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December 2016 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 6
1.1 Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission 6
2 Blind Children’s Vocational Discovery and Development Program (BCVDDP) 7
2.1 Overview 7
2.2 Enrollment 7
2.3 Services, Benefits, Limitations, and Prior Authorization 7
2.3.1 Prior Authorization 7
2.4 Documentation Requirements 7
2.5 Claims Filing and Reimbursement 8
3 Case Management for Children and Pregnant Women 8
3.1 Overview 8
3.1.1 Eligibility 8
3.1.2 Referral Process 9
3.2 Enrollment 9
3.3 Services, Benefits, Limitations, and Prior Authorization 10
3.3.1 Prior Authorization 11
3.4 Technical Assistance 11
3.4.1 Assistance with Program Concerns 11
3.5 Documentation Requirements 11
3.6 Claims Filing and Reimbursement 11
3.6.1 Claims Information 11
3.6.2 Managed Care Clients 12
4 Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), and Licensed Professional Counselor (LPC) 12
4.1 Enrollment 12
4.1.1 LCSW 12
4.1.2 LMFT 12
4.1.3 LPC 12
4.2 * Services, Benefits, Limitations, and Prior Authorization 13
4.2.1 Prior Authorization 17
4.2.1.1 Initial Prior Authorization Request for Encounters or Visits Beyond the 30 Encounter or Visit Limit 17
4.2.1.1.1 Client Condition Requirements 18
4.2.1.1.2 Initial Assessment Requirements 18
4.2.1.1.3 Active Treatment Plan Requirements 19
4.2.1.1.4 Discharge Plan Requirements 19
4.2.1.2 Subsequent Prior Authorization Request for Encounters or Visits after the Initial Prior Authorized Encounters 19
4.2.1.2.1 Client Condition Requirements 19
4.2.1.2.2 Active Treatment Plan Requirements 19
4.2.1.2.3 Discharge Plan Requirements 20
4.2.1.3 Prior Authorization for Court-Ordered and Department of Family and Protective Services (DFPS)-Directed Services 20
4.3 Documentation Requirements 20
4.4 Claims Filing and Reimbursement 21
5 Intellectual Disability Service Coordination, Mental Health Targeted Case Management, and Mental Health Rehabilitative Services 22
5.1 Enrollment 22
5.1.1 Local Intellectual and Developmental Disability Authority (LIDDA) Providers 22
5.1.2 Local Mental Health Authority (LMHA) Providers 22
5.1.3 Non-Local Mental Health Authority (Non-LMHA) Providers 22
5.2 Services, Benefits, Limitations, and Prior Authorization 22
5.2.1 Intellectual and Developmental Disabilities Service Coordination 22
5.2.2 Mental Health Targeted Case Management 23
5.2.3 MH Rehabilitative Services 24
5.2.3.1 Day Program 25
5.2.3.2 Medication Training and Support 25
5.2.3.3 Crisis Intervention 25
5.2.3.4 Skills Training and Development 26
5.2.3.5 Psychosocial Rehabilitative Services 26
5.2.3.6 Rehabilitative Services Limitations 26
5.2.3.7 Billing Units 27
5.2.4 Prior Authorization 27
5.3 Documentation Requirements 27
5.4 Claims Filing and Reimbursement 27
5.4.1 Managed Care Clients 27
5.4.2 Reimbursement Reductions 27
6 Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers 28
6.1 Enrollment 28
6.1.1 Physicians 28
6.1.2 Psychologists 28
6.1.3 Licensed Psychological Associate (LPA) 28
6.1.4 Provisionally Licensed Psychologist (PLP) 29
6.2 Services, Benefits, Limitations, and Prior Authorization 30
6.2.1 Physicians 30
6.2.2 Psychologists, LPAs, and PLPs 30
6.3 The 12-Hour System Limitation 30
6.3.1 Retrospective Review of Behavioral Health Services Billed in Excess of 12 Hours per Day 31
6.3.2 Procedure Codes Included in the 12-Hour System Limitation 31
6.3.3 Formula Applied 32
6.4 Outpatient Behavioral Health Services 34
6.4.1 Annual Encounter or Visit Limitations 35
6.5 Prior Authorization Requirements After the Annual Encounter or Visit Limitations Have Been Met 35
6.6 Court-Ordered and DFPS-Directed Services 37
6.6.1 Prior Authorization 37
