TMPPM 2008 > Provider Information > Managed Care > PCCM

7.5.10.3 Behavioral Health Services

Behavioral health services are provided for the treatment of mental disorders, emotional disorders, and chemical dependency disorders. Behavioral health services do not require a primary care provider referral. PCCM clients may self-refer to any Medicaid-enrolled behavioral health provider for treatment. A referral from the client's primary care provider is not required. A primary care provider may, in the course of treatment, refer a patient to a behavioral health provider for an assessment or for treatment of an emotional, mental, or chemical dependency disorder. A primary care provider may also provide behavioral health services within the scope of his practice.

PCCM clients may receive any behavioral health service that is medically necessary, currently covered by the Texas Medicaid Program, and provided by a Medicaid-enrolled behavioral health provider. Behavioral health providers include psychiatrists, psychologists, LCSWs, LPCs, LMFTs, and TCADA licensed facilities. See each individual aforementioned section for benefits and limitations.

In addition, many services are offered through DADS and DSHS that do not require a referral. These include case management for mental health and mental retardation, mental health rehabilitative services, and mental retardation diagnosis and assessment.

Behavioral health providers are encouraged to contact a client's primary care provider to discuss the patient's general health. Primary care providers are encouraged to maintain contact with the behavioral health provider to document behavioral health assessments and treatments and to inform the behavioral health provider of any condition the client may have that could impact the behavioral health service delivery. However, client approval for any exchange of information between the primary care provider and behavioral health provider is required. Please use the "Primary Care Case Management (PCCM) Behavioral Health Consent Form".

Primary care providers are responsible for documenting referrals to behavioral health providers and any known self-referrals for behavioral health services in each client's medical record.

Outpatient Services

Outpatient Behavioral health services that exceed 30 visits per client, per calendar year must be prior authorized by TMHP. Clinicians should plan therapy with the 30-encounter limitation in mind and should request extension authorizations before the client's twenty-fifth visit. The current policies and guidelines require that authorizations be obtained before rendering service.

Fax the completed form, "Request for Extended Outpatient Psychotherapy/Counseling Form" to TMHP/Special Medical Prior Authorizations at 1-512-514-4213 for prior authorization. Refer to individual provider sections of this manual for additional information on extension requirements ("Psychologist" , "Psychiatric Services" , "Licensed Clinical Social Worker (LCSW)" , "Licensed Marriage and Family Therapist (LMFT)" , "Licensed Professional Counselor (LPC)" ) or contact TMHP at 1-800-925-9126.

Inpatient Services

PCCM requires notification for urgent or emergent inpatient psychiatric care in an acute care facility prior to claims submission for in-network facilities. Scheduled admissions for psychiatric care require prior authorization. Out-of-network admissions require notification within the next business day and submission of clinical information to determine appropriateness for transfer to a contracted facility. Fax the completed PCCM Inpatient/Outpatient Authorization Form to the PCCM Inpatient Prior Authorization Department at 1-512-302-5039 or call 1-888-302-6167.

Prior authorization is required for psychiatric admissions of patients under 21 years of age to a freestanding psychiatric facility. Fax the completed "Psychiatric Inpatient Initial Admission Request Form" to 1-512-514-4211 to obtain authorization. Inpatient psychiatric admissions to freestanding facilities for clients 21 years of age and older are not covered under the Texas Medicaid Program.

Refer to "Psychiatric Hospital/Facility (Freestanding) (THSteps-CCP Only)" for additional information concerning the requirements of freestanding psychiatric admissions, or contact the TMHP Comprehensive Care Inpatient Psychiatric (CCIP) Unit at 1-800-213-8877.