Behavioral Health and Case Management Services
Handbook

1 ​General Information

The information in this handbook is intended for the Case Management for the Blind Children’s Vocational Discovery and Development Program (BCVDDP), Case Management for Children and Pregnant Women, and services provided by a licensed clinical social worker (LCSW), licensed marriage and family therapist (LMFT), licensed professional counselor (LPC), psychologist, physician, advanced practice registered nurse (APRN), physician assistant (PA), or providers of intellectual and developmental disability (IDD) case management, mental health targeted case management, and mental health rehabilitative services.

All providers are required to report suspected child abuse or neglect as outlined in subsection 1.7.1.2, “Reporting Child Abuse or Neglect” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) and subsection 1.7.1.5, “Training” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

​Important:All providers are required to read and comply with “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information). In addition to required compliance with all requirements specific to Texas Medicaid, it is a violation of Texas Medicaid rules when a provider fails to provide health-care services or items to Medicaid eligible persons in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Administrative Code (TAC) §371.1659. Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to Texas Medicaid, providers can also be subject to Texas Medicaid sanctions for failure to deliver, at all times, health-care items and services to Medicaid eligible persons in full accordance with all applicable licensure and certification requirements including, without limitation, those related to documentation and record maintenance.

​Refer to: “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

Section 1.1, “About the Vendor Drug Program” in the Outpatient Drug Services Handbook (Vol. 2, Provider Handbooks) for information about this program.

1.1​Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission

According to the three-day and one-day payment window reimbursement guidelines, most professional and outpatient diagnostic and nondiagnostic services that are rendered within the designated timeframe of an inpatient hospital stay and are related to the inpatient hospital admission will not be reimbursed separately from the inpatient hospital stay if the services are rendered by the hospital or an entity that is wholly owned or operated by the hospital.

These reimbursement guidelines do not apply in the following circumstances:

•​The professional services are rendered in the inpatient hospital setting.

•​The hospital and the physician office or other entity are both owned by a third party, such as a health system.

•​The hospital is not the sole or 100-percent owner of the entity.

​Refer to: Subsection 3.7.4.17, “Payment Window Reimbursement Guidelines” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks) for additional information about the payment window reimbursement guidelines.

2 ​Blind Children’s Vocational Discovery and Development Program (BCVDDP)

2.1​Overview

BCVDDP services are provided to help children who are blind and visually impaired to develop their individual potential. This program offers a wide range of services that are tailored to each child and their family’s needs and circumstances. By working directly with the entire family, this program can help children develop the concepts and skills needed to realize their full potential.

BCVDDP services include the following:

•​Assisting the child in developing the confidence and competence needed to be an active part of their community

•​Providing support and training to children in understanding their rights and responsibilities throughout the educational process

•​Assisting family and children in the vocational discovery and development process

•​Providing training in areas like food preparation, money management, recreational activities, and grooming

•​Supplying information to families about additional resources

2.2​Enrollment

Texas Health and Human Services Commission (HHSC) Blind Children’s Vocational Discovery and Development Program (BCVDDP) is the Medicaid provider of case management for persons who are 22 years of age and younger and blind or visually impaired. Providers must meet educational and work experience requirements that are commensurate with their job responsibilities and must be trained in BCVDDP case management activities.

​Refer to: Subsection 1.1, “Provider Enrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about procedures for enrolling as a Medicaid provider.

2.3​Services, Benefits, Limitations, and Prior Authorization

Services eligible for reimbursement are limited to one contact per month, per person, regardless of the number of contacts that are made during the month. HHSC BCVDDP providers should bill procedure code G9012.

A contact is defined as “an activity performed by a case manager with the person or organization on behalf of the person to locate, coordinate, and monitor necessary services.”

​Refer to: Subsection A.8, “Texas Health and Human Services Commission Blind Children’s Vocational Discovery and Development Program (BCVDDP)” in “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information).

2.3.1​Prior Authorization

Prior authorization is not required for BCVDDP case management services.

2.4​Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including BCVDDP services.

BCVDDP services are subject to retrospective review and recoupment if documentation does not support the service billed.

2.5​Claims Filing and Reimbursement

BCVDDP case management services must be submitted to the Texas Medicaid & Healthcare Partnership (TMHP) in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms.

When completing a CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills or itemized statements are not accepted as claim supplements. Providers must not submit a claim when or after the person turns 21 years of age.

Claims may be submitted up to 365 days from the date of service in accordance with 1 TAC §354.1003.

Any child who has a suspected or diagnosed visual impairment may be referred to BCVDDP. HHSC BCVDDP assesses the impact the visual impairment has on the child’s development and provides blindness-specific services to increase the child’s skill level in the areas of independent living, communication, mobility, social, recreational, and vocational discovery and development. For more information, visit the HHS website at www.hhs.texas.gov/.

Providers can refer to the Online Fee Lookup (OFL) or the applicable fee schedule on the TMHP website at www.tmhp.com.

Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied.

Additional information about rate changes is available on the TMHP website at www.tmhp.com/resources/rate-and-code-updates/rate-changes.

​Refer to: “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information about electronic claims submissions.

Subsection 6.1, “Claims Information” in “Section 6: Claims Filing” (Vol. 1, General Information) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information).

Subsection 2.9, “Federal Medical Assistance Percentage (FMAP)” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for federal matching percentage.

3 ​Case Management for Children and Pregnant Women

3.1​Overview

Case management services are provided to help Medicaid eligible persons gain access to necessary medical, social, educational, and other services. Case managers assess a person’s need for these services and then develop a service plan to address those needs. Case management for children and pregnant women (CPW) services are outlined in Title 25 Texas Administrative Code (TAC) Part 1, Chapter 27, subchapters A-C.

3.1.1​Eligibility

CPW services are a benefit for children birth through 20 years of age who:

•​Are enrolled in Medicaid or are Medicaid eligible.

•​Have a health condition or are at risk for a medical condition, illness, injury, or disability that results in the limitation of function, activities, or social roles compared to healthy same age peers in the general areas of physical, cognitive, emotional, or social growth and development.

•​Need assistance in gaining access to necessary medical, social, educational, or other services related to their health condition or health risk.

•​Desire case management services.

CPW services are a benefit for pregnant women of any age who:

•​Are enrolled in Medicaid, or are Medicaid eligible.

•​Are pregnant with a high-risk condition, including medical conditions or psychosocial condition(s) that place the woman and her fetus at a greater than average risk for complications, either during pregnancy, delivery, or following birth.

•​Need assistance in gaining access to necessary medical, social, educational, or other services related to their high-risk condition.

•​Desire case management services.

Verbal or written consent must be obtained from the person or parent or legal guardian prior to the initiation of any CPW services. If the person receiving CPW services is a child or youth 17 years of age or younger, all CPW services and visits must be completed with a parent or legal guardian.

3.1.2​Referral Process

To refer a Medicaid eligible person for Case Management for Children and Pregnant Women services, providers may do one of the following:

•​Visit www.hhs.texas.gov/providers/health-services-providers/case-management-providers-children-pregnant-women to obtain a referral form.

•​Call THSteps toll free at 877-847-8377 from 8 a.m. to 6 p.m., Central Time, Monday through Friday.

•​Contact a Case Management for Children and Pregnant Women provider directly at www.hhs.texas.gov/providers/health-services-providers/case-management-providers-children-pregnant-women. A case management provider will contact the family to offer a choice of providers and obtain information necessary to request prior authorization for case management services.

A referral for Case Management for Children and Pregnant Women services can be received from any source.

3.2​Enrollment

Providers must be enrolled in Medicaid and approved by the Health and Human Services Commission (HHSC) to provide CPW services. Enrollment for Case Management for Children and Pregnant Women providers is a two-step process.

Step 1

Potential providers must submit a Health and Human Services Commission (HHSC) Case Management for Children and Pregnant Women provider application to the HHSC Health Screening and Case Management Unit.

