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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 : 8.8.2 Prior Authorization for Ambulatory (Outpatient) Detoxification Treatment Services : 8.8.2.2 Continued Stay Criteria for Ambulatory (Outpatient) Detoxification Treatment Services

8.8.2.2
A client is considered eligible for continued stay in the ambulatory (outpatient) detoxification treatment service when the client meets at least one of the conditions for either chemical substance withdrawal or psychiatric or medical complications. Requests for continuation of services must be received on or before the last date authorized or denied. The prior authorization unit will notify the provider by fax or electronic portal. If the date of the prior authorization unit determination letter is on or after the last date authorized or denied, the request for continuation of services is due by 5 p.m. of the next business day. Documentation in the client’s medical record must support either Chemical Substance Withdrawal or Psychiatric or Medical Complications as outlined below.
Chemical Substance Withdrawal
The client must meet at least one of the following conditions with regard to chemical substance withdrawal complications:
The client, while physically abstinent from chemical substance use, is exhibiting incomplete stable withdrawal from alcohol or drugs, as evidenced by psychological and physical cravings.
The client, while physically abstinent from chemical substance use, is exhibiting incomplete stable withdrawal from alcohol or drugs, as evidenced by significant drug levels.
Psychiatric or Medical Complications
The client must meet both of the following psychiatric or medical complication conditions:

Texas Medicaid & Healthcare Partnership
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