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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 : 8.8.4 Prior Authorization for Residential Treatment Services : 8.8.4.1 Admission Criteria for Residential Treatment Services

8.8.4.1
The diagnosis must meet the criteria for the definition of chemical dependence, as detailed in the most current revision of the ICD-10-CM, or the most current revision of the Diagnostic and Statistical Manual for Professional Practitioners, accompanied by evidence that some of the symptoms have persisted for at least one month or have occurred repeatedly over a longer period of time.
Clients must meet the following conditions in order to receive treatment in a residential treatment service program:
Medical Functioning
The following must be present with regard to medical functioning:
Documented medical assessment following admission (except in instances where the client is being referred from an inpatient service) indicates that the client is medically stable and not in acute withdrawal.
Family, Social, or Academic Dysfunction and Logistic Impairments
At least one of the following must be present with regard to family, social, or academic dysfunction and logistic impairments:
The client lives in an environment (social and interpersonal network) in which treatment is unlikely to succeed (e.g., a chaotic family dominated by interpersonal conflict, which undermines client’s efforts to change).
Logistic impairments (e.g., distance from treatment facility or mobility limitations) preclude participation in a partial hospitalization or ambulatory (outpatient) treatment service.
Emotional and Behavioral Status
The client must meet all three of the following criteria with regard to emotional and behavioral status:
Mental state of the client does not preclude the client’s ability to comprehend and understand the materials presented and participate in rehabilitation or the treatment process.
The medical record contains documentation that with continued treatment the client will be able to improve or internalize the client’s motivation toward recovery within the recommended length of stay time frames (e.g., becoming less defensive, verbalizing, and working on alcohol or drug related issues). Interventions, treatment goals, or contracts are in place to help the client deal with or confront the blocks to treatment (e.g., family intervention or employee counseling confrontation).
Chemical Substance Use
The client must meet at least one of the following criteria with regard to chemical substance use:
The client’s chemical substance use is excessive, and the client has attempted to reduce or control it but has been unable to do so (as long as chemical substances are available).
Virtually all of the client’s daily activities revolve around obtaining, using, or recuperating from the effects of chemical substances, and the client requires a secured environment to control the client’s access to chemical substances.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.