Both registered nurses who have an associate’s, bachelor’s, or advanced degree and social workers who have a bachelor’s or advanced degree are eligible to become case managers if they are currently licensed by their respective Texas licensure boards and the license is not temporary in nature. Registered nurses with associate degrees must also have at least two years of cumulative, paid, full-time work experience or two years of supervised full-time, educational, internship/practicum experience in the past ten years. The experience must be with pregnant women or with children who are 20 years of age and younger. The experience must include assessing psychosocial and health needs and making community referrals for these populations. Registered nurses with bachelor or advance degrees and social workers do not have to meet any experience requirements.

For more information about provider qualifications and enrollment, or visit the case management website at www.hhs.texas.gov/providers/health-services-providers/case-management-providers-children-pregnant-women.

​Note:Before providing services, each case manager must attend HHSC case manager training. Training is conducted by DSHS regional staff.

Step 2

Upon approval by HHSC, potential providers must enroll as a Medicaid provider for Case Management for Children and Pregnant Women and submit a copy of their HHSC approval letter. Facility providers must enroll as a Case Management for Children and Pregnant Women group, and each eligible case manager must enroll as a performing provider for the group. Federally Qualified Health Center (FQHC) facilities that provide Case Management for Children and Pregnant Women services will use their FQHC number and should not apply for an additional provider number for Case Management for Children and Pregnant Women.

​Refer to: Subsection 1.1, “Provider Enrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about the procedures for enrolling as a Medicaid provider.

3.3​Services, Benefits, Limitations, and Prior Authorization

Case Management for Children and Pregnant Women services are limited to one contact per day per person. Additional provider contacts on the same day are denied as part of another service rendered on the same day.

Procedure code G9012 is to be used for all Case Management for Children and Pregnant Women services. Modifiers are used to identify which service component is provided.

Comprehensive visits completed in-person must be billed with procedure code G9012 and modifiers U2 and U5.

Comprehensive visits completed using synchronous audiovisual technology must be billed with procedure code G9012 and modifiers U2, U5 and 95.

Comprehensive visits may not be completed or billed using synchronous telephone (audio-only) technology.

Follow-up visits completed in-person must be billed with procedure code G9012 and modifiers U5 and TS.

Follow-up visits completed using synchronous audiovisual technology must be billed with procedure code G9012 and modifiers U5, TS and 95.

Follow-up visits completed using synchronous telephone (audio-only) technology must be billed with procedure code G9012 and modifiers TS and 93.

Procedure code G9012 is limited to once per day, any service, any provider.

​Refer to: The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for information on policy restrictions for services delivered by synchronous telephone (audio-only) technologies. Services delivered using audio-only technologies must be billed using the 93 modifier.

Providers must adhere to Case Management for Children and Pregnant Women program rules, policies, and procedures.

​Note:Case Management for Children and Pregnant Women providers are not required to file claims with other health insurance before filing with Medicaid.

​Reminder:Billable services are defined in program rule 25 TAC §27.11.

Case Management for Children and Pregnant Women services are not billable when a person is an inpatient at a hospital or other treatment facility.

Reimbursement will be denied for services rendered by providers who have not been approved by HHSC.

CPW services may be provided using synchronous audiovisual technologies if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit.

​Note:For CPW services delivered through a managed care organization (MCO), providers must refer to the MCO for information about benefits, limitations, prior authorization, reimbursement, and specific claim processing procedures.

During a Declaration of State Disaster, HHSC may issue direction to providers regarding the use of a telemedicine or telehealth service to include the use of synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

3.3.1​Initial Intake

CPW providers must complete an initial intake with the person or family/guardian to determine the need for CPW services. The following information must be obtained during the initial intake:

•​The health condition(s), health risk, or high-risk condition of the person who would receive case management services

•​How the health condition, health risk, or high-risk condition impacts the person’s level of functioning

•​Detailed information about the person’s current need(s) related to the health condition, health risk, or high-risk condition

•​How the CPW provider will assist the person with their current need(s)

If the person to receive services is a child or youth who is 17 years of age or younger, the initial intake must be completed with the person’s parent or legal guardian.

The CPW initial intake service is not billable. If the CPW initial intake indicates the person is eligible for services and a need for CPW services is identified, the provider must submit an Initial Prior Authorization Request for CPW services.

3.3.2​Comprehensive Visits

Comprehensive visits require prior authorization. The comprehensive visit must be completed within seven business days of the prior authorization approval. If the person receiving CPW services is a child or youth who is 17 years of age or younger, the comprehensive visit must be completed with the person’s parent or legal guardian. The comprehensive visit must include the completion of a Family Needs Assessment (FNA) and a Service Plan (SP).

​Note:The FNA and SP forms are available on the HHSC CPW website at: www.hhs.texas.gov/providers/health-services-providers/case-management-providers-children-pregnant-women

The FNA is completed to determine the need for any medical, educational, social, or other services required to address the person’s short- and long-term health and the overall well-being of the person. The FNA must include but is not limited to:

•​Completing a personal and family medical, mental health, and medication history.

•​Identifying the person’s needs.

•​Addressing personal and family issues that impact the person’s health condition, health risk, or high-risk condition.

•​Obtaining information from other sources, such as family members, medical providers, social workers, and educators.

The Service Plan (SP) must be completed during the comprehensive visit. The Service Plan (SP) is completed to determine a planned course of action based on needs identified in the Family Needs Assessment (FNA). The service plan must include, but is not limited to:

•​Activities and goals that are developed with the person or the person’s parent or guardian to address the medical, social, educational, and other services that are needed by the person receiving CPW services.

•​A course of action to respond to the assessed needs of the person receiving CPW services.

The Service Plan may also include:

•​Coordinating services with third parties such as medical or behavioral health providers, government agencies, community resources, schools, Medicaid managed care plans, other service coordinators, medical equipment and supply providers, and medical transportation agencies.

•​Contacting third parties to find resources, obtain information, or provide information related to service plan needs.

•​Participating in meetings.

•​Providing referrals.

•​Providing resource information.

•​Advocating for the person.

The Service Plan Consent form must be signed by the person or the person’s parent or legal guardian.

The Comprehensive Visit may be completed in-person or through the use of synchronous audiovisual technology. Comprehensive visits using synchronous audiovisual technology should only be provided if agreed to by the person or the person’s parent or legal guardian.

​Refer to: The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for information on policy restrictions for services delivered by synchronous telephone (audio-only) technologies.

3.3.3​Follow-up Visits

Follow-up visits require prior authorization. Follow-up visits may only be completed after the comprehensive visit has been completed. If the person receiving CPW services is a child or youth who is 17 years of age or younger, the follow-up visit must be completed with the person’s parent or legal guardian.

​Note:Follow-up visit forms are available on the HHSC CPW website at: www.hhs.texas.gov/providers/health-services-providers/case-management-providers-children-pregnant-women  

Follow-up visits are completed to ensure the service plan is implemented and adequately addresses the person’s needs. A follow-up visit must include but is not limited to:

•​Ensuring services are being furnished in accordance with the person’s service plan.

•​Ensuring services in the service plan are adequate.

•​Ensuring the service plan is modified when the person’s need(s) changes.

Activities during the follow-up visit include but are not limited to:

•​Reviewing all outstanding needs documented on the Service Plan.

•​Problem solving with the person or the person’s parent or guardian.

•​Problem solving when the person or the person’s parent or guardian has not followed through with identified Service Plan action steps.

•​Assessing for new needs.

•​Determining the next course of action to address outstanding needs.

A follow-up visit may be completed in-person or through the use of synchronous audiovisual technology, or synchronous telephone (audio-only) technology. Follow-up visits completed using synchronous audiovisual technology or synchronous telephone (audio-only) technology should only be provided if agreed to by the person or the person’s parent or guardian.

