TMPPM 2008 > Texas Medicaid Services > Hospital (Medical/Surgical Acute Care Facility) > Outpatient

25.3.3.30 Psychiatric Services

Each individual behavioral health practitioner is limited to a combined total of 12 hours of Medicaid reimbursement per day for behavioral health services. Each individual delegated to perform behavioral health services by a doctor of medicine (MD) or doctor of osteopathy (DO) is also limited to a combined total of 12 hours. MDs and DOs who delegate and providers who perform group therapy may possibly submit claims in excess of 12 hours in a given day.

Retrospective review may occur for both the total hours of services performed per day and for the total hours of services billed per day. If inappropriate payments are identified, the money will be recouped. Documentation requirements for all services billed are listed for each individual specialty in this manual.

Outpatient behavioral health services without prior authorization are limited to 30 encounters/visits per client per calendar year. An encounter/visit is defined as any and all outpatient behavioral health services rendered per hour by any provider, in the office, outpatient, nursing home, and home settings. This limitation includes encounters/visits by all practitioners.

The following services are not counted towards the 30-encounter/visit limitation:

•School Health and Related Services (SHARS) behavioral health rehab services.

•Mental Health and Mental Retardation (MHMR) services.

•Laboratory and radiology services.

•Pharmacological management (1-90862).

Services that exceed 30 encounters/visits per calendar year per client must be prior authorized. Prior authorization must be obtained before providing the 25th service in a calendar year. Prior authorization requests in increments of up to 10 additional encounters/visits may be considered. 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.

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 unable to submit the prior authorization request by the client's 25th encounter/visit.

All authorization requests for extension of outpatient psychotherapy sessions beyond the annual 30-encounter/visit limitation are limited to 10 encounters/visits per request, and must be submitted on the Extended Outpatient/ Counseling Request Form. Requests must include the following:

•Client name and Medicaid number.

•Provider name and provider identifier.

•Clinical update, including current specific symptoms and response to past treatment, and 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 and type of services requested and the dates (based on the frequency of visits) that the services will be provided.

•All areas of the request must be completed with the information required on the form. If additional room is needed providers may state "see attached." The attachment must contain the specific information required in that section of the form.

Prior authorization is not granted to providers who have seen a client for an extended period of time or from the start of the calendar year and who have not requested prior authorization before the 25th encounter/visit. It is recommended that a request for extension of outpatient behavioral health be submitted no sooner than 30 days before the date of service being requested, so that the most current information is provided.

The number of encounters/visits authorized is dependent on the client'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 request for additional encounters/visits must include new documentation addressing the client's current condition, treatment plan, and the therapist's rationale supporting the medical necessity for these additional encounters/visits. Prior authorization for an extension of outpatient behavioral health services is granted when the treatment is mandated by the courts for court-ordered services. A copy of the court order for outpatient treatment signed by the judge must accompany prior authorization requests.

Mail or fax the request to the following address:

Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway, Suite 150
Austin, TX 78727
Fax: 1-512-514-4213

Use revenue code A-124 for inpatient psychiatric services. The following psychiatric services are not benefits of the Texas Medicaid Program:

•The services of a licensed chemical dependency counselor (LCDC), psychological associate (masters level psychologist), psychiatric nurse, or behavioral health worker.

•Psychiatric daycare.

•Recreational therapy.

•Biofeedback.

•Music/dance.

•Thermogenic therapy.

Outpatient psychiatric services for the diagnosis or treatment of a mental, psychoneurotic, or personality disorder are reimbursed at the hospital's designated reimbursement rate as determined by the annual cost settlement.

Note: NorthSTAR is a managed care program in the Dallas service area that covers behavioral health services. Psychiatrists that provide behavioral health services to clients in NorthSTAR must be members of the NorthSTAR BHOs.

Refer to: "Request for Extended Outpatient Psychotherapy/Counseling Form".

"Medicaid Managed Care" for more information or contact the client's BHO.