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2012 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook

Behavioral Health, Rehabilitation, and Case Management Services Handbook
Table of Contents
1. General Information BH-7
2. Blind Children’s Vocational Discovery and Development Program (BCVDDP) BH-7
2.1 Overview BH-7
2.2 Enrollment BH-8
2.3 Services, Benefits, Limitations, and Prior Authorization BH-8
2.3.1 Prior Authorization BH-8
2.4 Documentation Requirements BH-8
2.5 Claims Filing and Reimbursement BH-8
3. Case Management for Children and Pregnant Women BH-9
3.1 Overview BH-9
3.1.1 Eligibility BH-9
3.1.2 Referral Process BH-10
3.2 Enrollment BH-10
3.3 Services, Benefits, Limitations, and Prior Authorization BH-11
3.3.1 Prior Authorization BH-11
3.4 Technical Assistance BH-11
3.4.1 Assistance with Program Concerns BH-11
3.5 Documentation Requirements BH-12
3.6 Claims Filing and Reimbursement BH-12
3.6.1 Claims Information BH-12
4. Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist
(LMFT), and Licensed Professional Counselor (LPC ) BH-12
4.1 Enrollment BH-12
4.1.1 LCSW BH-12
4.1.2 LMFT BH-13
4.1.3 LPC BH-13
4.2 Services, Benefits, Limitations, and Prior Authorization BH-13
4.2.1 Prior Authorization BH-16
4.2.1.1 Initial Prior Authorization Request for Encounters or Visits beyond
the 30‑encounter or Visit Limi t BH-16
4.2.1.1.1 Client Condition Requirements BH-17
4.2.1.1.2 Initial Assessment Requirements BH-17
4.2.1.1.3 Active Treatment Plan Requirements BH-17
4.2.1.1.4 Discharge Plan Requirements BH-18
4.2.1.2 Subsequent Prior Authorization Request for Encounters or Visits after
the Initial Prior Authorized Encounters BH-18
4.2.1.2.1 Client Condition Requirements BH-18
4.2.1.2.2 Active Treatment Plan Requirements BH-18
4.2.1.2.3 Discharge Plan Requirements BH-18
4.2.1.2.4 Prior Authorization for Court-Ordered and Department of Family
and Protective Services (DFPS)-Directed Services BH-19
4.3 Documentation Requirements BH-19
4.4 Claims Filing and Reimbursement BH-19
5. Mental Health Rehabilitation, Mental Health Case Management, and Intellectual
Disability Service Coordination BH-20
5.1 Enrollment BH-20
5.1.1 Local Authority (LA) Providers BH-20
5.2 Services, Benefits, Limitations, and Prior Authorization BH-21
5.2.1 Service Coordination and Case Management BH-21
5.2.2 MH Rehabilitative Services BH-23
5.2.2.1 Rehabilitative Services Limitations BH-24
5.2.2.2 Billing Units BH-24
5.2.3 Prior Authorization BH-24
5.3 Documentation Requirements BH-24
5.4 Claims Filing and Reimbursement BH-25
5.4.1 Managed Care Clients BH-25
6. Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers BH-25
6.1 Enrollment BH-25
6.1.1 Physicians BH-25
6.1.2 Psychologists BH-26
6.1.3 Licensed Psychological Associate (LPA) BH-26
6.2 Services, Benefits, Limitations, and Prior Authorization BH-27
6.2.1 Physicians BH-27
6.2.2 Psychologists and LPAs BH-27
6.3 The 12-Hour System Limitation BH-27
6.3.1 Retrospective Review of Behavioral Health Services Billed in Excess of
12 Hours per Day BH-28
6.3.2 Procedure Codes included in the 12-hour System Limitation BH-28
6.3.3 Formula Applied BH-30
6.4 Outpatient Behavioral Health Services BH-31
6.4.1 Annual Encounter or Visit Limitations BH-31
6.4.2 Prior Authorization Requirements after the Annual encounter or visit
Limitations Have Been Met BH-31
6.5 Court-Ordered and DFPS-Directed Services BH-33
6.5.1 Prior Authorization BH-33
6.5.2 Documentation Requirements BH-33
6.6 Electroconvulsive Therapy (ECT) BH-34
6.7 Family Therapy or Counseling Services BH-34
6.7.1 Prior Authorization BH-35
6.7.2 Documentation Requirements BH-35
6.7.3 Reimbursement BH-35
6.8 Pharmacological Regimen Oversight and Pharmacological Management Services BH-35
6.8.1 Indications for Pharmacological Regimen Oversight and Pharmacological
Management Services BH-36
6.8.2 Prior Authorization BH-37
6.8.3 Documentation Requirements BH-37
6.8.4 Reimbursement BH-37
6.9 Psychiatric Diagnostic Interviews BH-38
6.9.1 Prior Authorization BH-39
6.9.2 Documentation Requirements BH-40
6.9.3 Domains of a Clinical Evaluation BH-40