​Refer to: The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for information on policy restrictions for services delivered by synchronous telephone (audio-only) technologies.

CPW activities that occur between follow-up visits are necessary components of case management for children and pregnant women services, but are not billable. These activities may include, but are not limited to:

•​Phone calls to the person or the person’s parent or guardian between billable follow-up visits.

•​Collateral contacts on behalf of the person or the person’s parent or guardian.

CPW follow-up contacts with pregnant women with a high-risk condition may occur through the 59th day post-partum. When all needs related to the health condition, health risk, or high-risk pregnancy have been addressed, CPW services must no longer be provided.

3.3.4​Prior Authorization

All CPW services must be prior authorized, including the comprehensive visit and follow-up visits. People receiving CPW services must meet one of the following eligibility requirements:

•​Pregnant woman of any age may have a high risk pregnancy, medical conditions, or psychosocial conditions that place the woman and her fetus at a greater than average risk for complications during pregnancy, delivery or after childbirth.

•​Children birth through 20 years of age who may have a health condition or are at risk for a medical condition, illness, injury, or disability that results in the limitation of function, activities, or social roles compared to healthy same-age peers in the general areas of physical, cognitive, emotional, or social growth and development.

Prior authorization requests for CPW services must be submitted to TMHP within three business days of the initial intake. TMHP CPW prior authorization forms may be found on the TMHP website.

​Refer to: www.tmhp.com/topics/prior-authorization

A TMHP CPW Initial Prior Authorization Request form must be submitted to TMHP within three business days of the initial intake. TMHP CPW Initial Prior Authorization Request forms and CPW Prior Authorization Request For Additional Visits forms may be submitted to TMHP using the TMHP Prior Authorization (PA) Portal or by mail.

The information indicated on the Initial Intake form must be entered into the TMHP CPW Initial Prior Authorization Request form, including but not limited to:

•​The health condition(s), health risk, or high-risk condition of the person who would receive case management services

•​How the health condition, health risk, or high-risk condition impacts the person’s level of functioning

•​Detailed information about the person’s current need(s) related to the health condition, health risk, or high-risk condition

•​How the CPW provider will assist the person with their current need(s)

A TMHP CPW Initial Prior Authorization Request form must be submitted and approval received prior to the initiation of CPW services including the comprehensive visit. The information provided on the TMHP CPW Initial Prior Authorization Request form must support the need for CPW services.

Needs identified that do not support the need for CPW services include, but are not limited to:

•​Needs identified are not related to health condition, health-risk, or if pregnant, a high-risk condition

•​Needs identified are anticipatory

•​Needs identified are not current

•​Needs identified are for monitoring the client’s health only

•​Need identified is a routine Medicaid need (e.g., finding a doctor or dentist, [unless there is a documented barrier to finding a provider])

•​Needs identified are for other family members only

•​Need identified is for support group(s)

Needs identified are for basic information and referral (example: baby supplies, financial assistance, school supplies, GED/parents’ educational needs, etc.).

Approved TMHP CPW Initial Prior Authorization Request forms will include one comprehensive visit and two follow-up visits.

CPW prior authorization approvals are valid for one year. Prior authorization is a condition of reimbursement, not a guarantee of payment.

3.3.4.1​Prior Authorization for Additional Follow-up Visits

Additional CPW follow-up visits may be considered when:

•​All previously authorized follow-up visits have been completed

•​The person still meets eligibility requirements

•​Additional visits are needed to resolve previously identified needs or newly identified needs

•​Documentation supports the reason(s) needs originally identified have not been addressed

A TMHP CPW Prior Authorization Request for Additional Visits form must be submitted to TMHP, using the TMHP PA Portal or by mail, when an additional follow-up visit is requested. Approved TMHP CPW Prior Authorization Request for Additional Visits will include one follow-up visit. CPW prior authorization approvals are valid for one year.

3.4​Technical Assistance

Providers may contact HHSC program staff as needed for assistance with program concerns. Providers should contact TMHP provider relations staff as needed for assistance with claims problems or concerns.

3.4.1​Assistance with Program Concerns

Providers who have questions, concerns, or problems with program rule, policy, or procedure may contact HHSC program staff at askcm@hhs.texas.gov.

Regional DSHS staff make routine contact with providers to ensure providers are delivering services as required.

3.5​Documentation Requirements

All CPW services require documentation to support the medical necessity of the service rendered.

Case Management for Children and Pregnant Women services are subject to retrospective review and recoupment if documentation does not support the service billed.

Documentation in the person’s record must include that verbal or written consent was obtained from the person or the person’s parent or legal guardian prior to the initiation of any CPW services.

Prior authorization requests must be submitted to TMHP using a TMHP CPW Initial Prior Authorization Request form or CPW Prior Authorization Request for Additional Visits form. CPW forms including the Family Needs Assessment, Service Plan, Follow-Up form, follow-up documentation, and progress notes must be completed and maintained in the person’s record.

Signatures must be included on all forms and documents that require signatures. All forms and documents completed in relation to CPW services must be maintained in the person’s record.

All contacts with or on behalf of the person or the person’s parent or guardian must be documented and maintained in the person’s record. Documentation of activities, not otherwise documented on CPW required forms, must be recorded on progress notes. Documentation in the person’s record must include the reason(s) a CPW service was not provided or completed.

Records are subject to review by HHSC or its designee.

All needs identified during the completion of the service plan must be documented on the Service Plan form. CPW activities that occur between follow-up visits must be documented on a progress note and maintained in the person’s chart.

​Note:CPW documentation forms are available on the HHSC CPW website at: www.hhs.texas.gov/providers/health-services-providers/case-management-providers-children-pregnant-women

3.6​Claims Filing and Reimbursement

3.6.1​Claims Information

CPW services are subject to retrospective review and recoupment if documentation does not support the service billed.

Claims submitted for services that have not been prior authorized will be denied.

The comprehensive visit must not be billed until the FNA and SP are completed, and the SP Consent form is signed by the person or the person’s parent or legal guardian. The CPW initial intake service is not billable.

Activities that occur between follow-up visits are necessary components of case management but are not billable. These activities must be documented on a progress note. These activities may include, but are not limited to:

•​Phone calls to the person or the person’s parent or guardian between billable follow-up visits.

•​Collateral contacts on behalf of a person or a person’s parent or guardian.

Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied.

Additional information about rate changes is available on the TMHP website at www.tmhp.com/resources/rate-and-code-updates/rate-changes.

​Refer to: “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

Subsection 6.1, “Claims Information” in “Section 6: Claims Filing” (Vol. 1, General Information) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information).

Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more information about reimbursement.

3.6.1.1​Exclusions

CPW services are limited to one service per day, any provider.

CPW services are not billable when provided in the inpatient setting.

3.6.2​Managed Care Clients

Case Management for Children and Pregnant Women services are carved in to Medicaid managed care and must be billed to the client’s managed care organization (MCO).

4 ​Outpatient Mental Health Services

Outpatient mental health services are used for the treatment of mental illness and emotional disturbances in which the clinician establishes a professional contract with the person and, utilizing therapeutic interventions, attempts to alleviate the symptoms of mental illness or emotional disturbance, and reverse, change, or ameliorate maladaptive patterns of behavior.

Outpatient mental health services include psychiatric diagnostic evaluation, psychotherapy (including individual, family, or group), psychological, neurobehavioral, or neuropsychological testing, pharmacological management, and electroconvulsive therapy (ECT).

Outpatient mental health services are benefits when provided in the office, home, skilled nursing or intermediate care facility (SNF/ICF), outpatient hospital, extended care facility (ECF), or in other locations.

Outpatient mental health services are benefits of Texas Medicaid when provided to persons who are experiencing a mental health condition that is causing distress, dysfunction, or maladaptive functioning as a result of a confirmed or suspected psychiatric condition as defined in the current edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).