6.6.2 Documentation Requirements 37
6.7 Electroconvulsive Therapy (ECT) 37
6.8 Family Therapy or Counseling Services 38
6.8.1 Prior Authorization 38
6.8.2 Documentation Requirements 38
6.8.3 Reimbursement 38
6.9 Pharmacological Management Services 39
6.9.1 Indications for Pharmacological Management Services 39
6.9.2 Prior Authorization 39
6.9.3 Documentation Requirements 39
6.9.4 Reimbursement 40
6.10 Psychiatric Diagnostic Evaluations 40
6.10.1 Psychiatric Diagnostic Evaluation Without Medical Services 40
6.10.2 * Psychiatric Diagnostic Evaluation With Medical Services 40
6.10.3 Prior Authorization 43
6.10.4 Documentation Requirements 43
6.10.5 Domains of a Clinical Evaluation 44
6.11 * Psychological and Neuropsychological Testing 44
6.11.1 Prior Authorization 50
6.11.2 Documentation Requirements 50
6.11.3 Reimbursement 51
6.12 Psychotherapy or Counseling 52
6.12.1 Prior Authorization 54
6.12.2 Documentation Requirements 55
6.12.3 Initial Outpatient Psychotherapy or Counseling for an Individual, Group, or Family 55
6.12.4 Subsequent Outpatient Psychotherapy or Counseling for an Individual, Group or Family 56
6.12.4.1 Active Treatment Plan Requirements 57
6.12.4.2 Discharge Plan Requirements 57
6.12.5 Reimbursement 57
6.13 Treatment for Alzheimer’s Disease and Dementia 58
6.14 Narcosynthesis 59
6.15 Noncovered Services 59
6.16 Psychiatric Services for Hospitals 59
6.16.1 Prior Authorization Requirements 60
6.16.2 Documentation Requirements 60
6.16.3 Psychological and Neuropsychological Testing Services 60
6.16.4 Inpatient Hospital Discharge 60
6.17 Claims Filing and Reimbursement 61
6.17.1 NCCI and MUE Guidelines 61
7 Screening, Brief Intervention, and Referral to Treatment (SBIRT) 62
7.1 SBIRT Training 62
7.2 Screening 62
7.3 Brief Intervention 63
7.4 Referral to Treatment 63
7.5 Reimbursement and Limitations 63
7.6 Documentation Requirements 64
7.7 Claims Filing and Reimbursement 64
8 Substance Use Disorder (SUD) Services (Abuse and Dependence) 65
8.1 Overview 65
8.2 Enrollment 66
8.2.1 CDTFs 66
8.3 Assessment 66
8.4 Opioid Treatment Program (OTP) 66
8.5 Detoxification Services 67
8.5.1 Ambulatory (Outpatient) Detoxification Services 67
8.5.2 Residential Detoxification Services 67
8.6 Treatment Services 68
8.6.1 Residential Treatment Services 68
8.6.2 Ambulatory (Outpatient) Treatment Services 68
8.6.3 Physician Services 69
8.7 Medication Assisted Therapy (MAT) 69
8.8 Prior Authorization 70
8.8.1 Prior Authorization for Fee-for-Service Clients 70
8.8.2 Prior Authorization for Ambulatory (Outpatient) Detoxification Treatment Services 71
8.8.2.1 Admission Criteria for Ambulatory (Outpatient) Detoxification Treatment Services 71
8.8.2.2 Continued Stay Criteria for Ambulatory (Outpatient) Detoxification Treatment Services 72
8.8.3 Prior Authorization for Residential Detoxification Treatment Services 73
8.8.3.1 Admission Criteria for Residential Detoxification Treatment Services 73
8.8.3.2 Continued Stay Criteria for Residential Detoxification Treatment Services 74
8.8.4 Prior Authorization for Residential Treatment Services 75
8.8.4.1 Admission Criteria for Residential Treatment Services 75
8.8.4.2 Residential Treatment Services for Adolescents 76
8.8.4.3 Continued Stay Criteria for Residential Treatment Services 76
8.8.5 Prior Authorization for Ambulatory (Outpatient) Treatment Services for Clients Who Are 20 Years of Age and Younger 77
8.9 Documentation Requirements 77
8.10 Reimbursement and Limitations 77
8.10.1 Detoxification Services 77
8.10.2 Treatment Services 78
8.10.3 MAT Services 78
8.11 Noncovered Services 80
8.12 Claims Filing 80
9 Claims Resources 81
10 Contact TMHP 81
11 Forms 81
12 Claim Form Examples 82
 

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