Table of Contents Previous Next

December 2016 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 3 Inpatient Hospital (Medical/Surgical Acute Care Inpatient Facility) : 3.4 Services, Benefits, Limitations, and Prior Authorization - Inpatient Psychiatric Services : 3.4.4 Freestanding and State Psychiatric Facilities : 3.4.4.1 CCIP Services

3.4.4.1
Inpatient psychiatric treatment in a nationally accredited freestanding psychiatric facility or a nationally-accredited state psychiatric hospital is a benefit of Texas Medicaid for clients who are 20 years of age and younger, and who are eligible for THSteps benefits at the time of the service request and service delivery.
Admissions to freestanding and state psychiatric facilities must be medically necessary, unless they are court-ordered services for mental health commitments or they are a condition of probation.
Revenue code 124 must be used for inpatient psychiatric services that are rendered to children and adolescents in freestanding and state psychiatric facilities.
Note:
3.4.4.1.1
Prior authorization is not required for initial admission to freestanding psychiatric facilities or state psychiatric hospitals for clients who are birth through 20 years of age.
A toll-free telephone and fax line are available to complete the authorization process. Contact the TMHP CCIP Unit at 1-800-213-8877 or fax to 1-512-514-4211.
Authorization procedures and approved providers may be different for managed care clients. Contact the client’s specific health care plan for details.
Prior authorization requests may be submitted to the TMHP Prior Authorization Department via mail, fax, or the electronic portal. The supervising psychiatrist may sign prior authorization forms and supporting documentation using electronic or wet signatures.
Refer to:
To facilitate a determination of medical necessity and avoid unnecessary denials, the physician must provide correct and complete information, including accurate documentation of medical necessity for the services requested.
Initial admissions may be prior authorized for a maximum of five days based on Medicaid eligibility and documentation of medical necessity.
The prior authorization requests will be reviewed as follows:
Providers must submit a Psychiatric Inpatient Extended Stay Request Form to the TMHP CCIP unit requesting prior authorization for an extended stay. Requests for an extension of stay must be received on or before the fifth day of an initial admission and/or on or before the last day authorized or denied for subsequent stay requests. If an extended stay is requested and the fifth day of the initial admission or the last date authorized or denied of the previous stay falls on a holiday or a weekend, the request for an extended stay is due by 5 p.m. of the next business day. The provider is notified of the decision in writing by the CCIP unit.
Psychiatric admission extended stay requests for clients who are 12 through 20 years of age will be reviewed by a mental health professional. Any requests for psychiatric extended stays that do not meet the medical necessity criteria for extended stays will be referred to a psychiatrist for final determination.
The Psychiatric Inpatient Extended Stay Request Form must reflect the need for extended stay in relation to the original need for admission. Any change in the client’s diagnosis must be noted on the request. Additional documentation or information supporting the need for extended stay may be attached to the form. Up to seven days may be authorized for an extension request.
Medicaid Clinical Criteria for the Initial Inpatient Psychiatric Stay
The client must have a valid diagnosis as listed in the current version of the DSM as the principal admitting diagnosis and one of the following:
Recent self-mutilative behavior or active threats of same with likelihood of acting on the threat, and there is an absence of appropriate supervision or structure to prevent self-mutilation (e.g., intentionally cutting/burning self).
Active hallucinations or delusions directing or likely to lead to serious self-harm or debilitating psychomotor agitation or impairment resulting in a significant inability to care for self.
Significant inability to comply with prescribed medical health regimens due to concurrent psychiatric illness and such failure to comply is potentially hazardous to the life of the client. The medical diagnosis must be treatable in a psychiatric setting.
The client is a danger to others. This behavior must be attributable to the client’s specific diagnosis as listed in the current version of the DSM, and can be adequately treated only in a hospital setting. This danger is demonstrated by one of the following:
Recent life-threatening action or active homicidal threats of same with a deadly plan, availability of means to accomplish the plan, and with likelihood of acting on the threat.
Recent serious assaultive or sadistic behavior or active threats of same with likelihood of acting on the threat, and there is an absence of appropriate supervision or structure to prevent assaultive behavior.
The client exhibits acute onset of psychosis or severe thought disorganization, or there is significant clinical deterioration in the condition of someone with a chronic psychosis, rendering the client unmanageable and unable to cooperate in treatment, and the client is in need of assessment and treatment in a safe and therapeutic setting.
The client’s evaluation and treatment cannot be carried out safely or effectively in other settings due to severely disruptive behaviors and other behaviors, which may also include physical, psychological, or sexual abuse.
The client is involved in the legal system, manifests psychiatric symptoms, and is ordered by a court to undergo a comprehensive assessment in a hospital setting to clarify diagnosis and treatment needs.
Active supervision by a psychiatrist with the appropriate credentials as determined by the Texas Medical Board (TMB) and with documented specialized training, supervised experience, and demonstrated competence in the care and treatment of children and adolescents. Treatment/therapy plans must be guided by the standards of treatment specified by the Texas Society of Child and Adolescent Psychiatry.
Provision of services that can reasonably be expected to improve the client’s condition or prevent further regression so that a lesser level of care can be implemented.
Documentation that proper treatment of the client’s psychiatric condition requires services on an inpatient basis under the direction of a psychiatrist and is being provided in the least restrictive environment available, and ambulatory care resources available in the community do not meet the client’s needs.
Medicaid Clinical Criteria for Extended Stays
Extended stays are considered for THSteps clients in freestanding and state psychiatric hospitals when the client meets at least one of the criteria from above and have a treatment or therapy regimen, which must include all of the following:
Active supervision by a psychiatrist with the appropriate credentials as determined by the Texas Medical Board (TMB) and with documented specialized training, supervised experience, and demonstrated competence in the care and treatment of children and adolescents. Treatment/therapy plans must be guided by the standards of treatment specified by the Texas Society of Child and Adolescent Psychiatry.
Initial discharge plans have been formulated and actions have been taken toward implementation, including documented contact with a local mental health provider.
Extended stays are also considered for children and adolescents whose discharge plan does not include returning to their natural home. If the party responsible for placement has provided the inpatient provider with three documented placement options for which the child meets admission criteria, but cannot accept the child, up to five days may be authorized, per request, to allow alternative placement to be located. Up to three 5-day extensions may be authorized.
Court-Ordered Services
A request for prior authorization of court-ordered services must be submitted no later than seven calendar days after the date on which the services began.
Court-ordered services are not subject to the five-day admission limitation or the seven-day extended stay limitation. Court-ordered services include:
For court-ordered admissions, a copy of the doctor’s certificate and all court-ordered commitment papers signed by the judge must be submitted with the Psychiatric Inpatient Extended Stay Request Form.
Prior Authorization Appeals
All prior authorization requests not submitted or received by the TMHP CCIP unit in accordance with established policies are denied through the submission date, and claim payment is not made for the dates of service denied.
All denials may be appealed. The TMHP CCIP unit must receive these appeals within 15 days of the TMHP CCIP unit denial notice.
Appeals of a denial for an extended stay, must be accompanied by the documentation supporting medical necessity that the provider believes warrants reconsideration.
Appeals of a denial for late submission of information, must be accompanied by documentation that the provider believes supports the compliance with HHSC claims submission guidelines.
Appeals are reviewed first by an experienced psychiatric licensed clinical social worker (LCSW) or a registered nurse (RN) to determine if the required criteria is documented and then forwarded to a psychiatrist for final determination. The TMHP CCIP unit will notify the provider of all denial determinations in writing.

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