​Note:Claims will require the corresponding diagnosis code(s) from the current edition of the International Classification of Diseases (ICD).

4.1​Provider Enrollment

Mental health service providers include physicians, PAs, APRNs, LCSWs, LMFTs, LPCs, psychologists, licensed psychological associates (LPAs), provisionally licensed psychologists (PLPs), post-doctoral fellows, and pre-doctoral psychology interns.

​Refer to: Subsection 1.1, “Provider Enrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about procedures for enrolling as a Medicaid provider.

4.1.1​Physicians

To enroll in Texas Medicaid to provide medical services, physicians (doctor of medicine [MD] or doctor of osteopathy [DO]) and doctors (doctor of dental medicine [DMD], doctor of dental surgery [DDS], doctor of optometry [OD], and doctor of podiatric medicine) must be authorized by the licensing authority of their profession to practice in the state where the services are performed at the time they are provided.

Providers cannot be enrolled in Texas Medicaid if their licenses are due to expire within 30 days. A current Texas license must be submitted.

All physicians except gynecologists, pediatricians, pediatric subspecialists, pediatric psychiatrists, and providers performing only THSteps medical or dental checkups must be enrolled in Medicare before enrolling in Medicaid. TMHP may waive the Medicare enrollment prerequisite for pediatricians or physicians whose type of practice and service may never be billed to Medicare.

4.1.2​Physician Assistants (PAs)

To enroll in Texas Medicaid, a PA must be licensed as a PA and be recognized as a PA by the Texas Physician Assistant Board. All PAs are enrolled within the categories of practice as determined by the Texas Medicaid Board. PAs can enroll as an individual, group, or as a performing provider into a clinic/group practice. If enrolling into a Medicare enrolled clinic/group practice, Medicare enrollment is required.

4.1.3​Advanced Practice Registered Nurses (APRNs)

To enroll in Texas Medicaid, whether as an individual or as part of a group, a nurse practitioner (NP) or clinical nurse specialist (CNS) recognized as an APRN must be licensed by the Texas Board of Nursing (TBON). NP/CNSs must also be enrolled in Medicare or obtain a pediatric practice exemption from TMHP Provider Enrollment. If a pediatric-based NP/CNSs is enrolling as part of a Medicare-enrolled group, then the NP/CNSs must also be enrolled in Medicare.

Providers that hold a temporary license are not eligible to enroll in Medicaid. NP/CNSs cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted.

4.1.4​Licensed Clinical Social Workers (LCSWs)

To enroll in Texas Medicaid, whether as an individual or as part of a group, an LCSW must be licensed by the Texas State Board of Social Worker Examiners. LCSWs must also be enrolled in Medicare or obtain a pediatric practice exemption from TMHP Provider Enrollment. If a pediatric-based LCSW is enrolling as part of a Medicare-enrolled group, then the LCSW must also be enrolled in Medicare.

Providers that hold a temporary license are not eligible to enroll in Medicaid. LCSWs cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted.

4.1.5​Licensed Marriage and Family Therapists (LMFTs)

To enroll in Texas Medicaid, whether as an individual or as part of a group, an LMFT must be licensed by the Texas State Board of Examiners of Licensed Marriage and Family Therapists. LMFTs must also be enrolled in Medicare or obtain a pediatric practice exemption from TMHP Provider Enrollment. If a pediatric-based LMFT is enrolling as part of a Medicare-enrolled group, then the LMFT must also be enrolled in Medicare. Providers that hold a temporary license are not eligible to enroll in Medicaid. LMFTs cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted.

4.1.6​Licensed Professional Counselors (LPCs)

To enroll in Texas Medicaid, whether as an individual or as part of a group, an LPC must be licensed by the Texas Board of Examiners of Professional Counselors. LPCs must also be enrolled in Medicare or obtain a pediatric practice exemption from TMHP Provider Enrollment. If a pediatric-based LPC is enrolling as part of a Medicare-enrolled group, then the LPC must also be enrolled in Medicare. Providers that hold a temporary license are not eligible to enroll in Medicaid. LPCs cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted.

4.1.7​Psychologists

To enroll in Texas Medicaid, whether as an individual or as part of a group, a psychologist must be licensed by the Texas State Board of Examiners of Psychologists (TSBEP). Psychologists must also be enrolled in Medicare or obtain a pediatric practice exemption from TMHP Provider Enrollment. If a pediatric-based psychologist is enrolling as part of a Medicare-enrolled group, then the psychologist must also be enrolled in Medicare. Psychologists cannot be enrolled if they have a license that is due to expire within 30 days. A current license must be submitted. Texas Medicaid accepts temporary licenses for psychologists.

4.1.8​Licensed Psychological Associates (LPAs)

LPAs must be licensed by TSBEP. LPAs are expected to abide by their scope and standards of practice.

Services performed by an LPA are a Medicaid-covered benefit when the following conditions are met:

•​The services must be performed under the required supervision of a licensed, Medicaid-enrolled psychologist.

•​The supervising psychologist must be in the same office, building, or facility when the service is provided and must be immediately available to furnish assistance and direction.

•​The LPA performing the service must be an employee of either the licensed psychologist or the legal entity that employs the licensed psychologist.

Psychological services provided by an LPA must be billed under the supervising psychologist’s National Provider Identifier (NPI) or the NPI of the legal entity employing the supervising psychologist.

4.1.9​Provisionally Licensed Psychologists (PLPs)

PLPs must be licensed by TSBEP. A PLP may perform all of the services that are benefits of Texas Medicaid when the services are performed by a psychologist.

PLPs are expected to abide by their scope and standards of practice. Services performed by a PLP are a Medicaid-covered benefit when the following conditions are met:

•​The services must be performed under the required supervision of a licensed psychologist in accordance with the TSBEP guidelines.

•​The supervising psychologist must be in the same office, building, or facility when the service is provided and must be immediately available to furnish assistance and direction.

•​The PLP who is performing the service must be an employee of either the licensed psychologist or the legal entity that employs the licensed psychologist.

The TSBEP requires a PLP to work under the required supervision of a licensed psychologist and does not allow a PLP to engage in independent practice. Therefore, a PLP will not be independently enrolled in the Medicaid program and must provide services under the delegating psychologist’s NPI.

Psychological services provided by a PLP must be billed under the supervising psychologist’s NPI or the NPI of the legal entity employing the supervising psychologist.

4.1.10​Post-Doctoral Fellows

Post-doctoral psychology fellows who satisfy the provisional licensure examination requirements but have not yet been awarded the PLP designation are eligible to perform delegated psychological services within their scope of practice and under the required supervision of a licensed psychologist.

Psychology interns are not independently enrolled in the Medicaid program and must provide services under the delegating psychologist’s NPI.

Psychological services provided by an intern must be billed under the supervising psychologist’s NPI or the NPI of the legal entity employing the supervising psychologist.

4.1.11​Pre-doctoral Psychology Interns

Pre-doctoral psychology interns who are participating in a pre-doctoral psychology internship at a site that is a member of the Association of Psychology Postdoctoral and Internship Centers (APPIC) are eligible to perform delegated psychological services within their scope of practice and under the required supervision of a licensed psychologist.

Psychology interns are not independently enrolled in the Medicaid program and must provide services under the delegating psychologist’s NPI.

4.2​Services, Benefits, Limitations

The following procedure codes may be reimbursed for outpatient mental health services:

The following psychotherapy procedure codes are limited to 30 visits per calendar year. Additional services require prior authorization:

Procedure codes 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, and 90853 are limited to the following diagnosis codes:

In addition to the diagnosis codes listed in the table above, procedure code 90791 or 90792 is a benefit when submitted with the following diagnosis codes:

Procedure codes 96116, 96121, 96130, 96131, 96132, 96133, 96136, and 96137 are limited to the following diagnosis codes:

4.2.1​Telemedicine and Telehealth Services

Providers must defer to the needs of the person receiving services, allowing the mode of service delivery to be accessible, person- and family-centered, and primarily driven by the person’s choice and not provider convenience.

