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December 2016 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

Each Medicaid client is limited to 30 encounters or visits per calendar year. It is anticipated that this limitation, which allows for 6 months of weekly therapy or 12 months of biweekly therapy, is adequate for 75 to 80 percent of clients. Clinicians should plan therapy with this limit in mind, and the documentation must support the medical necessity of the behavioral therapy for the duration of the therapy from beginning to end. However, it may be medically necessary for some clients to receive extended encounters or visits. In these situations, prior authorization is required.
Providers with established clients must request prior authorization when they determine the client is approaching 30 encounters or visits to all behavioral health providers for the calendar year and more visits are needed to accomplish goals of treatment. If the client changes providers during the year and the new provider is unable to obtain complete information on the client’s encounters or visits, providers are encouraged to obtain prior authorization before rendering services.
After the 30 encounter or visit annual limitation has been met, prior authorization will be considered in increments of up to 10 additional encounters or visits per request. All requests for prior authorization of extensions beyond the 30 initial encounter or visit annual limit must be submitted on a completed Outpatient Psychotherapy/Counseling Request Form, which must include the following:
Clinical update, including specific symptoms and response to past treatment, 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 or visits)
Refer to:
All areas of the request form must be completed with the required information as stated on the form. If additional room is needed for a particular section of the form, providers may state “see attached,” in that section and attach the additional pages to the form. The attachment must contain the specific information required in that section of the form.
A request for outpatient behavioral health services must be submitted no sooner than 30 days before the date of service being requested and no later than the date of service being requested so that the most current information is provided.
Prior authorization requests will be reviewed by a mental health professional. The number of encounters or visits authorized will be dependent upon 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 additional requests must include new documentation concerning the client’s current condition.
The following documentation requirements indicating the client’s condition must be submitted when requesting prior authorization of initial outpatient services beyond the 30-encounter or visit annual limitation:
There must be a pertinent history containing the following assessment requirements:
The treatment plan must contain the following:
Discharge planning must reflect the following:

Texas Medicaid & Healthcare Partnership
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