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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 : 6.12 Psychotherapy or Counseling : 6.12.1 Prior Authorization

Prior authorization for inpatient psychotherapy or counseling is not required for 30 encounters or visits per calendar year.
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 include a completed Outpatient Psychotherapy/Counseling Request Form, including:
Clinical update, including specific symptoms and response to past treatment, treatment plan (measurable short term goals, specific therapeutic interventions to be used in therapy, measurable expected outcomes of therapy, length of treatment anticipated, and planned frequency of encounters or visits)
All areas of the request form must be completed with the required information. 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 information specific to 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, so that the most current information is provided.
The number of encounters or visits authorized will be dependent upon the client’s symptoms and response to past treatment. The provider must submit a new prior authorization request at the end of each extension period. The additional requests must include new documentation concerning the client’s current condition.
Prior authorization requests will be reviewed by a mental health professional.

Texas Medicaid & Healthcare Partnership
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