Providers must provide outpatient mental health services to Medicaid eligible persons in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Administrative Code (TAC) §371.1659. In addition, providers must deliver, to include delivery by telemedicine or telehealth, outpatient mental health services in full accordance with all applicable licensure and certification requirements.

During a Declaration of State of Disaster, the Health and Human Services Commission (HHSC) may issue direction to providers regarding the use of a telemedicine or telehealth services to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

4.2.1.1​Synchronous Audiovisual Technology

The following outpatient mental health services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the billing provider, and agreed to by the person receiving services. Outpatient mental health services provided by synchronous audiovisual technology must be billed using modifier 95.

•​Psychiatric diagnostic evaluation services with and without medical services (procedure codes 90791 and 90792)

•​Psychotherapy (individual, family, or group) services (procedure codes 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, and 90853)

•​Pharmacological management services (most appropriate E/M code with modifier UD) for psychiatric care only

•​Neurobehavioral services (procedure codes 96116 and 96121).

•​Neuropsychological and psychological testing services (procedure codes 96130, 96131, 96132, 96133, 96136 and 96137) if the following conditions are met:

•​The psychometric test must be available in an online format, except for tests that are administered and responded to orally;

•​The provider, or test administrator, must observe the person, in real-time, for the duration of the test; and

•​The provider delivers the psychometric test in accordance with their licensing board and professional guidelines.

4.2.1.2​Synchronous Telephone (audio-only) Technology

The following outpatient mental health services may be provided by synchronous telephone (audio-only) technology to persons with whom the billing provider has an existing clinical relationship and, if clinically appropriate and safe, as determined by the billing provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as, the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers of outpatient mental health services must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology.

Outpatient mental health services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ.

•​Psychiatric diagnostic evaluation services with and without medical services (procedure codes 90791 and 90792)

•​Psychotherapy (individual, family, or group) services (procedure codes 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, and 90853)

•​Pharmacological management services (most appropriate E/M code with modifier UD) for psychiatric care only

An existing clinical relationship occurs when a person has received at least one in-person or synchronous audiovisual outpatient mental health service (psychiatric diagnostic evaluation, psychotherapy [individual, family, or group], pharmacological management, testing [neurobehavioral, psychological, or neuropsychological], or ECT) from the same billing provider within the six months prior to the initial service delivered by synchronous telephone (audio-only) technology. The six-month requirement for at least one in-person or synchronous audiovisual outpatient mental health service by the same billing provider prior to the initial synchronous telephone (audio-only) service may not be waived.

​Note:“Same billing provider” refers to providers that are within the same entity or organization, as identified by the entity’s or organization’s NPI number or numbers, if the entity or organization has multiple locations (e.g., a clinic/group practice, federally qualified health clinic or rural health clinic, and can include providers within the same community mental health center).

​Note:The required in-person or synchronous audiovisual-delivered outpatient mental health service (psychiatric diagnostic evaluation, psychotherapy [individual, family, or group], pharmacological management, testing [neurobehavioral, psychological, or neuropsychological], or ECT) may be delivered by another authorized professional or paraprofessional of the same billing provider as the professional or paraprofessional who delivers the service by synchronous telephone (audio-only) technology.

The billing provider is required to conduct at least one in-person or synchronous audiovisual outpatient mental health service (psychiatric diagnostic evaluation, psychotherapy [individual, family, or group], pharmacological management, testing [neurobehavioral, psychological, or neuropsychological] or ECT) every rolling 12 months from the date of the initial service delivered by synchronous telephone (audio-only) technology unless the person receiving services and the billing provider agree that an in-person or synchronous audiovisual service is clinically contraindicated, or the risks or burdens of an in-person or synchronous audiovisual service outweigh the benefits. The decision to waive the 12-month requirement applies to that particular rolling 12-month period and the basis for the decision must be documented in the person’s medical record. Examples of when a synchronous telephone (audio-only) service may be more clinically appropriate or beneficial than an in-person or synchronous audiovisual service include, but are not limited to, the following:

•​The person receiving services is located at a qualifying originating site in an eligible geographic area, e.g., a practitioner office in a rural Health Professional Shortage Area

•​An in-person or synchronous audiovisual service is likely to cause disruption in service delivery or has the potential to worsen the person’s condition(s)

​Note:The required in-person or synchronous audiovisual-delivered outpatient mental health service (psychiatric diagnostic evaluation, psychotherapy [individual, family, or group], pharmacological management, testing [neurobehavioral, psychological, or neuropsychological], or ECT) may be delivered by another authorized professional or paraprofessional of the same billing provider (see note above for the definition of same billing provider) as the professional, or paraprofessional, who delivers the service by synchronous telephone (audio-only) technology.

​Refer to: The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for more information about telemedicine and telehealth requirements to include informed consent and privacy and security requirements.

4.2.2​Psychotherapy Services

Individual psychotherapy is defined as therapy that focuses on a single person.

Group psychotherapy is defined as a type of psychotherapy that involves one or more therapists working with several persons at the same time.

Family psychotherapy is defined as therapy that focuses on the dynamics of the family unit where the goal is to strengthen the family’s problem solving and communication skills.

Providers must bill a modifier to identify a separate and distinct service when performing individual psychotherapy (procedure code 90832, 90834, or 90837) and family psychotherapy (procedure code 90846 or 90847) on the same day for the same person. When billing for these services, providers must submit the family psychotherapy procedure code with the modifier on the claim to indicate that the procedure or service was distinct or independent from other services performed on the same day for the same person. Documentation that supports the provision of distinct or independent services must be maintained in the person’s medical record and made available to Texas Medicaid upon request.

​Note:The add-on codes may only be billed by physician, APRN, or PA providers.

​Refer to: Subsection 9.2.59.6, “Prolonged Physician Services” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information about prolonged physician services.

Psychotherapy (individual, family, or group) is limited to 4 hours per person, per day.

Psychotherapy is limited to 30 individual, group, or family psychotherapy visits per person, per calendar year. Additional psychotherapy services must be prior authorized. Prior authorization requests in increments of up to 10 additional visits may be considered. The request must be submitted on an Outpatient Mental Health Services Request Form and include the following information:

•​Identifying information for the person receiving services

•​Provider name and NPI

•​Current DSM diagnosis(es)

•​Current psychotropic medications

•​Current symptoms requiring additional psychotherapy

•​Treatment plan, including measurable short-term goals, specific therapeutic interventions utilized, and measurable expected outcomes of therapy

•​Number and type of services requested and anticipated dates that the services will be provided

•​Indication of court-ordered or Department of Family and Protective Services (DFPS)-directed services

Providers with an established relationship with a person receiving services must request prior authorization when they determine the person is approaching 30 psychotherapy visits for the calendar year. If the person changes providers during the year and the new provider is unable to obtain complete information on the person’s previous treatment history, providers are encouraged to obtain prior authorization before rendering services. Requests submitted on the same day as the initial session with a new provider will be considered based on medical necessity criteria.

Providers must bill the preponderance of each half hour of psychotherapy and indicate the number of units on the claim form.

LMFTs must bill with modifier U8 to differentiate from LPCs.

Supporting documentation for individual, family, or group psychotherapy services must include:

•​Start and end time of session

•​Modality or modalities utilized

•​Frequency of psychotherapy sessions

•​Clinical notes for each visit must include diagnosis, symptoms, functional status, focused mental status examination (if indicated), treatment plan (goals and objectives addressed), prognosis, and progress, and the name, signature, and credentials of the individual performing the services.

4.2.2.1​Family Psychotherapy

Family psychotherapy may be provided to Medicaid eligible persons 20 years of age and younger using procedure code 90846 or persons of any age using procedure code 90847.

