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December 2016 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 8 Substance Use Disorder (SUD) Services (Abuse and Dependence) : 8.8 Prior Authorization

8.8
The following services do not require prior authorization:
The following services require prior authorization:
Ambulatory (outpatient) treatment for clients who are 20 years of age and younger and who exceed the benefit limitation of 135 hours of group service and 26 hours of individual services per calendar year
Providers must submit the appropriate prior authorization request form for the initial or continuation of ambulatory (outpatient) or residential detoxification treatment and residential treatment services. A physician (who does not need to be affiliated with the CDTF) must complete and sign the Ambulatory (Outpatient) Substance Abuse Extension Request Form. A QCC (as defined by the DSHS licensure standard) must complete and sign the other prior authorization request forms listed below.
Providers must submit one of the following forms to obtain prior authorization:
Prior authorization for ambulatory and residential detoxification services will not be issued for clients who are 12 years of age or younger unless the request is accompanied by a waiver from DSHS Regulatory and Licensing Division.
Prior authorization will be considered for the least restrictive environment appropriate to the client’s medical need as determined in the client’s plan of care (POC), based on national standards.
Prior authorization requests for clients who are 20 years of age and younger for services beyond the limitations outlined in this section, may be considered with documentation from a physician (who does not need to be affiliated with the CDTF) supporting the medical necessity for continuation of the treatment.

Texas Medicaid & Healthcare Partnership
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