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WARNING: THIS IS A TEXAS HEALTH AND HUMAN SERVICES INFORMATION RESOURCES SYSTEM THAT CONTAINS STATE AND/OR U.S. GOVERNMENT INFORMATION. BY USING THIS SYSTEM YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE NO RIGHT OF PRIVACY IN CONNECTION WITH YOUR USE OF THE SYSTEM OR YOUR ACCESS TO THE INFORMATION CONTAINED WITHIN IT. BY ACCESSING AND USING THIS SYSTEM YOU ARE CONSENTING TO THE MONITORING OF YOUR USE OF THE SYSTEM, AND TO SECURITY ASSESSMENT AND AUDITING ACTIVITIES THAT MAY BE USED FOR LAW ENFORCEMENT OR OTHER LEGALLY PERMISSIBLE PURPOSES. ANY UNAUTHORIZED USE OR ACCESS, OR ANY UNAUTHORIZED ATTEMPTS TO USE OR ACCESS, THIS SYSTEM MAY SUBJECT YOU TO DISCIPLINARY ACTION, SANCTIONS, CIVIL PENALTIES, OR CRIMINAL PROSECUTION TO THE EXTENT PERMITTED UNDER APPLICABLE LAW.
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AMA/ADA End User License Agreement
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT® ")

You, your employees and agents are authorized to use CPT only as contained in materials on the Texas Medicaid & Healthcare Partnership (TMHP) website solely for your own personal use in directly participating in healthcare programs administered by THHS. You acknowledge that AMA holds all copyright, trademark and other rights in CPT.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, 515 N. State Street, Chicago, Illinois, 60610. Applications are available at the American Medical Association website, www.ama-assn.org/go/cpt.

U.S. Government Rights

This product includes CPT which is commercial technical data and/or computer databases and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer databases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

Disclaimer of Warranties and Liabilities

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the American Medical Association (AMA) is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with THHS, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the for egoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "accept".

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONTINUED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD, AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NO AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

1. Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights included in the materials.

2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org.

3. U.S. GOVERNMENT RIGHTS. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government Use. This product includes CDT, which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Dental Association, 211 East Chicago Avenue, Chicago Illinois, 60611. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal Procurements.

4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does no t directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with TMHP or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of the Agreement. The ADA is a third party beneficiary to this Agreement.

5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must exit from this computer screen.

Effective September 1, 2022, Non-LMHA Providers May Deliver Mental Health Targeted Case Management and Mental Health Rehabilitation Services

Last updated on 7/18/2022

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after September 1, 2022, nonlocal mental health authorities (henceforth referred to as private providers) may deliver mental health targeted case management (MHTCM) and mental health rehabilitation (MHR) services to persons in traditional, fee-for-service (FFS) Medicaid prior to the persons’ enrollment with a managed care organization (MCO).

Senate Bill (SB) 1921, 87th Legislature, Regular Session, 2021, directed the Texas Health and Human Services Commission (HHSC) to provide public or private providers of behavioral health services medical assistance reimbursement through an FFS delivery model prior to persons’ enrollment with and receipt of medical assistance services through an MCO. Except for MHTCM and MHR services, both public and private providers of behavioral health services may provide Medicaid services to persons enrolled in FFS Medicaid and managed care. Currently, private providers of MHTCM and MHR services may provide these services only to persons enrolled in managed care, whereas local mental health and behavioral health authorities (LMHAs/LBHAs) may provide these services to persons enrolled in FFS Medicaid and managed care. Therefore, as directed by SB 1921, the MHTCM and MHR state plan benefits have been updated to include a prior authorization process to allow private providers to deliver these services to persons enrolled in FFS Medicaid until the person is enrolled and begins receiving services though an MCO.

Note: MHTCM and MHR claims submitted by private providers for dual-eligible persons will be processed by the Texas Medicaid & Healthcare Partnership (TMHP) in the same manner that dual-eligible LMHA claims are processed to pay cost sharing. These claims will be carved out of managed care and will not be sent to the person’s MCO. MHTCM and MHR claims submitted by private providers for persons with Medicaid-only eligibility (all persons who are not dual-eligible) will be carved in for managed care, meaning that FFS will pay the claims until the person chooses an MCO, and then the claims will be forwarded to the person’s MCO for processing and reimbursement.