Family psychotherapy is only reimbursable for one Medicaid eligible person per session regardless of the number of family members present per session.

Family psychotherapy for Medicaid eligible persons 20 years of age and younger may be provided to the child’s parent(s), foster parent(s), or legal guardian without the child present, as clinically appropriate, using procedure code 90846. Parent- or guardian-only sessions may be indicated when addressing sensitive topics such as parenting challenges or related stressors that would be inappropriate to discuss with the child present at the session.

Only the following specific relatives may participate in family psychotherapy services:

•​Biological parent, foster parent, or legal guardian

•​Child

•​Grandfather or grandmother

•​Sibling (biological, foster, or kinship)

•​Uncle, aunt, nephew, or niece

•​First cousin or first cousin once removed

•​Stepfather, stepmother, stepbrother, or stepsister

4.2.2.2​Treatment for Alzheimer’s Disease and Dementia

Psychotherapy for persons with Alzheimer’s disease or dementia is a benefit of Texas Medicaid for persons with very mild or mild cognitive decline.

Documentation to support the treatment for Alzheimer’s disease or dementia must be maintained in the person’s medical record and may be subject to retrospective review. Psychotherapy services must not be continued if no longer beneficial to the person due to diminished cognitive functioning.

4.2.3​Delegated Services

Services provided by a psychologist, LPA, PLP, psychology intern, or post-doctoral fellow must be billed with a modifier on each detail. Psychological services provided by an LPA, PLP psychology intern, or post-doctoral fellow must be billed under the supervising psychologist’s NPI or the NPI of the legal entity employing the supervising psychologist.

Services performed by a LPA or PLP will be reimbursed at 70 percent of the psychologist rate. Services performed by the psychology intern or post-doctoral fellow will be reimbursed at 50 percent of the psychologist rate.

The following modifiers are to be used with procedure codes for licensed psychologist and delegated services:

Claims submitted without a modifier or with two of these modifiers on the same detail will be denied.

Only the LCSW, LMFT, LPC, APRN, or PA performing the mental health service may bill Texas Medicaid. The LCSW, LMFT, LPC, APRN, or PA must not bill for services performed by people under his or her supervision.

4.2.4​Pharmacological Management Services

Pharmacological management is the in-depth management of psychopharmacological agents to treat a person’s mental health symptoms.

Pharmacological management is a physician service and cannot be provided by a non-physician or “incident to” a physician service, except for APRNs and PAs whose scope of license in this state permits them to prescribe.

Pharmacological management is limited to one service per day, per person, by any provider in any setting.

The treating provider should use the most appropriate E/M code for the pharmacological management visit depending on the place of service and complexity of the person’s condition, along with modifier UD to designate the visit as primarily focused on pharmacological management.

Supporting documentation for pharmacological management services must include:

•​Complete diagnosis utilizing diagnostic criteria from the current edition of the DSM

•​Current list of medications

•​Current psychiatric symptoms and problems, including presenting mental status

•​Problems, reactions, and side effects, if any, to medications

•​Any medication modifications made during a visit and the reasons for medication adjustments, changes, or discontinuation

•​Desired therapeutic drug levels, if applicable, for medications requiring blood level monitoring, e.g. Lithium

•​Current laboratory values, if applicable, for medications requiring monitoring for potential side effects, e.g. hyperglycemia caused by anti-psychotic medications

•​Treatment goals

4.2.5​Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is the induction of convulsions by the passage of an electric current through the brain used in the treatment of certain psychiatric disorders.

Individual psychotherapy, psychological, neurobehavioral, or neuropsychological testing billed in addition to ECT on the same day, by any provider will be denied as part of another procedure on the same day.

ECT billed in addition to psychiatric diagnostic evaluation or group or family psychotherapy on the same day, by the same provider will be denied as part of another procedure.

4.2.6​Psychiatric Diagnostic Evaluation Services

Psychiatric diagnostic evaluation is an integrated biopsychosocial assessment, including history, mental status, and recommendations. Psychiatric diagnostic evaluation with medical services also includes a medical assessment, other physical examination elements as indicated, and may also include prescription of medications, and laboratory or other diagnostic studies.

A psychiatric diagnostic evaluation without medical services (procedure code 90791) may be reimbursed to physicians, psychologists, APRNs, PAs, LCSWs, LPCs, LMFTs, PLPs, psychology interns, and post-doctoral fellows.

A psychiatric diagnostic evaluation with medical services (procedure code 90792) may be reimbursed to physicians, APRNs, and PAs.

Psychiatric diagnostic evaluations with and without medical services (procedure codes 90791 and 90792) are limited to once per person, per rolling year, same provider in the office, home, outpatient hospital, or other settings, regardless of the number of professionals involved in the interview. Additional psychiatric diagnostic evaluations may be considered for prior authorization on a case-by-case basis when submitted on an Outpatient Mental Health Services Request Form with supporting documentation, including but not limited to:

•​A court order or a DFPS directive

•​If a major change of status occurs

Supporting documentation for psychiatric diagnostic evaluation services must include:

•​Reason for referral or presenting problem

•​Prior diagnoses and any prior treatment

•​Other pertinent medical, social, and family history

•​Clinical observations and results of mental status examination

•​Complete diagnosis utilizing diagnostic criteria from the current edition of the DSM

•​Recommendations, including expected long- and short-term goals

4.2.7​Psychological, Neurobehavioral, and Neuropsychological Testing Services

Psychological, neurobehavioral, and neuropsychological testing involves the use of formal tests and other assessment tools to measure and assess a person’s emotional, and cognitive functioning in order to arrive at a diagnosis and guide treatment.

Psychological testing (procedure codes 96130, 96131, 96136, and 96137) and neuropsychological testing (procedure codes 96132, 96133, 96136, and 96137) are limited to eight hours per person, per calendar year. Additional hours require prior authorization when medically necessary. The request must be submitted on an Outpatient Mental Health Services Request Form and include the following information:

•​Identifying information for the person receiving services

•​Provider name and NPI

•​Current DSM diagnoses

•​Indication of court-ordered or DFPS-directed services

•​Type of testing requested (psychological, neurobehavioral, or neuropsychological) including specific procedure codes

•​Rationale for requested testing, to include the current symptoms of the person receiving services

•​Previous history and testing results

Psychological, neurobehavioral, and neuropsychological testing will not be reimbursed to an APRN or a PA. The most appropriate office visit procedure code must be billed. Mental health screening may be performed during an assessment by an APRN or a PA, but will not be reimbursed separately.

Psychological testing (procedure codes 96130, 96131, 96136, and 96137) or neuropsychological testing (procedure codes 96132, 96133, 96136, and 96137) may be reimbursed on the same date of service as an initial psychiatric diagnostic evaluation (procedure code 90791 or 90792).

Neurobehavioral testing (procedure code 96116) may not be reimbursed on the same date of service as an initial psychiatric diagnostic evaluation (procedure code 90791 or 90792) to the same provider.

Neurobehavioral testing (procedures codes 96116 and 96121) will not be paid for the same date of service to the same provider as psychological testing (procedure codes 96130, 96131, 96136 and 96137) or neuropsychological testing (procedure codes 96132, 96133, 96136, and 96137). All documentation must be maintained by the provider in the person’s medical record.

The reimbursement for procedure codes 96116, 96121, 96130, 96131, 96132, 96133, 96136, and 96137 includes the face-to-face testing and the scoring and interpretation of the results. The number of units of testing on the claim for procedure codes 96116, 96121, 96130, 96131, 96132, 96133, 96136, and 96137 must be in accordance with the allowable activities outlined in each code description.

​Note:Add-on procedure codes indicated with asterisk must be billed with the appropriate primary procedure code.

Assessment, treatment planning, and documentation time, including time to document test results in the person’s medical record, is not reimbursed separately. Reimbursement is included in the covered procedure codes.

