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2012 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 4. Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), and Licensed Professional Counselor (LPC) : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.1 Prior Authorization : 4.2.1.2 Subsequent Prior Authorization Request for Encounters or Visits after the Initial Prior Authorized Encounters

4.2.1.2
Subsequent Prior Authorization Request for Encounters or Visits after the Initial Prior Authorized Encounters
4.2.1.2.1
The following documentation requirements indicating the client’s condition must be submitted when requesting prior authorization for subsequent encounters or visits.
All of the requirements for the initial authorized treatment sessions must be met in addition to an assessment of the client’s response to treatment, which indicates one of the following:
The client has not achieved the discharge goals necessary to conclude treatment, but the client’s progress indicates that treatment can be concluded within a short period of time.
The client’s psychiatric condition has not responded to a trial of short-term outpatient therapy and there is potential for serious regression or admission to a more intensive setting without ongoing outpatient management (requiring several months or longer of outpatient therapy).
4.2.1.2.2
There must be an assessment that explains why the client was unable to achieve the expected treatment objectives that were previously set. The assessment must address the following:
4.2.1.2.3
Discharge planning must reflect the following:
4.2.1.2.4
Prior Authorization for Court-Ordered and Department of Family and Protective Services (DFPS)-Directed Services
A request for prior authorization of court-ordered or DFPS-directed services must be submitted no later than seven calendar days after the date on which the services began.
Specific court-ordered outpatient behavioral health services for evaluations, psychological or neuropsychological testing, or treatment may be prior authorized as mandated by the court. Prior authorization requests must be accompanied by a copy of the court document signed by the judge. If the requested services differ from or go beyond the court order, the additional services will be reviewed for medical necessity.
Specific DFPS-directed services for outpatient behavioral health services may be prior authorized as directed. Prior authorization requests must be accompanied by a copy of the directive or summary signed by the DFPS employee. If the requested services differ from or go beyond the DFPS direction, the additional services will be reviewed for medical necessity.
Court-ordered or DFPS-directed services will be prior authorized with modifier H9.
Mail or fax prior authorization request to:
Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway, Suite 150
Austin, TX 78727
Fax: (512) 514-4213
Providers can submit requests for extended outpatient psychotherapy or counseling through the TMHP website at www.tmhp.com.
Refer to:
Subsection 5.5.1, “Prior Authorization Requests Through the TMHP Website” in Section 5, “Prior Authorization” (Vol. 1, General Information) for additional information, including mandatory documentation and retention requirements.

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