Initial Prior Authorization Requirements

Private providers must register to use the HHSC Clinical Management for Behavioral Health Services (CMBHS) clinical record-keeping system before providing services to Texas Medicaid-eligible persons.

Private providers of MHTCM and MHR services must not bill Texas Medicaid for services prior to the establishment of a diagnosis of mental illness and the authorization or reauthorization of services. Eligibility and continued eligibility determinations occur at the facility (provider) that is providing MHTCM or MHR services using the CMBHS software system. Criteria used to make these service determinations are from the recommended level of care (LOC) for the person generated by the CMBHS software system, as derived from the uniform assessment, the needs of the person, and the Texas Resilience and Recovery (TRR) Utilization Management Guidelines. Private providers of MHTCM and MHR services must ensure the following:

A qualified mental health professional-community services (QMHP-CS) or licensed practitioner of the healing arts (LPHA) performs a screening for eligibility using the uniform assessment.
An LPHA determines the diagnosis, which must include an interview with the person conducted either in person or by telemedicine or telehealth.
The clinical needs of the person are evaluated to determine whether the amount of MHTCM or MHR services associated with the recommended LOC, described in the TRR Utilization Management Guidelines, is sufficient to meet those needs.
An LPHA reviews the recommended LOC and verifies whether the services are medically necessary.

If the provider determines that the type of MHTCM or MHR services associated with the recommended LOC generated by the CMBHS software system is sufficient to meet the needs of the person, the provider must submit a request for prior authorization according to the recommended LOC. If the provider determines that an LOC other than the recommended LOC is more appropriate for the person, then the provider must submit a prior authorization “deviation” request that includes the following:

The word “deviation” with a note that the request is for prior authorization of an LOC that is higher or lower than initially recommended
The clinical justification for the request, including the specific reasons that the person requires interventions at a higher or lower level than the recommended LOC (refusal of the recommended LOC by the person receiving services may be noted as part of the justification)

For persons enrolled in managed care, private providers contracted with MCOs must submit prior authorization requests to the MCO with which the person is enrolled. MCOs must follow the requirements set forth in the Uniform Managed Care Manual regarding utilization management for MHTCM and MHR services. MCOs may choose to waive prior authorization submission requirements.

For persons enrolled in FFS Medicaid, private providers of MHTCM or MHR services must obtain prior authorization from the TMHP Prior Authorization Department using the Special Medical Prior Authorization request form and the information obtained from the CMBHS software system. When completing the Special Medical Prior Authorization request form for prior authorization, private providers must complete the following sections of the form as follows:

Section A: Client information: Complete as indicated on the form.

Section B: Requested procedure or service information

The type of request is “Other.”
The expected dates of service are the start and end dates provided by CMBHS.
The procedure-related Current Procedural Terminology (CPT) code is the code for MHTCM or codes for MHR services and the appropriate modifiers.
The comments text box must indicate whether the prior authorization request is an initial assessment or reassessment.

Section C: To be completed by the requesting physician or requesting provider

The diagnoses are the International Classification of Diseases, Tenth Revision (ICD-10) primary diagnosis and any related ICD-10 diagnosis codes.
The statement of medical necessity section must indicate the recommended LOC generated by the CMBHS software system. If the request is a deviation from the recommended LOC, then the provider must include the following:
The word “deviation” with a note that the request is for prior authorization of a LOC that is higher or lower than the recommended LOC
The clinical justification for the request, to include the specific reason or reasons that the person requires interventions outside the recommended LOC (refusal of the recommended LOC by the person receiving services may be noted as part of the justification)
If requested by the TMHP Prior Authorization Department, a copy of the Child and Adolescent Needs and Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA) functional assessment.
Complete provider information as indicated on the form.
The Special Medical Prior Authorization request form must be signed and dated within 30 calendar days of the expected start date of services.

All plans of care are subject to retrospective review.

Reauthorization Requirements

At a minimum, providers must ensure that a QMHP-CS administers the uniform assessment and obtains a recommended LOC from the CHMBS software system for the person receiving the MHTCM or MHR services:

Every 90 calendar days for persons 20 years of age or younger.
Every 180 calendar days for persons 21 years of age or older.

Note: Providers must follow the same process that is used for initial authorization for reauthorization of services at the specified intervals indicated above (i.e., every 90 or 180 calendar days, as applicable.)

For more information, call the TMHP Contact Center at 800-925-9126.