6.9.4 Reimbursement BH-40
6.10 Psychological and Neuropsychological Testing BH-42
6.10.1 Prior Authorization BH-44
6.10.2 Documentation Requirements BH-44
6.10.3 Reimbursement BH-45
6.11 Psychotherapy or Counseling BH-46
6.11.1 Prior Authorization BH-47
6.11.2 Documentation Requirements BH-48
6.11.3 Initial Outpatient Psychotherapy or Counseling for an Individual, Group,
or Family BH-48
6.11.4 Subsequent Outpatient Psychotherapy or Counseling for an Individual,
Group or Family BH-49
6.11.4.1 Active Treatment Plan Requirements BH-49
6.11.4.2 Discharge Plan Requirements BH-49
6.11.5 Reimbursement BH-50
6.11.6 Insight Oriented Behavior Modifying and Supportive Outpatient Psychotherapy
or Counseling BH-50
6.12 Narcosynthesis BH-51
6.13 Noncovered Services BH-51
6.14 Psychiatric Services for Hospitals BH-52
6.14.1 Prior Authorization Requirements BH-53
6.14.2 Documentation Requirements BH-53
6.14.3 Psychological and Neuropsychological Testing Services BH-53
6.14.4 Inpatient Hospital Discharge BH-53
6.14.5 Inpatient Consultations BH-53
6.15 Claims Filing and Reimbursement BH-53
7. Screening, Brief Intervention, and Referral to Treatment (SBIRT) BH-54
7.1 Screening BH-55
7.2 Brief Intervention BH-55
7.3 Brief Treatment BH-55
7.4 Referral to Treatment BH-56
7.5 Reimbursement and Limitations BH-56
7.6 Documentation Requirements BH-57
7.7 Claims Filing and Reimbursement BH-57
8. Substance Use Disorder (SUD) Services (Abuse and Dependence) BH-58
8.1 Overview BH-58
8.2 Enrollment BH-59
8.2.1 CDTFs BH-59
8.3 Assessment BH-59
8.4 Detoxification Services BH-59
8.4.1 Ambulatory (Outpatient) Detoxification Services BH-59
8.4.2 Residential Detoxification Services BH-60
8.5 Treatment Services BH-60
8.5.1 Residential Treatment Services BH-60
8.5.2 Ambulatory (Outpatient) Treatment Services BH-60
8.5.3 Physician Services BH-61
8.6 Medication Assisted Therapy (MAT) BH-61
8.7 Prior Authorization BH-62
8.7.1 Prior Authorization for Fee-for-Service Clients BH-62
8.7.2 Prior Authorization for Ambulatory (Outpatient) Detoxification Treatment
Services BH-63
8.7.2.1 Admission Criteria for Ambulatory (Outpatient) Detoxification
Treatment Services BH-63
8.7.2.2 Continued Stay Criteria for Ambulatory (Outpatient) Detoxification
Treatment Services BH-64
8.7.3 Prior Authorization for Residential Detoxification Treatment Services BH-65
8.7.3.1 Admission Criteria for Residential Detoxification Treatment Services BH-65
8.7.3.2 Continued Stay Criteria for Residential Detoxification Treatment Services BH-66
8.7.4 Prior Authorization for Residential Treatment Services BH-67
8.7.4.1 Admission Criteria for Residential Treatment Services BH-67
8.7.4.2 Residential Treatment Services for Adolescents BH-68
8.7.4.3 Continued Stay Criteria for Residential Treatment Services BH-68
8.7.5 Prior Authorization for Ambulatory (Outpatient) Treatment Services for
Clients Who Are 20 Years of Age and Younger BH-69
8.8 Documentation Requirements BH-69
8.9 Reimbursement and Limitations BH-70
8.9.1 Detoxification Services BH-70
8.9.2 Treatment Services BH-70
8.9.3 MAT Services BH-70
8.10 Noncovered Services BH-72
8.11 Claims Filing BH-72
9. Claims Resources BH-73
10. Contact TMHP BH-73
11. Forms BH-73
BH.1 Ambulatory (Outpatient) Detoxification Authorization Request Form BH-74
BH. 2 Ambulatory (Outpatient) Substance Abuse Counseling Extension Request Form BH-75
BH. 3 Outpatient Psychotherapy/Counseling Request Form BH-76
BH. 4 Psychological/Neuropsychological Testing Request Form BH-77
BH. 5 Residential Detoxification Authorization Request Form BH-78
BH. 6 Residential Substance Abuse Treatment Authorization Request Form BH-79
12. Claim Form Examples BH-80
BH. 7 Blind Children’s Vocational Discovery and Development Program (BCVDDP) BH-81
BH. 8 Case Management for Children and Pregnant Women BH-82
BH. 9 Licensed Clinical Social Worker (LCSW) BH-83
BH. 10 Licensed Marriage and Family Therapist (LMFT) BH-84
BH. 11 Licensed Professional Counselor (LPC) BH-85
BH. 12 Mental Health Case Management BH-86
BH. 13 Psychologist BH-87
Index BH-88

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.