requested. The provider must maintain documentation of medical necessity in the client's medical record. The requesting provider may be asked for additional information to clarify or complete a request for outpatient behavioral health services.
The diagnosis code that supports medical necessity for the billed outpatient behavioral health service must be referenced on the claim.
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