4.2.7.1​Testing in Facilities

Psychological testing, neurobehavioral testing, or neuropsychological testing may be reimbursed when provided in a skilled nursing facility (SNF), intermediate care facility (ICF), or extended care facility (ECF) as clinically indicated. Testing may be indicated, for example, when a person has experienced significant change in mental status requiring specialized testing, or to evaluate a person’s competency to return to a community-based setting. Persons with well-established mental or cognitive issues do not require additional testing.

Psychological, neurobehavioral, or neuropsychological testing will not be reimbursed in a SNF, ICF, or ECF when conducted prior to the performance of initial intake assessments such as the Minimum Data Set or Preadmission Screening and Resident Review (PASRR) (a completed Level I Screening and a Level II Evaluation, as applicable).

Supporting documentation for psychological, neurobehavioral, or neuropsychological testing services must include:

•​Reason for referral or presenting problem

•​The name of the tests (e.g.,WAIS-R, Rorschach, MMPI) performed

•​The scoring of the test

•​Location where the testing is performed

•​The name and credentials of each provider involved in administering, interpreting, and preparing the report

•​Test interpretations, including narrative descriptions of the test findings

•​Length of time spent by each provider, as applicable, in administration, interpretation, integrating the test interpretation, and documenting the comprehensive report based on the integrated data

•​Recommended treatment, including how test results affect the prescribed treatment

•​Recommendations for further testing, including an explanation to substantiate the necessity for retesting, if applicable

•​Rationale or extenuating circumstances that impact the ability to complete the testing, such as, but not limited to, the person’s condition requires testing over two days and the person does not return, or the person’s condition precludes completion of the testing.

Original testing material must be maintained by the provider and must be readily available for retrospective review by HHSC.

When psychological, neurobehavioral, or neuropsychological testing is performed in a SNF, ICF, or ECF, a copy of the test and the resulting report must also be maintained in the person’s medical record at the facility.

4.3​Prior Authorization

Prior authorization requests must be submitted to the TMHP Prior Authorization Department via mail, fax, or the electronic portal. Performing providers may sign prior authorization forms and supporting documentation using electronic or wet signatures.

​Refer to: Subsection 5.5.1.2, “Document Requirements and Retention” in “Section 5: Fee-for-Service Prior Authorizations” (Vol. 1, General Information) for additional information about electronic signatures.

All providers must adhere to prior authorization requirements.

4.3.1​Services Requiring Prior Authorization

Prior Authorization is required for the following services:

•​Psychiatric diagnostic evaluation (procedure code 90791 or 90792) after the one evaluation per person, per provider, per rolling year limitation has been met

•​Individual, family, or group psychotherapy (procedure codes 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, and 90853) after the 30 visit per calendar year limitation has been met

•​Neurobehavioral testing (procedure codes 96116 and 96121) after the 4 hour per day limitations have been met

•​Psychological testing (procedure code 96130, 96131, 96136, or 96137) or neuropsychological testing (procedure code 96132, 96133, 96136, or 96137) after the 8 hour per calendar year limitations have been met

•​Unlisted psychiatric service or procedure (procedure code 90899)

Requests for prior authorization for procedure code 90899 must be submitted by the provider to the Special Medical Prior Authorization (SMPA) department using the Special Medical Prior Authorization (SMPA) Request Form with documentation supporting medical necessity including:

•​Diagnosis(es)

•​Prior treatment for this diagnosis and the medical necessity of the requested procedure

•​A clear, concise description of the evidence-based service or procedure to be performed, and the intended fee for the service or procedure

•​The reason for recommending this particular service or procedure

•​A procedure code that is comparable to the service or procedure being requested

•​Documentation that this service or procedure is not investigational or experimental

4.3.2​Prior Authorization Not Required

Prior authorization is not required for the following services:

•​One psychiatric diagnostic evaluation (procedure codes 90791 and 90792) per person, per rolling year, per provider (same provider)

•​30 individual, family, or group psychotherapy (procedure codes 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, and 90853) visits per person per calendar year

•​4 hours of psychotherapy services per person per day

•​4 hours of neuropsychological testing (procedure codes 96116 and 96121) per person per day

•​8 hours of psychological, neurobehavioral, or neuropsychological testing (procedure codes 96130, 96131, 96132, 96133, 96136, or 96137) per person, per calendar year

•​ECT (procedure code 90870)

4.4​Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including mental health services. The documentation must support the medical necessity of the treatment for its entire duration.

Mental health services outlined in this handbook are subject to retrospective review to ensure that the documentation in the person’s medical record supports the medical necessity of the services provided. Documentation requirements for a telemedicine or telehealth service are the same as for an in-person visit and must accurately reflect the services rendered. Documentation must identify the means of delivery when provided by telemedicine or telehealth.

​Refer to: The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for more information about telemedicine and telehealth documentation requirements including requirements for informed consent.

4.5​Twelve Hour System Limitation

The following provider types are limited to a maximum combined total of 12 hours per provider, per day, regardless of the number of persons seen for outpatient mental health services:

•​Psychologist

•​APRN

•​PA

•​LCSW

•​LMFT

•​LPC

The following table lists the procedure codes for mental health services included in the system limitation, along with the time increments the system will apply based on the billed procedure code. The time increments applied will be used to calculate the 12-hour per day system limitation.

Court-ordered and DFPS directed services are not subject to the 12-hour per provider, per day system limitation when billed with modifier H9.

Physicians are not subject to the 12-hour system limitation since they can delegate and may submit claims in excess of 12 hours per day.

Psychologists can delegate to multiple LPAs, PLPs, interns, or post-doctoral fellows and therefore delegated services are not subject to the 12-hour system limitation since they may submit claims for delegated services in excess of 12 hours per day.

4.6​Court-Ordered Services

The court-ordered services listed below for persons who are age 20 years of age and younger or 65 years of age and older are not subject to utilization management reviews, including prior authorization, concurrent reviews, or retrospective reviews that have the effect of denying, reducing, or controverting the court-ordered service. In these situations, the court order is considered the determination of medical necessity.

When billed with modifier H9, court-ordered services are not subject to the 12-hour system limitation per provider, per day.

Federal law prohibits the use of federal Medicaid funding for medical care provided to persons who are considered incarcerated. A person is considered incarcerated when a criminal justice facility has custody of the person. Examples include:

•​A person who is currently residing in a criminal justice facility and receiving treatment through a program at the criminal justice facility.

•​A person who is committed under Title 1 Texas Code of Criminal Procedure §46(B), which addresses persons ages 18 and older who have been ordered to receive competency restoration.

•​A person who is committed under Title 3 Texas Family Code §§55.01-55.45. These sections refer to persons committed to inpatient psychiatric care because they are deemed unfit to proceed.

The following court-ordered services are required to be provided to Medicaid eligible persons who are not considered incarcerated:

•​Emergency detention ordered by a judge or magistrate under Title 7 Texas Health and Safety Code §§573. 011-573.026.

•​Mental health services ordered under Title 7 Texas Health and Safety Code §§574.01-574.110. Mental health services may include:

•​A mental health examination.

•​Inpatient or outpatient treatment.

•​Detention under protective custody and temporary mental health services.

•​Treatment of persons who are found not guilty based on lack of responsibility under Title 3 Texas Family Code §55.

•​Treatment that is a condition of probation.

•​Treatment of persons with chemical dependencies ordered under Title 6 Texas Health and Safety Code §462.042.

For authorization of court-ordered services, the provider must submit documentation that includes:

•​The court-order.

•​Information about the statute under which the court is ordering the services.

•​Verification of the person’s incarceration status.

For court-ordered inpatient admissions, providers must submit documentation that includes:

•​A copy of the doctor’s certificate.

•​All court-ordered commitment papers signed by the judge.

