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December 2016 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 6 Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers : 6.5 Prior Authorization Requirements After the Annual Encounter or Visit Limitations Have Been Met

6.5
All outpatient behavioral health services for all provider types approved to deliver outpatient services will require prior authorization with the exception of the following:
Prior authorization requests in increments of up to 10 additional encounters or visits may be considered. 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. 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.
All requests for prior authorization with the exception of psychological and neuropsychological testing must include a completed Outpatient Psychotherapy/Counseling Request Form dated and signed by the performing provider with the following information:
Clinical update, including specific symptoms and responses to past treatment, treatment plan (measurable short term goals for the extension of services, specific therapeutic interventions to be used, measurable expected outcomes of therapy, anticipated length of treatment, and the planned frequency of encounters or visits)
The Outpatient Psychotherapy/Counseling Request Form may be mailed to the TMHP Special Medical Prior Authorization Department at:
Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization Department
12357-B Riata Trace Parkway, Suite 100
Austin, TX 78727
The form may also be faxed to 1-512-514-4211 or submitted online on the TMHP website at www.tmhp.com.
All of the required areas on the request form must be completed. If additional space 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.
The request must be signed and received no later than the start date listed on the request form and no earlier than 30 days prior to the start date listed on the form so the most current clinical information is provided.
To avoid unnecessary denials, the provider must provide correct and complete information, including accurate documentation of medical necessity for the services requested. The provider must maintain documentation of medical necessity in the client’s medical record. The requesting provider may be asked for additional information to clarify or complete a request for outpatient behavioral health services.
Requests for prior authorization for procedure code 90899 (psychiatric service or a procedure that is unlisted) must be submitted by the provider to the Special Medical Prior Authorization Department by mail or approved electronic method using the Special Medical Prior Authorization Request Form with documentation supporting medical necessity including:
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.

Texas Medicaid & Healthcare Partnership
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