For persons with fee-for-service benefits, this supporting documentation must be submitted with the Psychiatric Inpatient Extended Stay Request Form.

Requested services beyond those that are court-ordered are subject to medical necessity review.

4.7​Exclusions

The following services are not benefits of Texas Medicaid:

•​Psychoanalysis

•​Multiple family group psychotherapy

•​Marriage or couples counseling

•​Narcosynthesis

•​Biofeedback training as part of psychophysiological therapy

•​Psychiatric day treatment programs

•​Services provided by a psychiatric assistant, psychological assistant (excluding master’s level LPA), or a licensed chemical dependency counselor

4.8​Claims Filing and Reimbursement

Providers must bill Medicare before Medicaid when a person is eligible for services under both programs. Medicaid’s responsibility for the coinsurance or deductible is determined in accordance with Medicaid benefits and limitations. Providers must check the person’s Medicare card for Part B coverage before billing Medicaid. When Medicare is primary, it is inappropriate to bill Medicaid without first billing Medicare.

​Note:Texas Medicaid may reimburse the full amount of the Medicare coinsurance and deductible for services rendered by psychiatrists, psychologists, LCSW, LMFT, and LPC providers.

​Refer to: Subsection 2.7.3, “Part B” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information).

Subsection 4.9.2, “Medicare Part B Crossovers” in “Section 4: Client Eligibility” (Vol. 1, General Information) for information about how coinsurance and deductibles may be reimbursed by Texas Medicaid.

LCSW, LMFT, and LPC services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.

​Refer to: “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

Subsection 6.1, “Claims Information” in “Section 6: Claims Filing” (Vol. 1, General Information) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information). Blocks that are not referenced are not required for processing by TMHP and may be left blank.

According to 1 TAC §355.8091, the Texas Medicaid rate for LCSWs, LMFTs, and LPCs is 70 percent of the rate paid to a psychiatrist or psychologist for a similar service per 1 TAC §355.8085. Providers can refer to the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com. Under 1 TAC §355.8261, an FQHC is reimbursed according to its specific prospective payment system (PPS) rate per visit for LCSW services.

Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied.

Additional information about rate changes is available on the Reimbursement Rate Changes page of the TMHP website at www.tmhp.com.

​Note:Texas Medicaid may reimburse the full amount of the Medicare coinsurance and deductible for services rendered by psychiatrists, psychologists, LCSW, LMFT, and LPC providers.

​Refer to: Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more information about reimbursement.

Subsection 4.5, “Twelve Hour System Limitation” in this handbook for details about the 12-hours-per-day behavioral health services limitation.

4.9​NCCI and MUE Guidelines

The HCPCS and CPT codes included in the Texas Medicaid Provider Procedures Manual are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manual. The CMS NCCI and MUE guidelines can be found in the NCCI Policy and Medicaid Claims Processing manuals, which are available on the CMS website. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations.

Whenever Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail.

5 ​Intellectual Disability Service Coordination, Mental Health Targeted Case Management, and Mental Health Rehabilitative Services

5.1​Enrollment

5.1.1​Local Intellectual and Developmental Disability Authority (LIDDA) Providers

A LIDDA provider who is authorized by HHSC to provide service coordination must be enrolled as a Long Term Care provider, and must submit claims through the Long Term Care system.

LIDDAs are the only entities that provide case management (service coordination) services to persons who have an intellectual disability.

​Refer to: The TMHP website at www.tmhp.com for additional information about Long Term Care enrollment and billing requirements.

5.1.2​Local Mental Health Authority (LMHA) Providers

LMHA providers are authorized by the HHSC to provide targeted case management services and mental health rehabilitative services. To enroll in Texas Medicaid, LMHA providers must contact HHSC at performance.contracts@hhsc.state.tx.us to be approved.

5.1.3​Non-Local Mental Health Authority (Non-LMHA) Providers

Non-LMHAs are private providers of both mental health (MH) case management and MH rehabilitative services, but they are not LMHAs. They must comply with all applicable federal and local laws and all of the regulations that are related to the services they provide. After receiving approval for enrollment in Texas Medicaid, the Non-LMHA provider must be credentialed by a Texas Medicaid managed care organization (MCO) to provide services to Texas Medicaid eligible persons.

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

5.1.4​Provider Credentials for Facilities Delivering MHTCM and Mental Health Rehabilitative Services

Community Services Specialist (CSSP), Qualified Mental Health Professional - Community Services (QMHP-CS), family partners, and peer providers are eligible to deliver some or all of the mental health rehabilitative services and mental health targeted case management services. The credentialing requirements and services each provider may deliver are listed in the following sections.

Staff administering the assessment instruments must have documentation of current certification in the CANS or ANSA. Certification must be updated annually through an approved entity.

5.1.4.1​Community Services Specialist (CSSP)

CSSP providers are eligible to deliver Mental Health Targeted Case Management (MHTCM) and Mental Health (MH) Rehabilitative services and must meet the following minimum credentialing requirements:

•​High school diploma or high school equivalency;

•​Three continuous years of documented full-time experience in the provision of MH rehabilitative services prior to August 30, 2004; and

•​Demonstrated competency in the provision and documentation of MHTCM and MH rehabilitative services.

A CSSP performing MHTCM and MH rehabilitative services must:

•​Be an employee of the provider where MHTCM services are delivered.

•​Be clinically supervised by at least a QMHP-CS.

5.1.4.2​Qualified Mental Health Professional - Community Services (QMHP-CS)

QMHP-CS providers are eligible to deliver MHTCM and MH rehabilitative services and must meet the following minimum credentialing requirements:

•​Completed a standardized training curriculum

•​Demonstrated competency in the work to be performed

•​Obtained one of the following:

•​A bachelor’s degree from an accredited college or university with a minimum number of hours that are equivalent to a major in psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human growth and development, physician assistant, gerontology, special education, educational psychology, early childhood education, or early childhood intervention

•​A license as a registered nurse (RN)

Staff administering the functional assessment instruments must have documentation of current certification in either the Child and Adolescent Needs and Strengths Assessment (CANS) or the Adult Needs and Strengths Assessment (ANSA). Certification in either the CANS or ANSA must be updated annually through an approved entity.

An individual who possesses any of the following licenses is considered a Licensed Practitioner of the Healing Arts (LPHA) and is automatically certified as a QMHP-CS:

•​Physician

•​Physician Assistant

•​Advanced Practice Registered Nurse

•​Psychologist

•​Licensed Clinical Social Worker (LCSW)

•​Licensed Marriage and Family Therapist (LMFT)

•​Licensed Professional Counselor (LPC)

A QMHP-CS must be clinically supervised by another QMHP-CS. If a QMHP-CS is clinically supervised by another QMHP-CS, the supervising QMHP-CS must be clinically supervised by an LPHA.

5.1.4.3​Peer Provider

Peer providers must have a high school diploma or high school equivalency, one cumulative year of receiving mental health services, and be clinically supervised by an LPHA. The supervising LPHA must conduct at least monthly documented meetings with the peer provider and conduct an additional monthly documented observation of the peer providing services.

A peer provider must satisfy all staff credentialing, competency, training, and clinical supervision requirements.

Services provided by a peer provider must be included in the treatment plan.

5.1.4.4​Family Partner

A certified family partner (CFP) must have a high school diploma or high school equivalency and one cumulative year of participating in mental health services as the parent or legally authorized representative (LAR) of a child receiving mental health services.

A CFP must be supervised by at least a QMHP-CS and must satisfy all staff credentialing, competency, training, and clinical supervision requirements.

Services provided by a CFP must be included in the treatment plan.

Family partners must be credentialed as a CFP within one year of their hire date.

The family partner service is provided to parents or LARs for the benefit of the Medicaid eligible child.

5.1.4.5​Certifications for Mental Health Rehabilitative Services

The following provider certifications are required for mental health rehabilitative services: