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.

1.1Payment 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)

2.1Overview

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

2.2Enrollment

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.

2.3Services, 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).

2.3.1Prior Authorization

Prior authorization is not required for BCVDDP case management services.

2.4Documentation 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.

2.5Claims 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

3.1Overview

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.

3.1.1Eligibility

To be eligible for services, a person must:

Be eligible for Texas Medicaid.

Be a pregnant woman who has a high-risk condition or a child (birth through 20 years of age) who has a health condition or health risk.

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

Want to receive case management services.

Pregnant women who have a high-risk condition are defined as those who have a medical or psycho­social condition that places them and their fetuses at a greater than average risk for complications, either during pregnancy, delivery, or following birth. Children with a health condition are defined as children who have a health condition or health risk or children who have or are at risk for a medical condition, illness, injury, or disability that results in the limitation of function, activities, or social roles in comparison with healthy same-age peers in the general areas of physical, cognitive, emotional, or social growth and development.

3.1.2Referral 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 1-877-847-8377 from 8 a.m. to 8 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.

3.2Enrollment

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, contact HHSC at 1-512-458-7111, ext. 2168, visit the case management website at www.hhs.texas.gov/providers/health-services-providers/case-management-providers-children-pregnant-women, or write to the following address:

Health and Human Services Commission
Case Management for Children and Pregnant Women
PO Box 149347, MC 1938
Austin, TX 78714-9347

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.

3.3Services, 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.

Service

Contact Code

Comprehensive visit

G9012 with modifier U5 and modifier U2

Follow-up face-to-face

G9012 with modifier U5 and modifier TS

Follow-up telephone

G9012 with modifier TS

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.

3.3.1Prior Authorization

All services must be prior authorized. One comprehensive visit is approved for all Medicaid eligible persons. Follow-up visits are authorized based on contributing factors. Additional visits can be requested and may be authorized based on a continuing need for services. A prior authorization number is required on all claims for Case Management for Children and Pregnant Women services.

Note:Prior authorization is a condition of reimbursement, not a guarantee of payment.

Approved case management providers may submit requests for prior authorization from HHSC on the Department of State Health Services (DSHS) website at www.cpwforms.dshs.state.tx.us/cpw/.

3.4Technical 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.

3.4.1Assistance with Program Concerns

Providers who have questions, concerns, or problems with program rule, policy, or procedure may contact HHSC program staff. Contact names and numbers can be obtained from the case management website at www.hhs.texas.gov/providers/health-services-providers/case-management-providers-children-pregnant-women, or by calling 1-512-458-7111, Ext. 2168.

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

3.5Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including Case Management for Children and Pregnant Women services.

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

3.6Claims Filing and Reimbursement

3.6.1Claims Information

Case Management for Children and Pregnant Women 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.

Case Management for Children and Pregnant Women providers are reimbursed in accordance with 1 TAC §355.8401. Providers can refer to the 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 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.

3.6.2Managed Care Clients

Case Management for Children and Pregnant Women services are carved out of Medicaid managed care and must be billed to TMHP for payment consideration. Carved-out services are those that are rendered to Medicaid managed care clients, but are administered by TMHP and not 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, group, or family psychotherapy), psychological, neurobehavioral, or neuropsychological testing, pharmacological management services, 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 issue that is causing distress, dysfunction, and/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).

4.1Provider 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.

4.1.1Physicians

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.

4.1.2Physician 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.

4.1.3Advanced 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.

4.1.4Licensed 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.

4.1.5Licensed 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 are covered as Medicaid-only providers; therefore, enrollment in Medicare is not a requirement. LMFTs can enroll as part of a clinic/group practice whether or not they are 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.

4.1.6Licensed 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 are covered as Medicaid-only providers; therefore, enrollment in Medicare is not a requirement. LPCs can enroll as part of a clinic/group practice whether or not they are 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.

4.1.7Psychologists

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.

[Revised] 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.

[Revised] 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.

[Revised] 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.

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

[Revised] 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.

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

4.2Services, Benefits, Limitations

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

Procedure Codes

90791

90792

90832

90833

90834

90836

90837

90838

90846

90847

90853

90870

90899

96116

96121*

96130

96131*

96132

96133*

96136

96137*

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

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

Procedure codes

90832

90833*

90834

90836*

90837

90838*

90846

90847

90853

*Add-on procedure code must be billed with the appropriate E/M code

The following add-on procedure codes may be used for prolonged psychotherapy services:

Procedure codes

99354

99355

 

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

Diagnosis Codes

F0390

F0391

F04

F05

F060

F061

F062

F0630

F0631

F0632

F0633

F0634

F064

F068

F070

F0781

F0789

F09

F1010

F1011

F10120

F10121

F10130

F10131

F10132

F10139

F1014

F10150

F10151

F10159

F10180

F10181

F10182

F10188

F1019

F1020

F1021

F10220

F10221

F10230

F10231

F10232

F10239

F1024

F10250

F10251

F10259

F1026

F1027

F10280

F10281

F10282

F10288

F1029

F10921

F10930

F10931

F10932

F10939

F1094

F10950

F10951

F10959

F1096

F10980

F10981

F10982

F10988

F1099

F1110

F1111

F11120

F11121

F11122

F11129

F1113

F1114

F11150

F11151

F11159

F11181

F11182

F11188

F1119

F1120

F1121

F11220

F11221

F11222

F11229

F1123

F1124

F11250

F11251

F11259

F11281

F11282

F11288

F1129

F11920

F11921

F11922

F11929

F1193

F1194

F11950

F11951

F11959

F11981

F11982

F11988

F1199

F1210

F1211

F12120

F12121

F12122

F12129

F1213

F12150

F12151

F12159

F12180

F12188

F1219

F1220

F1221

F12220

F12221

F12222

F12229

F1223

F12250

F12251

F12259

F12280

F12288

F1229

F12920

F12921

F12922

F12929

F1293

F12950

F12951

F12959

F12980

F12988

F1299

F1310

F1311

F13120

F13121

F13129

F13130

F13131

F13132

F13139

F1314

F13150

F13151

F13159

F13180

F13181

F13182

F13188

F1320

F1321

F13220

F13221

F13229

F13230

F13231

F13232

F13239

F1324

F13250

F13251

F13259

F1326

F1327

F13280

F13281

F13282

F13288

F13920

F13921

F13929

F13930

F13931

F13932

F13939

F1394

F13950

F13951

F13959

F1396

F1397

F13980

F13981

F13982

F13988

F1399

F1410

F1411

F14120

F14121

F14122

F14129

F1413

F1414

F14150

F14151

F14159

F14180

F14181

F14182

F14188

F1419

F1420

F1421

F14220

F14221

F14222

F14229

F1423

F1424

F14250

F14251

F14259

F14280

F14281

F14282

F14288

F1429

F14920

F14921

F14922

F14929

F1493

F1494

F14950

F14951

F14959

F14980

F14981

F14982

F14988

F1499

F1510

F1511

F15120

F15121

F15122

F15129

F1513

F1514

F15150

F15151

F15159

F15180

F15181

F15182

F15188

F1519

F1520

F1521

F15220

F15221

F15222

F15229

F1523

F1524

F15250

F15251

F15259

F15280

F15281

F15282

F15288

F1529

F15920

F15921

F15922

F15929

F1593

F1594

F15950

F15951

F15959

F15980

F15981

F15982

F15988

F1599

F1610

F1611

F16120

F16121

F16122

F16129

F1614

F16150

F16151

F16159

F16180

F16183

F16188

F1619

F1620

F1621

F16220

F16221

F16229

F1624

F16250

F16251

F16259

F16280

F16283

F16288

F1629

F16920

F16921

F16929

F1694

F16950

F16951

F16959

F16980

F16983

F16988

F1699

F1810

F1811

F18120

F18121

F18129

F1814

F18150

F18151

F18159

F1817

F18180

F18188

F1819

F1820

F1821

F18220

F18221

F18229

F1824

F18250

F18251

F18259

F1827

F18280

F18288

F1829

F1890

F18920

F18921

F18929

F1894

F18950

F18951

F18959

F1897

F18980

F18988

F1899

F1910

F1911

F19120

F19121

F19122

F19129

F19130

F19131

F19132

F19139

F1914

F19150

F19151

F19159

F1916

F1917

F19180

F19181

F19182

F19188

F1919

F1920

F1921

F19220

F19221

F19222

F19229

F19230

F19231

F19232

F19239

F1924

F19250

F19251

F19259

F1926

F1927

F19280

F19281

F19282

F19288

F1929

F19920

F19921

F19922

F19930

F19931

F19932

F19939

F1994

F19950

F19951

F19959

F1996

F1997

F19980

F19981

F19982

F19988

F1999

F200

F201

F202

F203

F205

F2081

F2089

F209

F21

F22

F23

F24

F250

F251

F258

F259

F28

F29

F3010

F3011

F3012

F3013

F302

F303

F304

F308

F309

F310

F3110

F3111

F3112

F3113

F312

F3130

F3131

F3132

F314

F315

F3160

F3161

F3162

F3163

F3164

F3171

F3172

F3173

F3174

F3175

F3176

F3177

F3178

F3181

F3189

F319

F320

F321

F322

F323

F324

F325

F3281

F3289

F329

F32A

F330

F331

F332

F333

F338

F3341

F3342

F339

F340

F341

F3481

F3489

F349

F39

F4001

F4002

F4010

F4011

F40210

F40218

F40220

F40228

F40230

F40231

F40232

F40233

F40240

F40241

F40242

F40243

F40248

F40290

F40291

F40298

F408

F409

F410

F411

F413

F418

F419

F422

F423

F424

F428

F429

F430

F4310

F4311

F4312

F4320

F4321

F4322

F4323

F4324

F4325

F4329

F438

F439

F440

F441

F442

F444

F445

F446

F447

F4481

F4489

F449

F450

F451

F4520

F4521

F4522

F4529

F4541

F4542

F458

F459

F481

F482

F488

F489

F5000

F5001

F5002

F502

F5081

F5082

F5089

F509

F5101

F5102

F5103

F5104

F5105

F5109

F5111

F5112

F5113

F5119

F513

F514

F515

F518

F519

F520

F521

F5221

F5222

F5231

F5232

F524

F525

F526

F528

F529

F530

F531

F54

F550

F551

F552

F553

F554

F558

F600

F601

F602

F603

F604

F605

F606

F607

F6081

F6089

F609

F630

F631

F632

F633

F6381

F6389

F639

F640

F641

F642

F648

F649

F650

F651

F652

F653

F654

F6551

F6552

F6581

F6589

F659

F66

F6810

F6811

F6812

F6813

F68A

F69

F70

F800

F801

F802

F804

F8082

F809

F8181

F819

F82

F840

F842

F843

F845

F849

F900

F901

F902

F908

F909

F910

F911

F912

F913

F918

F919

F930

F938

F939

F940

F941

F942

F948

F949

F950

F951

F952

F959

F980

F981

F9821

F9829

F983

F984

F985

F988

F989

G300

G301

G308

G309

G3101

G3109

G3184

G4720

G4721

G4722

G4723

G4724

G4725

G4726

G4727

G4729

I69212

O906

R413

R41840

R41841

R41842

R41843

R41844

R4189

R45850

R45851

R4588

T5892XD

T5892XS

T7401XA

T7401XD

T7401XS

T7402XA

T7412XD

T7412XS

T7421XA

T7421XD

T7421XS

T7422XA

T7422XD

T7422XS

T7431XA

T7431XD

T7431XS

T7432XA

T7432XD

T7432XS

T7451XA

T7451XD

T7451XS

T7452XA

T7452XD

T7452XS

T7461XA

T7461XD

T7461XS

T7462XA

T7462XD

T7462XS

T7601XA

T7601XD

T7601XS

T7602XA

T7602XD

T7602XS

T7611XA

T7611XD

T7611XS

T7612XA

T7612XD

T7612XS

T7621XA

T7621XD

T7621XS

T7622XA

T7622XD

T7622XS

T7631XA

T7631XD

T7631XS

T7632XA

T7632XD

T7632XS

T7651XA

T7651XD

T7651XS

T7652XA

T7652XD

T7652XS

T7661XA

T7661XD

T7661XS

T7662XA

T7662XD

T7662XS

Z0389

Z600

Z608

Z609

Z620

Z621

Z622

Z6221

Z62810

Z62811

Z62812

Z62813

Z62820

Z62821

Z62822

Z62890

Z6331

Z6332

Z634

Z635

Z6372

Z638

Z644

Z654

Z655

Z658

Z69010

Z69011

Z69020

Z69021

Z6912

Z6982

Z72810

Z72811

Z736

Z781

Z818

Z8651

Z9151

Z9152

Z9183

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

Diagnosis Codes

F71

F72

F73

F78A1

F78A9

F79

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

Diagnosis Codes

A8100

A8101

A8109

A8181

A8183

B1001

B1009

B451

D8681

E7500

E7501

E7502

E7509

E7510

E7511

E7519

E7523

E7525

E7526

E7529

E754

F0150

F0151

F0280

F0281

F0390

F0391

F04

F05

F060

F061

F062

F0630

F0631

F0632

F0633

F0634

F064

F068

F070

F0781

F0789

F09

F1010

F1011

F10120

F10121

F10129

F10130

F10131

F10132

F10139

F1014

F10150

F10151

F10159

F10180

F10181

F10182

F10188

F1019

F1020

F1021

F10220

F10221

F10229

F10230

F10231

F10232

F10239

F1024

F10250

F10251

F10259

F1026

F1027

F10280

F10281

F10282

F10288

F1029

F10920

F10921

F10929

F10930

F10931

F10932

F10939

F1094

F10950

F10951

F10959

F1096

F1097

F10980

F10981

F10982

F10988

F1099

F1110

F1111

F11120

F11121

F11122

F11129

F1113

F1114

F11150

F11151

F11159

F11181

F11182

F11188

F1119

F1120

F1121

F11220

F11221

F11222

F11229

F1123

F1124

F11250

F11251

F11259

F11281

F11282

F11288

F1129

F11920

F11921

F11922

F11929

F1193

F1194

F11950

F11951

F11959

F11981

F11982

F11988

F1199

F1210

F1211

F12120

F12121

F12122

F12129

F1213

F12150

F12151

F12159

F12180

F12188

F1219

F1220

F1221

F12220

F12221

F12222

F12229

F1223

F12250

F12251

F12259

F12280

F12288

F1229

F1290

F12920

F12921

F12922

F12929

F1293

F12950

F12951

F12959

F12980

F12988

F1299

F1310

F1311

F1314

F13120

F13121

F13129

F13130

F13131

F13132

F13139

F13150

F13151

F13159

F13180

F13181

F13182

F13188

F1320

F1321

F13220

F13221

F13229

F13230

F13231

F13232

F13239

F1324

F13250

F13251

F13259

F1326

F1327

F13280

F13281

F13282

F13288

F13920

F13921

F13929

F13930

F13931

F13932

F13939

F1394

F13950

F13951

F13959

F1396

F1397

F13980

F13981

F13982

F13988

F1399

F1410

F1411

F14120

F14121

F14122

F14129

F1413

F1414

F14150

F14151

F14159

F14180

F14181

F14182

F14188

F1419

F1420

F1421

F14220

F14221

F14222

F14229

F1423

F1424

F14250

F14251

F14259

F14280

F14281

F14282

F14288

F1429

F14920

F14921

F14922

F14929

F1493

F1494

F14950

F14951

F14959

F14980

F14981

F14982

F14988

F1499

F1510

F1511

F15120

F15121

F15122

F15129

F1513

F1514

F15150

F15151

F15159

F15180

F15181

F15182

F15188

F1519

F1520

F1521

F15220

F15221

F15222

F15229

F1523

F1524

F15250

F15251

F15259

F15280

F15281

F15282

F15288

F1529

F15920

F15921

F15922

F15929

F1593

F1594

F15950

F15951

F15959

F15980

F15981

F15982

F15988

F1599

F1610

F1611

F16120

F16121

F16122

F16129

F1614

F16150

F16151

F16159

F16180

F16183

F16188

F1619

F1620

F1621

F16220

F16221

F16229

F1624

F16250

F16251

F16259

F16280

F16283

F16288

F1629

F16920

F16921

F16929

F1694

F16950

F16951

F16959

F16980

F16983

F16988

F1699

F1810

F1811

F18120

F18121

F18129

F1814

F18150

F18151

F18159

F1817

F18180

F18188

F1819

F1820

F1821

F18220

F18221

F18229

F1824

F18250

F18251

F18259

F1827

F18280

F18288

F1829

F1890

F18920

F18921

F18929

F18950

F18951

F18959

F1897

F18980

F18988

F1894

F1899

F1910

F1911

F19120

F19121

F19122

F19129

F19130

F19131

F19132

F19139

F1914

F19150

F19151

F19159

F1916

F1917

F19180

F19181

F19182

F19188

F1919

F1920

F1921

F19220

F19221

F19222

F19229

F19230

F19231

F19232

F19239

F1924

F19250

F19251

F19259

F1926

F1927

F19280

F19281

F19282

F19288

F1929

F19920

F19921

F19922

F19929

F19930

F19931

F19932

F19939

F1994

F19950

F19951

F19959

F1996

F1997

F19980

F19981

F19982

F19988

F1999

F200

F201

F202

F203

F205

F2081

F2089

F209

F21

F22

F23

F24

F250

F251

F258

F259

F28

F29

F3010

F3011

F3012

F3013

F302

F303

F304

F308

F309

F310

F3110

F3111

F3112

F3113

F312

F3130

F3131

F3132

F314

F315

F3160

F3161

F3162

F3163

F3164

F3170

F3171

F3172

F3173

F3174

F3175

F3176

F3177

F3178

F3181

F3189

F319

F320

F321

F322

F323

F324

F325

F3281

F3289

F329

F32A

F330

F331

F332

F333

F3341

F3342

F338

F339

F340

F341

F3481

F3489

F349

F39

F4001

F4002

F4010

F4011

F40210

F40218

F40220

F40228

F40230

F40231

F40232

F40233

F40240

F40241

F40242

F40243

F40248

F40290

F40291

F40298

F408

F409

F410

F411

F413

F418

F419

F422

F423

F424

F428

F429

F430

F4310

F4311

F4312

F4320

F4321

F4322

F4323

F4324

F4325

F4329

F438

F439

F440

F441

F442

F444

F445

F446

F447

F4481

F4489

F449

F450

F451

F4520

F4521

F4522

F4529

F4541

F4542

F458

F459

F481

F482

F488

F489

F5000

F5001

F5002

F502

F5081

F5082

F5089

F509

F5101

F5102

F5103

F5104

F5105

F5109

F5111

F5112

F5113

F5119

F513

F514

F515

F518

F519

F520

F521

F5221

F5222

F5231

F5232

F524

F525

F526

F528

F529

F530

F531

F54

F550

F551

F552

F553

F554

F558

F600

F601

F602

F603

F604

F605

F606

F607

F6081

F6089

F609

F630

F631

F632

F633

F6381

F6389

F639

F640

F641

F642

F648

F649

F650

F651

F652

F653

F654

F6551

F6552

F6581

F6589

F659

F66

F6810

F6811

F6812

F6813

F68A

F688

F69

F70

F71

F72

F73

F78A1

F78A9

F79

F800

F801

F802

F804

F8082

F8089

F809

F810

F812

F8181

F819

F82

F840

F842

F843

F845

F848

F849

F88

F89

F900

F901

F902

F908

F909

F910

F911

F912

F913

F918

F919

F930

F938

F939

F940

F941

F942

F948

F949

F950

F951

F952

F958

F959

F980

F981

F9821

F9829

F983

F984

F985

F988

F989

G000

G001

G002

G003

G008

G009

G01

G02

G030

G031

G032

G038

G039

G0400

G0401

G0402

G042

G0430

G0431

G0432

G0439

G0481

G0482

G0489

G0490

G0491

G053

G054

G060

G061

G062

G07

G210

G300

G301

G308

G309

G3101

G3109

G311

G312

G3181

G3182

G3183

G3184

G3185

G3189

G319

G3289

G35

G40001

G40009

G40011

G40019

G40B01

G40B09

G40B11

G40B19

G40101

G40109

G40111

G40119

G40201

G40209

G40211

G40219

G40301

G40309

G40311

G40319

G40501

G40509

G40801

G40802

G40803

G40804

G40811

G40812

G40813

G40814

G40821

G40822

G40823

G40824

G4089

G40901

G40909

G40911

G40919

G40A01

G40A09

G40A11

G40A19

G44209

G450

G451

G452

G454

G458

G459

G468

G4720

G4721

G4722

G4723

G4724

G4725

G4726

G4727

G4729

G910

G911

G912

G928

G929

G930

G931

G9340

G9341

G9349

G937

G9381

G9389

G939

G94

H93291

H93292

H93293

H93A1

H93A2

H93A3

H93A9

I6000

I6001

I6002

I6010

I6011

I6012

I602

I6030

I6031

I6032

I604

I6050

I6051

I6052

I606

I607

I608

I609

I610

I611

I612

I613

I614

I615

I616

I618

I619

I6200

I6201

I6202

I6203

I621

I629

I6300

I63011

I63012

I63013

I63019

I6302

I63031

I63032

I63033

I63039

I6309

I6310

I63111

I63112

I63113

I63119

I6312

I63131

I63132

I63133

I63139

I6319

I6320

I63211

I63212

I63213

I63219

I6322

I63231

I63232

I63233

I63239

I6329

I6330

I63311

I63312

I63313

I63319

I63321

I63322

I63323

I63329

I63331

I63332

I63333

I63339

I63341

I63342

I63343

I63349

I6339

I6340

I63411

I63412

I63413

I63419

I63421

I63422

I63423

I63429

I63431

I63432

I63433

I63439

I63441

I63442

I63443

I63449

I6349

I6350

I63511

I63512

I63513

I63519

I63521

I63522

I63523

I63529

I63531

I63532

I63533

I63539

I63541

I63542

I63543

I63549

I6359

I6381

I6389

I6501

I6502

I6503

I6509

I651

I6521

I6522

I6523

I6529

I658

I659

I6601

I6602

I6603

I6609

I6611

I6612

I6613

I6619

I6621

I6622

I6623

I6629

I663

I668

I669

I671

I672

I674

I675

I676

I677

I6781

I6782

I67850

I67858

I6789

I679

I680

I682

I688

I6900

I69010

I69011

I69012

I69013

I69014

I69015

I69018

I69019

I69020

I69021

I69022

I69023

I69028

I69031

I69032

I69033

I69034

I69039

I69041

I69042

I69043

I69044

I69049

I69051

I69052

I69053

I69054

I69059

I69061

I69062

I69063

I69064

I69065

I69069

I69090

I69091

I69092

I69093

I69098

I6910

I69110

I69111

I69112

I69113

I69114

I69115

I69118

I69119

I69120

I69121

I69122

I69123

I69128

I69131

I69132

I69133

I69134

I69139

I69141

I69142

I69143

I69144

I69149

I69151

I69152

I69153

I69154

I69159

I69161

I69162

I69163

I69164

I69165

I69169

I69190

I69191

I69192

I69193

I69198

I6920

I69210

I69211

I69212

I69213

I69214

I69215

I69218

I69219

I69220

I69221

I69222

I69223

I69228

I69231

I69232

I69233

I69234

I69239

I69241

I69242

I69243

I69244

I69249

I69251

I69252

I69253

I69254

I69259

I69261

I69262

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Z73819

Z781

Z818

Z8651

Z8659

Z87820

Z87890

Z9151

Z9152

Z9183

 

*Add-on procedure codes must be billed with the appropriate primary code

4.2.1Telemedicine and Telehealth

Certain outpatient mental health services may be provided by distant site providers through telemed­icine or telehealth when billed with modifier 95.

Mental health services delivered through telemedicine or telehealth do not require a patient site presenter unless the person is experiencing a mental health emergency.

Refer to:  The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for more infor­mation about telemedicine and telehealth.

4.2.2* Psychotherapy

Individual psychotherapy is therapy that focuses on a single person.

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

Family psychotherapy is 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 codes 90832, 90834, and 90837) and family psychotherapy (procedure codes 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.

Prolonged psychotherapy services delivered in addition to procedure code 90837 should be billed using the appropriate prolonged services add-on code (procedure code 99354 or 99355)

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

Refer to:  Subsection 9.2.58.5, “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

[Revised] 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 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 must include:

Start and end time of session

Modality or modalities utilized

Frequency of psychotherapy sessions

Clinical notes for each encounter must include: diagnosis; symptoms; functional status; focused mental status examination, if indicated; treatment plan, prognosis, and progress; name, signature and credentials of person performing the service

4.2.2.1Family 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 are allowed to 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

4.2.2.2Treatment for Alzheimer’s Disease and Dementia

Psychotherapy for persons with Alzheimer’s disease or dementia may be 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

[Revised] 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:

Modifier

Description

AH

Identifies service provided by a clinical psychologist

UB

Identifies service provided by a pre-doctoral psychology intern or post-doctoral psychology fellow

UC

Identifies service provided by an LPA

U9

Identifies service provided by a PLP

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 actually 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.

4.2.4Pharmacological Management

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, with the exception of 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 must include:

A complete diagnosis utilizing diagnostic criteria from the current edition of the DSM

Current list of medications

Current psychiatric symptoms and problems, to include presenting mental status

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

Any medication modifications made during 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

4.2.5Electroconvulsive 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 testing, neurobehavioral testing, 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, group psychotherapy, or family psycho­therapy on the same day, by the same provider will be denied as part of another procedure.

4.2.6Psychiatric Diagnostic Evaluation

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 (procedure codes 90791 or 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 Department of Family and Protective Services (DFPS) directive

If a major change of status occurs

Supporting documentation for psychiatric diagnostic evaluations must include:

Reason for referral and/or presenting problem

Prior diagnoses and any prior treatment

Other pertinent medical, social, and family history

Clinical observations and results of mental status examination

A complete diagnosis utilizing diagnostic criteria from the current edition of the DSM

Recommendations, including expected long term and short term goals

4.2.7* Psychological, Neurobehavioral, and Neuropsychological Testing

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.

Neurobehavioral testing (procedure codes 96116 and 96121*) is limited to four hours per person, per day and eight hours per person, per calendar year.

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

[Revised] 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 encounter/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.

4.2.7.1Testing 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 must include:

Reason for referral and/or presenting problem

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

The scoring of the test

Location the testing is performed

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

Interpretation of the test to include narrative descriptions of the test findings

Length of time spent by each provider, as applicable, in face-to-face 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 to include 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.

The 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.

4.3Prior Authorization

Prior authorization requests may 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 are required to adhere to prior authorization requirements.

4.3.1Services Requiring Prior Authorization

Prior Authorization is required for the following services:

Psychiatric diagnostic evaluation (procedure codes 90791 and 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 codes 96130, 96131*, 96136, and 96137*) or neuropsychological testing (procedure codes 96132, 96133*, 96136, and 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

4.3.2Prior 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

Electroconvulsive therapy (procedure code 90870)

4.4Documentation 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.

4.5Twelve 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.

Procedure Code

Time Applied

90791

60 minutes

90792

60 minutes

90832

30 minutes

90833*

30 minutes

90834

45 minutes

90836*

45 minutes

90837

60 minutes

90838*

60 minutes

90846

50 minutes

90847

50 minutes

96116

60 minutes

96121*

60 minutes

96130

60 minutes

96131*

60 minutes

96132

60 minutes

96133*

60 minutes

96136

30 minutes

96137*

30 minutes

* Add-on procedure codes to be billed with the most appropriate E/M procedure code.

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.

4.6Court-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.

4.7Exclusions

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

4.8Claims 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 LCSW providers.

Refer to:  Subsection 2.7.2, “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 LCSW 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.

4.9NCCI 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

5.1Enrollment

5.1.1Local 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.

5.1.2Local 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.

5.1.3Non-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.

5.1.4Provider 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.

5.1.4.1Community 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

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 facility where the case management is delivered.

Be clinically supervised by at least a QMHP-CS.

5.1.4.2Qualified 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 assessment instruments must have documentation of current certification in the Child and Adolescent Needs and Strengths Assessment (CANS) or the Adult Needs and Strengths Assessment (ANSA). Certification 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.

5.1.4.3Peer 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.

5.1.4.4Family Partner

A certified family partner 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 family partner 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 family partner must be included in the treatment plan.

Family partners must be credentialed as a certified family partner 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.

5.1.4.5Certifications for Mental Health Rehabilitative Services

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

Service

Provider Types

 

QMHP-CS

CSSP

Peer Provider

Licensed Medical Personnel

Family Partner

RN

Medication Training and Support - Child, Youth, LAR, Primary Caregiver

X

X

 

X

X

X

Medication Training and Support - adult or LAR

X

X

X

X

 

X

Psychosocial Rehabili­tation (adults only)

X

X

X

X

 

X

Skills training and development - adult or LAR

X

X

X

X

 

X

Skills training and development - child/youth or LAR

X

X

 

X

X

X

Crisis Intervention

X

 

 

X

 

X

Day Program for Acute Needs - Symptoms management and functioning skills

X

X

X

X

 

X

Day Program for Acute Needs - Pharmacology issues

 

 

 

X

 

X

Day Program for Acute Needs - Psychiatric Nursing services

 

 

 

X

 

X

5.2Services, Benefits, Limitations, and Prior Authorization

5.2.1Intellectual and Developmental Disabilities Service Coordination

Texas Medicaid provides the following:

Service coordination for persons who have an intellectual disability or a related condition (adult or child). Persons who have a related condition are eligible if they are being enrolled into the home and community based waiver (HCS); the Texas Home Living Waiver; or an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID).

Service coordination for persons who have an intellectual disability or a related condition who are enrolled in HCS or Texas Home Living waiver programs.

Service coordination funded by Medicaid as TCM is reimbursed by encounter.

There are two types of encounters:

Comprehensive encounter (Type A): A face-to-face contact with a person to provide service coordi­nation. The comprehensive encounter is limited to one billable encounter per person per calendar month. HHSC will not authorize payment for a comprehensive encounter that exceeds the cap of one encounter per person per calendar month.

Supportive encounter (Type B): A face-to-face, telephone, or telemedicine contact with a person or with a collateral on the person’s behalf to provide service coordination.

A LIDDA is allowed up to three Type B encounters per calendar month for each Type A encounter that has occurred within the calendar month.

The Type B encounters are not limited to three per person. Rather, the allowed Type B encounters may be delivered to any person who needs a Type B encounter. These Type B encounters are allowable as long as the person who received the Type B encounter also received a Type A encounter that same month.

For example, Sam and Mary receive a Type A encounter in June. It is allowable for the LIDDA to bill for one Type B encounter for Sam in June and five Type B encounters for Mary in June.

Payment for a person’s Type B encounter is contingent on that the person having a Type A encounter within the same calendar month.

Within the calendar month, the Type A encounter does not have to occur on a date before any of the Type B encounters occur.

Prior authorization is not required for IDD coordination services.

5.2.2Mental Health Targeted Case Management (MHTCM)

Targeted case management services are case management services to persons within targeted groups. The target population that may receive Mental Health Targeted Case Management (MHTCM) as part of the Texas Medicaid Program are persons, regardless of age, with a single diagnosis of chronic mental illness or a combination of chronic mental illnesses as defined in the latest edition of the American Psychiatric Association’s DSM, and who have been determined via a uniform assessment process to be in need of MHTCM services. Persons of any age with a single diagnosis of intellectual and develop­mental disabilities (IDD) and related conditions, or a single diagnosis of substance use disorder (SUD) are not eligible for MHTCM services.

MHTCM services are furnished to assist persons in gaining access to needed medical, social/behavioral, educational, and other services and supports. MHTCM activities and services include:

A comprehensive assessment and periodic reassessment, as medically necessary, of persons needs to determine the need for any medical, educational, social/behavioral, or other services.

The development (and periodic revision, as medically necessary) of a specific care plan that:

Is based on the information collected through the assessment;

Specifies the goals and actions to address the medical, social/behavioral, educational, and other services and supports needed by the person;

Includes activities such as ensuring the active participation of the eligible person and working with the person (or the person’s authorized health care decision maker) and others to develop these goals; and

Identifies a course of action to respond to the assessed needs of the eligible person.

Making referrals and performing other related activities, such as scheduling an appointment on behalf of the person, to help an eligible person obtain needed services and supports, including activ­ities that help link a person with:

Medical, social/behavioral, and educational providers; and

Other programs and services that are capable of providing needed services to address identified needs and achieve goals in the care plan.

Monitoring and performing the necessary follow-up that is necessary to ensure the care plan is implemented and adequately addresses the person’s needs.

MHTCM activities may be with the person, family members, LAR, providers, or other entities or individuals and conducted as frequently as necessary, and at least once annually, to determine whether the following conditions are met:

Services are being furnished in accordance with the person’s care plan;

Services in the care plan are adequate in amount, scope, and duration to meet the needs of the person; and

The care plan and service arrangements are modified when the person’s needs or status change.

MHTCM is a benefit for persons transitioning to a community setting for up to 180 consecutive days prior to leaving a nursing facility; however, MHTCM services are coordinated with and do not duplicate activities provided as part of nursing facility services and discharge planning activities.

MHTCM consists of intensive case management and routine case management. Intensive case management services are predominantly community-based case management activities provided to the person or to the LAR on behalf of the person (who may or may not be present) to assist a person and caregiver or LAR in obtaining and coordinating access to necessary care and services appropriate to the person’s needs. Routine case management services are primarily office-based case management activ­ities that assist a person, caregiver, or LAR in obtaining and coordinating access to necessary care and services appropriate to the person’s needs.

Intensive case management and routine case management are benefits for persons who are 20 years of age and younger. Intensive case management and routine case management are not payable on the same day.

Routine case management is a benefit for persons who are 21 years of age and older.

Providers must use procedure code T1017 and the appropriate modifier for MHTCM:

Modifier

Description

TF

Routine Case Management

TG

Intensive Case Management

HA

Child/Adolescent Program

HZ

Funded by criminal justice agency

Procedure code T1017 is limited to the following diagnosis codes:

Diagnosis Codes

F060

F061

F062

F0630

F0631

F0632

F0633

F0634

F064

F068

F070

F0789

F09

F200

F201

F202

F203

F205

F2081

F2089

F209

F21

F22

F23

F24

F250

F251

F258

F259

F28

F29

F3010

F3011

F3012

F3013

F302

F303

F304

F309

F310

F3110

F3111

F3112

F3113

F312

F3130

F3131

F3132

F314

F315

F3160

F3161

F3162

F3163

F3164

F3170

F3171

F3172

F3173

F3174

F3175

F3176

F3177

F3178

F3181

F3189

F319

F320

F321

F322

F323

F324

F325

F3281

F3289

F329

F32A

F330

F331

F332

F333

F3340

F3341

F3342

F338

F339

F340

F341

F3481

F3489

F349

F39

F4000

F4001

F4002

F4010

F4011

F40210

F40218

F40220

F40228

F40230

F40231

F40232

F40233

F40240

F40241

F40242

F40243

F40248

F40290

F40291

F40298

F408

F409

F410

F411

F413

F418

F419

F422

F423

F424

F428

F429

F430

F4310

F4311

F4312

F4320

F4321

F4322

F4323

F4324

F4325

F4329

F438

F439

F440

F441

F442

F444

F445

F446

F447

F4481

F4489

F449

F450

F451

F4520

F4521

F4522

F4529

F4541

F4542

F458

F459

F481

F482

F488

F489

F5000

F5001

F5002

F502

F5081

F5082

F5089

F509

F5101

F5102

F5103

F5104

F5105

F5109

F5111

F5112

F5113

F5119

F513

F514

F515

F518

F519

F530

F531

F54

F600

F601

F602

F603

F604

F605

F606

F607

F6081

F6089

F609

F630

F631

F632

F633

F6381

F6389

F639

F640

F641

F642

F648

F649

F6810

F6811

F6812

F6813

F68A

F69

F8082

F900

F901

F902

F908

F909

F910

F911

F912

F913

F918

F919

F930

F938

F939

F940

F941

F942

F948

F949

F980

F981

F9821

F9829

F983

F984

F985

F988

F989

F99

O906

T7402XA

T7402XD

T7402XS

T7412XA

T7412XD

T7412XS

T7422XA

T7422XD

T7422XS

T7452XA

T7452XD

T7452XS

T7462XA

T7462XD

T7462XS

T7602XA

T7602XD

T7602XS

T7612XA

T7612XD

T7612XS

T7622XA

T7622XD

T7622XS

T7652XD

T7652XS

T7662XA

T7662XD

T7662XS

An MHTCM reimbursable session is the provision of a case management activity by an authorized case manager during a face-to-face meeting with a person who is authorized to receive that specific type of case management. A billable unit of MHTCM is 15 continuous minutes of contact.

MHTCM is not payable when delivered on the same day as psychosocial rehabilitative services.

The following activities are included in the MHTCM rate and will not be reimbursed separately:

Documenting the provision of MHTCM services.

On-going administration of the Uniform Assessment to determine amount, duration, and type of MHTCM.

Travel time required to provide MHTCM services at a location not owned, operated, or under arrangement with the provider.

Texas Medicaid must not be billed for MHTCM services provided before the establishment of a diagnosis of mental illness and the authorization of services.

5.2.2.1Collateral Contacts

MHTCM may include contacts with non-eligible individuals who are directly related to identifying the eligible person’s needs and care for the purposes of helping the eligible person access services, identifying needs and supports to assist the eligible person in obtaining services, providing case managers with useful feedback, and alerting case managers to changes in the eligible person’s needs.

MHTCM services involving collateral contacts are only payable when the person or LAR is also present during the case management session.

5.2.2.2Intensive Case Management

Intensive case management incorporates a wraparound approach to care planning and treatment plan implementation. The wraparound process is a strengths-based course of action involving a child or youth and their family, including any additional people identified by the child or youth, LAR, primary caregiver, and family, that results in a unique set of community services and natural supports that are individualized for the child or youth to achieve a positive set of identified outcomes.

Intensive case management is primarily community-based, meaning that services are provided in whatever setting is clinically appropriate and person-centered.

A case manager assigned to a child or youth who is authorized to receive intensive case management services must have completed training in the National Wraparound Implementation Center’s Wraparound Practice model and must incorporate wraparound process planning or other approved models in developing a plan that addresses the child’s or youth’s unmet needs across life domains.

The case manager must develop an intensive case management treatment plan based on the child’s or youth’s needs that may include information across life domains from relevant sources.

The case manager must meet face-to-face with the child or youth and the LAR or primary caregiver:

Within seven days after the case manager is assigned to the child or youth;

Within seven days after discharge from an inpatient psychiatric setting, whichever is later; or

Document the reasons the meeting did not occur and meet at the soonest available opportunity.

The case manager must identify the child’s or youth’s strengths, service needs, and assistance that will be required to address the identified needs in the plan.

The case manager must take steps that are necessary to assist the child or youth in gaining access to the needed services and service providers, including:

Making referrals to potential service providers.

Initiating contact with potential service providers.

Arranging, and if necessary to facilitate linkage, accompanying the child or youth to initial meetings and non-routine appointments.

Arranging transportation to ensure the child or youth attendance.

Advocating with service providers.

Providing relevant information to service providers.

Monitoring the child’s or youth’s progress toward the goals set forth in the plan.

5.2.2.2.1Authorization Requirements

LMHAs delivering services to to persons with fee-for-service benefits must obtain authorization from their internal utilization management department. When providing care to persons enrolled in managed care, LMHAs and other providers contracted with MCOs must submit authorization requests to the MCO with whom the person is enrolled. The MCO may choose to waive this authorization submission requirement. Additionally, MCOs must follow the requirements set forth in the Uniform Managed Care Manual regarding utilization management for targeted case management and mental health rehabilitative services.

Eligibility determinations occur at the facility providing targeted case management services using the Clinical Management of Behavioral Health Services (CMBHS) software system.

Criteria used to make these service determinations are from the recommended Level of Care (LOC) of the person as derived from the Uniform Assessment (UA), the needs of the person, and the Texas Resil­ience and Recovery Utilization Management Guidelines.

In determining service, the Qualified Mental Health Professional-Community Services (QMHP-CS) or Licensed Practitioner of the Healing Arts (LPHA) performs a screening for eligibility utilizing the UA. The LPHA gives a diagnosis and determines if the services are medically necessary.

The LPHA determination of diagnosis shall include an interview with the person conducted either in-person or via telemedicine or telehealth.

Refer to:  The Telecommunication Services Handbook (Vol. 2, Provider Handbooks).

A facility that provides MHTCM must ensure that at minimum a QMHP-CS administers the uniform assessment to the person at specified intervals (every 90 calendar days for persons who are 20 years of age and younger and every 180 calendar days for persons who are 21 years of age and older), and obtains a recommended LOC for the person.

The facility must evaluate the clinical needs of the person to determine if the amount of MHTCM services associated with the recommended LOC described in the utilization management guidelines is sufficient to meet those needs and ensure that an LPHA reviews the recommended LOC and verifies whether the services are medically necessary.

If the facility determines that the type of MHTCM services associated with the recommended LOC is sufficient to meet the person’s needs, the facility must submit a request for service authorization according to the recommended LOC.

If the facility determines that a LOC other than the recommended LOC is more appropriate for the person, the provider must submit a deviation request that includes:

A request for an authorization of an LOC that is higher or lower than initially recommended; and

The clinical justification for the request.

The clinical justification must include the specific reasons why the person requires interventions outside the recommended LOC. Refusal of recommended LOC by the person receiving services may be noted as part of the justification.

All plans of care are subject to retrospective review by the state.

5.2.2.3Eligibility and Service Determinations for Persons Who are 20 Years of Age and Younger

MHTCM is available to persons who are 20 years of age and younger with a diagnosis of mental illness (excluding a single diagnosis of IDD and related disorders, or a single diagnosis of SUD) or serious emotional disturbance and who:

Have a serious functional impairment; or

Are at risk of disruption of a preferred living or child care environment due to psychiatric symptoms; or

Are enrolled in a school system’s special education program because of serious emotional disturbance.

The initial assessment is the clinical process of obtaining and evaluating historical, social/behavioral, functional, psychiatric, developmental, or other information from the person seeking services to determine specific treatment and support needs.

Functioning is assessed using one of the following standardized assessment tools:

The Child and Adolescent Needs and Strengths Assessment (CANS) for persons who are 17 years of age and younger

The Adult Needs and Strengths Assessment (ANSA) and any necessary supplemental assessments for persons who are 18 years of age and older

Services and supports to be provided to the person are determined jointly by the person receiving services, family, and the provider.

MHTCM services authorized for care by the provider through a clinical override are eligible for the duration of the authorization.

Continued eligibility for MHTCM services is based on a reassessment every 90 calendar days by the provider and reauthorization of services by the facility. Assignment of diagnosis in the CMBHS is required at any time the DSM diagnosis changes and at least annually from the last diagnosis entered into CMBHS.

5.2.2.4Eligibility and Service Determinations for Persons who are 21 Years of Age and Older

MHTCM is available to persons who are 21 years of age and older and who have severe and persistent mental illnesses such as schizophrenia, major depression, bipolar disorder, post-traumatic stress disorder, or other severely disabling mental disorders (excluding a single diagnosis of IDD and related disorders, or a single diagnosis of SUD) which require crisis resolution or ongoing and long-term support and treatment.

Adults with schizophrenia and bipolar disorder are automatically eligible for services. Adults with any other mental health diagnoses require evidence of significant difficulty functioning across one or more domains, such as work or school, to be eligible for services.

Functioning is assessed using a standardized assessment tool called the Adult Needs and Strengths Assessment (ANSA). Adults are reassessed every 180 calendar days for continued need for services. Assignment of diagnosis in the CMBHS is required at any time the DSM diagnosis changes and at least annually from the last diagnosis entered into CMBHS.

Adults with a diagnosis of schizophrenia or bipolar disorder are automatically eligible for continued services. Adults with major depressive disorder whose level of functioning qualified them initially are also automatically eligible for continued services, regardless of whether their level of functioning has improved or not.

Adults with any other mental health diagnoses are eligible should their level of functioning continue to be significantly impaired, as evidenced by the results of a standardized assessment tool.

5.2.2.5Documentation Requirements

A comprehensive diagnosis must be included in the person’s medical record, including documentation of applicable diagnostic criteria according to the latest edition of the DSM, as well as the specific justifi­cation of need for services.

MHTCM services, including attempts to provide MHTCM services, must be documented in the person’s medical record.

For routine case management, the case manager must document the person’s strengths, service needs, and assistance required to address the service needs as well as the steps that are necessary to accomplish the goals required to meet the person’s service needs.

For intensive case management, the assigned case manager must include the intensive case management treatment plan in the child’s or youth’s medical record and document steps taken to meet the child’s or youth’s goals and needs in the child’s or youth’s progress notes.

As a result of the face-to-face meetings, assessments, and reassessments conducted, the case manager must document the person’s identified strengths, service needs, and assistance given to address the identified need, and specific goals and actions to be accomplished.

The case manager must document the following for all services provided:

The event or behavior that occurs while providing the MHTCM service or the reason for the specific case management encounter

The person, persons, or entity, including other case managers, with whom the encounter or contact occurred

Collateral contacts such as contacts with non-eligible individuals that are directly related to identi­fying the needs and supports for helping the person access services and managing the person’s care, including coordination with other case managers

The recovery plan goal(s) that was the focus of the service, including the progress or lack of progress in achieving recovery plan goal(s)

The time line for obtaining the needed services

The specific intervention that is being provided

The date the MHTCM service was provided

The start and end time of the MHTCM service

The location where the MHTCM service was provided and whether it was a face-to-face or telephone contact

The name of the provider agency and the signature of the employee providing the MHTCM service, including their credentials

The time line for reevaluating the needed service

If the person refuses MHTCM services, the case manager must document the reason for the refusal in the most appropriate area of the person’s medical record and request that the person sign a waiver of MHTCM services that is filed in the person’s medical record.

The provider must retain documentation in compliance with applicable records retention requirements in federal and state laws, rules, and regulations.

5.2.2.6Exclusions

The following services are not covered by MHTCM:

Case management activities that are an integral component of another covered Medicaid service

The provision of a medical, educational, social/behavioral, or other service to which a person has been referred, including for foster care programs, services such as, but not limited to, the following:

Research gathering and completion of documentation required by the foster care program

Assessing adoption placements

Recruiting or interviewing potential foster care parents

Serving legal papers

Home investigations

Providing transportation, including transporting the person to his/her LAR/primary caregiver

Administering foster care subsidies

Making placement arrangements

Performing an activity that does not directly assist a person in gaining or coordinating access to needed services

Providing medical or nursing services

Performing preadmission or intake activities

Monitoring the person’s general health status

Performing outreach activities

Performing quality oversight of a service provider

Conducting utilization review or utilization management activities

Conducting quality assurance activities

Authorizing services or authorizing the provision of services

Services to inmates of public institutions

5.2.3Mental Health Rehabilitative Services

Mental health rehabilitative services are defined as providing assistance in maintaining or improving functioning and may be considered rehabilitative when necessary to help a person achieve a rehabili­tation goal as defined in the treatment plan.

Mental health rehabilitative services may be provided to a person with a serious mental illness as defined in the latest edition of the American Psychiatric Association’s DSM.

Mental health rehabilitative services are age-appropriate, individualized, and designed to ameliorate functional impairments that negatively affect any of the following:

Community integration

Community tenure

Behaviors resulting from serious mental illness (SMI) or severe emotional disturbance (SED) that interfere with a person’s ability to remain in the community as a fully integrated and functioning member of that community

Mental health rehabilitative services may include:

Medication training and support services

Psychosocial rehabilitative services

Skills training and development

Crisis intervention services

Day programs for acute needs

Mental health rehabilitative services may only be provided by a member of the person’s therapeutic team. The therapeutic team includes a sufficient number of staff to adequately address the rehabilitative needs of persons assigned to the team.

Team members must be appropriately credentialed and have completed required trainings to provide the full array of component services, have regularly scheduled team meetings either in person or by teleconference, and every member of the team must be knowledgeable of the needs and the services available to the specific persons assigned to the team.

Mental health rehabilitative services may be a benefit for persons residing in a nursing facility (NF) when medically necessary as determined via a uniform assessment protocol and determined through pread­mission screening and resident review (PASRR) to require specialized services.

The following procedure codes are a benefit for mental health rehabilitation:

Service Category

Procedure Codes

Modifiers

Day Program for Acute Needs

H2012

 

Medication Training and Support

H0034

HQ: group services for adults

HA/HQ: group services for child/youth

Crisis Intervention

H2011

HA: child/youth

Skills Training and Development

H2014

HQ: group services for adults

HA: individual services for child/youth

HA/HQ: group services for child/youth

Psychosocial Rehabilitation Services

H2017

TD: individual services provided by RN

HQ: group services

HQ/TD: group services provided by RN

ET: individual crisis services

Psychosocial rehabilitation is not reimbursable on the same day as mental health targeted case management or skills training and development.

Reimbursement for procedure codes H0034, H2012, H2014, and H2017 are limited to the following diagnosis codes:

Diagnosis Codes

F060

F061

F062

F0630

F0631

F0632

F0633

F0634

F064

F068

F070

F0789

F09

F200

F201

F202

F203

F205

F2081

F2089

F209

F21

F22

F23

F24

F250

F251

F258

F259

F28

F29

F3010

F3011

F3012

F3013

F302

F303

F304

F309

F310

F3110

F3111

F3112

F3113

F312

F3130

F3131

F3132

F314

F315

F3160

F3161

F3162

F3163

F3164

F3170

F3171

F3172

F3173

F3174

F3175

F3176

F3177

F3178

F3181

F3189

F319

F320

F321

F322

F323

F324

F325

F3281

F3289

F329

F32A

F330

F331

F332

F333

F3340

F3341

F3342

F338

F339

F340

F341

F3481

F3489

F349

F39

F4000

F4001

F4002

F4010

F4011

F40210

F40218

F40220

F40228

F40230

F40231

F40232

F40233

F40240

F40241

F40242

F40243

F40248

F40290

F40291

F40298

F408

F409

F410

F411

F413

F418

F419

F422

F423

F424

F428

F429

F430

F4310

F4311

F4312

F4320

F4321

F4322

F4323

F4324

F4325

F4329

F438

F439

F440

F441

F442

F444

F445

F446

F447

F4481

F4489

F449

F450

F451

F4520

F4521

F4522

F4529

F4541

F4542

F458

F459

F481

F482

F488

F489

F5000

F5001

F5002

F502

F5081

F5082

F5089

F509

F5101

F5102

F5103

F5104

F5105

F5109

F5111

F5112

F5113

F5119

F513

F514

F515

F518

F519

F530

F531

F54

F600

F601

F602

F603

F604

F605

F606

F607

F6081

F6089

F609

F630

F631

F632

F633

F6381

F6389

F639

F640

F641

F642

F648

F649

F6810

F6811

F6812

F6813

F68A

F69

F8082

F900

F901

F902

F908

F909

F910

F911

F912

F913

F918

F919

F930

F938

F939

F940

F941

F942

F948

F949

F980

F981

F9821

F9829

F983

F984

F985

F988

F989

F99

O906

T7402XA

T7402XD

T7402XS

T7412XA

T7412XD

T7412XS

T7422XA

T7422XD

T7422XS

T7452XA

T7452XD

T7452XS

T7462XA

T7462XD

T7462XS

T7602XA

T7602XD

T7602XS

T7612XA

T7612XD

T7612XS

T7622XA

T7622XD

T7622XS

T7652XD

T7652XS

T7662XA

T7662XD

T7662XS

No diagnosis is required for crisis intervention services (procedure code H2011); however, all CMS 1500 claim forms require a diagnosis.

A Medicaid provider may only bill for medically necessary mental health rehabilitative services that are provided face-to-face to:

A Medicaid-eligible person;

The LAR of a Medicaid-eligible person who is 21 years of age and older (on behalf of the person); or

The LAR or primary caregiver of a Medicaid-eligible person who is 20 years of age and younger (on behalf of the person).

Rehabilitative services delivered via group modality are limited to an 8-person maximum for adults and a 6-person maximum for children or adolescents (not including LARs or caregivers).

5.2.3.1Eligibility and Service Determinations for Persons Who are 20 Years of Age and Younger

Certain mental health rehabilitative services (crisis intervention services, medication training and support, and skills training and development) are available to persons who are 20 years of age and younger with a diagnosis of mental illness or serious emotional disturbance and who:

Have a serious functional impairment; or

Are at risk of disruption of a preferred living or child care environment due to psychiatric symptoms; or

Are enrolled in a school system’s special education program because of serious emotional disturbance.

Functioning is assessed using a standardized assessment tool, the Child and Adolescent Needs and Strengths Assessment (CANS) for persons who are 17 years of age and younger and the ANSA for persons who are 18 years of age and older.

Continued eligibility for mental health rehabilitative services for persons who are 17 years of age and younger is based on a reassessment at least every 90 calendar days, or more frequently if clinically indicated by the provider. Persons who are 18 years of age and older are reassessed every 180 calendar days, or more frequently if clinically indicated by the provider.

Assignment of diagnosis in the Clinical Management for Behavioral Health Services (CMBHS) is required at any time the mental illness diagnosis changes and at least annually from the last diagnosis entered into CMBHS.

The LPHA determination of diagnosis shall include an interview with the child or youth conducted either in person or via telemedicine or telehealth.

In order to complete a comprehensive diagnosis for a child or youth, documentation of the required diagnostic criteria according to the latest version of the DSM, as well as the specific level of functioning, shall be included in the child’s or youth’s record. This information shall be included as part of the required assessment information.

5.2.3.2Eligibility and Service Determinations for Persons Who are 21 Years of Age and Older

Persons who are 21 years of age and older with serious mental illness, determined to be medically necessary via a uniform assessment protocol, are eligible for Mental Health Rehabilitative Services if the adult is:

A resident of the state of Texas.

Determined by a uniform assessment and clinician observation to require mental health rehabili­tative services.

An LPHA has made a determination that such services are medically necessary.

Mental health rehabilitative services are available to persons who are 21 years of age and older who have serious mental illnesses and significant functional impairments which require crisis resolution or ongoing treatment. Functioning is assessed using a standardized assessment tool, the Adult Needs and Strengths Assessment (ANSA).

Adults with schizophrenia and bipolar disorder are automatically eligible for services. Adults with any other mental health diagnoses require evidence of significant difficulty functioning across one or more domains, such as work or school, to be eligible for services.

Persons who are 18 years of age and older are reassessed for continued need for services at least every 180 calendar days, or more frequently if clinically indicated by the provider.

Assignment of diagnosis in the Clinical Management for Behavioral Health Services (CMBHS) is required at any time the mental illness diagnosis changes and at least annually from the last diagnosis entered into CMBHS.

The LPHA determination of diagnosis shall include an interview with the adult conducted either in person or via telemedicine or telehealth.

In order to complete a comprehensive diagnosis for an adult, documentation of the required diagnostic criteria according to the latest version of the American Psychiatric Association’s DSM, as well as the specific level of functioning, shall be included in the adult’s record. This information shall be included as part of the required assessment information.

Adults with a diagnosis of schizophrenia or bipolar disorder are automatically eligible for continued services. An adult with major depressive disorder whose level of functioning qualified them initially also is automatically eligible for continued services, regardless of whether their level of functioning has improved or not. Adults with any other mental health diagnoses are eligible should their level of functioning continue to be significantly impaired, as evidenced by the results of a standardized assessment tool called the Adult Needs and Strengths Assessment (ANSA).

5.2.3.3Treatment Planning

Mental health rehabilitative services are part of a person’s treatment plan and are intended to:

Reduce a person’s functional impairments resulting from serious mental illness (SMI) for adults.

Reduce serious emotional disturbance in children.

Restore a person to his/her optimal functioning level in the community.

The treatment planning process for mental health rehabilitative services requires the active participation of the Medicaid eligible person or LAR when necessary due to the person’s age or legal status. Treatment plans are based on a comprehensive assessment and must address the person’s strengths, areas of need, the person’s preferences, and descriptions of the person’s treatment goals.

5.2.3.4Medication Training and Support

Medication training and support services consist of education and guidance about medications and their possible side effects. It is curriculum-based training and guidance that serves as an initial orientation for the person in understanding the nature of his/her mental illnesses or emotional disturbances and the role of medications in ensuring symptom reduction and increased tenure in the community.

Medication training and support includes:

Assisting the person to manage symptomology and maximize functioning.

Understanding the concepts of recovery and resilience within the context of the serious mental illness.

Developing an understanding of the relationship between mental illness and the medications prescribed to treat the illness.

The interaction of medication with other medications, diet, and mood altering substances.

Understanding the overdose precautions of the person’s medication.

The identification and management of potential side effects.

Learning self-administration of the person’s medication.

Necessity of taking medications prescribed and following the physician’s or other qualified health care professional’s orders.

Medication training and support is available to eligible children, youth, and adults. The LAR or primary caregiver may receive medication training and support services on behalf of an eligible adult, child or youth.

5.2.3.5Psychosocial Rehabilitative Services

Psychosocial rehabilitative services are social, behavioral, and cognitive interventions provided by members of a person’s therapeutic team that build on strengths and focus on restoring the person’s ability to develop and maintain social relationships, occupational or educational achievement, and other independent living skills that are affected by or the result of a serious mental illness in persons who are 17 years of age and older.

Psychosocial rehabilitative services include independent living services, coordination services, and employment, housing, and medication-related services. Psychosocial rehabilitative services may also address the impact of co-occurring disorders upon the person’s ability to reduce symptomology and increase daily functioning.

If psychosocial rehabilitation is in the treatment plan, the treatment plan cannot simultaneously include skills training and development or targeted case management services.

Psychosocial rehabilitative services may not be provided to a person who is currently admitted to a crisis stabilization unit.

5.2.3.5.1Independent Living Services

Independent living services assist a person in acquiring the most immediate, fundamental functional skills needed to enable the person to reside in the community and avoid more restrictive levels of treatment or reducing behaviors or symptoms that prevent successful functioning in the person’s environment of choice.

Independent living services include skills training and/or supportive interventions that focus on the improvement of communication skills, appropriate interpersonal behaviors, and other skills necessary for independent living or, when age appropriate, functioning effectively with family, peers, and teachers.

Training for independent living includes skills related to:

Personal hygiene.

Transportation utilization.

Money management.

The development of natural supports.

Access to needed services in the community (e.g., medical care, substance use services, legal services, living accommodations).

Social skills (e.g., communicating one’s needs to strangers and making appropriate choices for the use of leisure time).

5.2.3.5.2Coordination Services

Coordination services are training activities that assist a person in improving his or her ability to gain and coordinate access to necessary care and services appropriate to the needs of the person.

Training for coordination skills includes instruction and guidance in such areas as:

Identifying areas of need across all life domains.

Prioritizing needs and setting goals.

Identifying potential service providers and support systems.

Initiating contact with providers and support systems.

Participating in the development and subsequent revisions of their plan of care.

Coordinating their services and supports.

Advocating for necessary changes and improvements to ensure that they obtain maximum benefit from their services and supports.

5.2.3.5.3Employment-Related Services

Employment-related services provide supports and skills training that are not job-specific and focus on developing skills to reduce or manage the symptoms of serious mental illness that interfere with a person’s ability to make vocational choices or obtain or retain employment.

Included in employment-related services are activities such as:

Skills training related to task focus, task completion, planning and managing activities to achieve outcomes, personal hygiene, grooming and communication, and skills training related to securing appropriate clothing, developing natural supports, and arranging transportation.

Establishing supportive contacts related to the school or work-site situation to reduce or manage behaviors or symptoms related to the person’s mental illness or emotional disturbance that interfere with job performance or progress towards the development of skills that would enable the person to obtain or retain employment.

5.2.3.5.4Housing-Related Services

Housing-related services develop a person’s strengths and abilities to manage the symptoms of the person’s serious mental illness that interfere with the person’s capacity to obtain or maintain tenure in independent integrated housing.

Included in housing-related services are activities such as:

Skills training related to home maintenance and cleanliness.

Problem solving with landlord and other residents.

Maintaining appropriate interpersonal boundaries.

Establishing supportive contacts related to the housing situation to reduce or manage behaviors or symptoms related to the person’s mental illness or emotional disturbance that interfere with maintaining independent integrated housing.

5.2.3.5.5Medication-Related Services

Medication-related services provide individualized training regarding the person’s medication adherence and is different from medication-training and support.

Services consist of training and supportive interventions that focus on person-specific needs and goals regarding the administration of medication, monitoring efficacy and side effects of medication, and other nursing services that enable the person to attain or maintain an optimal level of functioning.

Medication-related services do not include services or activities that are incidental to services performed by a physician (or other qualified health care professional) during an evaluation and management services visit.

5.2.3.6Skills Training and Development

Skills training and development is training provided to an eligible person, the LAR, or primary caregiver on behalf of an eligible adult, child, or youth.

The training addresses:

Serious mental illness or SED and symptom-related problems that interfere with the person’s functioning and living, working, and learning environment.

Provides opportunities for the person to acquire and improve skills needed to function as appropri­ately and independently as possible in the community.

The person’s community integration and increases his or her community tenure.

Skills training and supportive interventions focus on the improvement of communication skills, appro­priate interpersonal behaviors and other skills necessary for independent living or, when age appropriate, functioning effectively with family, peers, and teachers.

Skills training and development may include:

Skills related to personal hygiene.

Pro-social skills.

Assertiveness skills.

Anger management skills.

Stress reduction techniques.

Communication skills.

Transportation utilization.

Money management.

The development of natural supports.

Access to needed services in the community, e.g., medical care, substance use services, legal services, living accommodations.

Social skills (e.g., communicating one’s needs to strangers and making appropriate choices for the use of leisure time).

Skills training and development services consist of increasing the LAR’s or primary caregiver’s under­standing of and ability to respond to the person’s needs identified in the uniform assessment or documented in the treatment plan.

Persons receiving skills training and development are not eligible to simultaneously receive psychosocial rehabilitative services and both services should not be simultaneously listed in the person’s treatment plan.

5.2.3.7Crisis Intervention

Crisis intervention services are intensive community-based one-to-one services provided to persons who require services to control acute symptoms that place the person at immediate risk of hospital­ization, incarceration, or placement in a more restrictive treatment setting.

This service includes assessment, behavioral skills training, problem-solving, and reality orientation to help a person identify and manage their symptoms of mental illness, and cope with stressors.

Crisis intervention services may be provided in extended observation or crisis residential units. Crisis intervention services may not be provided to a person who is currently admitted to a crisis stabilization unit.

Crisis intervention services consist of the following interventions:

An assessment of dangerousness of the person to self or others

The provision of emergency care services that include crisis screening and response, telephone access, emergency case services, urgent care services, routine care services, and access to emergency medical/crisis services

Behavior skills training to assist the person in reducing distress and managing symptoms

Problem-solving

Reality orientation to help the person identify and manage his or her symptoms of serious mental illness or SED

Providing instruction, structure, and emotional support to the person in adapting to and coping with immediate stressors

Crisis intervention services are available to eligible children youth and adults.

5.2.3.8Day Programs for Acute Needs

Day programs for acute needs provide short term, intensive treatment to an eligible persons who is 18 years of age or older and who requires multidisciplinary treatment to stabilize acute psychiatric symptoms or prevent admission to a more restrictive setting. Day program services are a site-based treatment provided in a group modality.

Day programs for acute needs are provided in a highly structured and safe environment with constant supervision and ensure an opportunity for frequent interaction between the adult and staff members.

Day programs for acute needs must at all times have sufficient staff to ensure safety and program adequacy according to an established staffing ratio and staff response times. This service focuses on intensive, medically-oriented, multidisciplinary interventions such as behavior skills training, crisis management, and nursing services that are designed to stabilize acute psychiatric symptoms.

These services may be provided in a residential facility; however, none of the residential facilities can contain greater than 16 beds.

Day programs for acute needs include:

Psychiatric nursing services.

Pharmacological instruction that addresses medication issues related to the crisis precipitating the need for provision of day programs for acute needs.

Symptom management training.

Functional skills training.

Day programs for acute needs must, at all times, have a sufficient number of staff members to ensure safety and program adequacy, and, at a minimum, include:

One RN for every 16 persons at the day program’s location,

One physician to be available by phone, with a response time not to exceed 15 minutes,

Two staff members who are QMHP-CSs, CSSPs, or peer providers at the day program’s location,

One additional QMHP-CS who is not assigned full-time to another day program to be physically available, with a response time not to exceed 30 minutes,

Additional QMHP-CSs, CSSPs, or peer providers at the day program’s location sufficient to maintain a ratio of one staff member to every four persons receiving care.

5.2.3.9Authorization Requirements

Providers must obtain prior authorization for mental health rehabilitative services, with the exception of crisis intervention services.

LMHAs delivering services to persons eligible for fee-for-service benefits must obtain authorization from their internal utilization management department. When providing care to persons enrolled in managed care, LMHAs and other providers contracted with MCOs must submit authorization requests to the MCO with whom the person is enrolled. The MCO may choose to waive this authorization submission requirement. Additionally, MCOs must follow the requirements set forth in the Uniform Managed Care Manual regarding utilization management for targeted case management and mental health rehabilitative services.

Eligibility determinations occur at the facility providing mental health rehabilitative services using the Clinical Management of Behavioral Health Services (CMBHS) software system.

Criteria used to make these service determinations are from the recommended LOC of the person as derived from the Uniform Assessment (UA), the needs of the person, and the Texas Resilience and Recovery Utilization Management Guidelines.

A facility that provides mental health rehabilitative services must ensure that at minimum a QMHP-CS administers the uniform assessment to the person at specified intervals (every 90 calendar days for persons who are 20 years of age and younger and every 180 calendar days for persons who are 21 years of age and older), and obtains a recommended LOC for the person.

The provider must evaluate the clinical needs of the person to determine if the amount of services associated with the recommended LOC described in the utilization management guidelines is sufficient to meet those needs and ensure that an LPHA reviews the recommended LOC and verifies whether the services are medically necessary.

Changes to the treatment plan with regard to type, amount, or duration of services must be approved by an LPHA practicing within the scope of his/her licensure.

If the facility determines that an LOC other than the recommended LOC is more appropriate for the person, the provider must submit a deviation request that includes:

A request for an authorization of an LOC that is higher or lower than initially recommended.

The clinical justification for the request.

The clinical justification must include the specific reason(s) why the person requires interventions outside the recommended LOC. Refusal of recommended LOC by the person receiving services may be noted as part of the justification.

All treatment plans are subject to retrospective review by the state.

5.2.3.9.1Reauthorization Requirements

A QMHP-CS must conduct the uniform assessment at specified intervals (every 90 calendar days for children/youth and every 180 calendar days for adults) to determine the type, amount, and duration of mental health rehabilitative services.

Prior to the expiration of the authorization period or depleting the amount of services authorized, the provider must make a determination of whether the person continues to need mental health rehabili­tative services. An LPHA must also determine whether the continuing need for mental health rehabilitative services meets the definition of medical necessity.

If the determination is that the person continues to need mental health rehabilitative services and that such services are medically necessary, the provider must:

Request another authorization for the same type and amount of mental health rehabilitative service previously authorized; or

Submit a request, with documented clinical reasons for such request, to change the type or amount of mental health rehabilitative services previously authorized if:

The provider determines that the type or amount of mental health rehabilitative services previ­ously authorized is inappropriate to address the person’s needs.

The criteria described in the utilization management guidelines for changing the type or amount of mental health rehabilitative services has been met.

5.2.3.10Documentation Requirements

All services require documentation to support the medical necessity of the service rendered. An LPHA must document in the person’s medical record that mental health rehabilitative services are medically necessary when the services are authorized and reauthorized.

Persons determined to need mental health rehabilitative services must have a treatment plan developed by the Medicaid enrolled provider of mental health rehabilitative services that describes in writing the type, amount, and duration of mental health rehabilitative services determined to be medically necessary to meet the needs of the person.

A rehabilitative services provider must document the following for all mental health rehabilitative services:

The name of the person to whom the service was provided

The type of service provided

The specific goal or objective addressed, and the modality and method used to provide the service

The date the service was provided

The start and end time of the service

The location where the service was provided

The signature of the staff member providing the service and a notation of their credentials

Any pertinent event or behavior relating to the person’s treatment which occurs during the provision of the service

The outcome or progress in achieving treatment plan goals

In addition to the general requirements described above, when providing crisis services, a provider must document the following information:

Risk of suicide or homicide

Substance use

Trauma, abuse, or neglect

The outcome of the crisis (e.g., person in hospital, person with friend and scheduled to see doctor at 9:00 a.m. the following day)

All actions (including rehabilitative interventions and referrals to other agencies) used by the provider to address the problems presented

The response of the person, and if appropriate, the response of the LAR and family members

Any pertinent event or behavior relating to the person’s treatment that occurs during the provision of the service

Follow up activities that may include referral to another provider

Documentation for day programs for acute needs must be made daily. Documentation must be made after each face-to-face contact occurs to provide the mental health rehabilitative service for all other services.

An LPHA must, within two business days after crisis intervention services are provided, determine whether the crisis intervention services met the definition of medical necessity. If medical necessity is met then the LPHA must document the medical necessity.

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

A provider must retain documentation in compliance with applicable federal and state laws, rules, and regulations.

5.2.3.11Exclusions

Persons receiving psychosocial rehabilitation services are not eligible to simultaneously receive skills training and development or targeted case management services.

Mental health rehabilitative services do not include any of the following services that must be billed to Texas Medicaid:

Rehabilitative services provided:

Before the establishment of a diagnosis of mental illness and authorization of services

To persons who reside in an institution for mental diseases

To general acute care hospital inpatients

Services to residents of institutions that furnish food, shelter, and treatment to four or more unrelated persons

Services to nursing facility residents who have not been identified through the PASSR process as needing specialized mental health services

Services to inmates of public institutions

Job task-specific vocational services

Educational services

Room and board residential costs

Services that are an integral and inseparable part of another Medicaid-reimbursable service, including targeted case management services, residential rehabilitative behavioral health services, institutional and waiver services

Services that are covered elsewhere in the state Medicaid plan

Services to persons with a single diagnosis of intellectual or developmental disability or substance use disorder who do not have a co-occurring diagnosis of mental illness in adults or serious emotional disturbance in children

Inpatient hospital services

Respite services

Family support services

5.2.3.12Non-reimbursable Activities

A Medicaid provider will not be reimbursed for a mental health rehabilitative service:

That is not included in the person’s treatment plan (except for crisis intervention services and psychosocial rehabilitative services provided in a crisis situation.

That is not authorized, except for crisis intervention services.

Provided in excess of the amount authorized.

Provided outside of the duration authorized.

Provided to a person receiving MH case management services.

That is not documented.

Provided to a person who does not meet the eligibility criteria.

Provided to a person who does not have a current uniform assessment (except for crisis intervention services).

Provided to a person who is not present, awake, and participating during such service.

Provided via electronic media.

A Medicaid provider will not be reimbursed for a crisis service provided to a person who does not have a serious mental illness.

The cost of the following activities is included in the Medicaid mental health rehabilitative services reimbursement rate(s) and may not be directly billed by the Medicaid provider:

Developing and revising the treatment plan and interventions that are appropriate to a person’s needs.

Staffing and team meetings to discuss the provision of mental health rehabilitative services to a specific person.

Monitoring and evaluating outcomes of interventions, including contacts with a person other than the person receiving services.

Documenting the provision of mental health rehabilitative services.

A staff member’s travel time to and from a location to provide mental health rehabilitative services.

All services provided within a day program for acute needs that are delivered by a staff member, including services delivered in response to a crisis or an episode of acute psychiatric symptoms.

Administering the uniform assessment to persons who are receiving mental health rehabilitative services.

5.3Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including MH and IDD services.

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

5.4Claims Filing and Reimbursement

IDD service coordination, MHTCM, and mental health rehabilitative services must be submitted to TMHP in an approved electronic claims 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 them.

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.

Services are cost reimbursed in accordance with 1 TAC §§355.743, 355.746, and 355.781. Providers can refer to the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com.

5.4.1Managed Care Clients

Claims for persons in managed care must be submitted to the client’s MCO. Mental health targeted case management and mental health rehabilitative services that are funded by a criminal justice agency (submitted with modifier HZ) are carved out and must be submitted to TMHP.

5.4.2Reimbursement Reductions

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). Blocks that are not referenced are not required for processing by TMHP and may be left blank.

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 and the federal matching percentage.

6 Peer Specialist Services

6.1Services, Benefits, Limitations, and Prior Authorization

Peer specialist services (procedure code H0038) for mental health conditions or substance use disorders are a benefit of Texas Medicaid for persons who are 21 years of age and older, and who have peer specialist services included as a component of their person-centered recovery plan.

Peer specialist services are recovery-oriented, person-centered, relationship-focused, voluntary, and trauma-informed.

Peer specialist services may include the following:

Recovery and wellness support services, which include providing information and support for recovery planning.

Mentoring, which includes serving as a role model and helping find needed community resources and services.

Advocacy, which includes providing support during stressful or urgent situations and helping to ensure that the person’s rights are respected. Advocacy may also include encouraging the person to advocate for him or herself to obtain services.

Peer specialist services are based on a mutual relationship between the peer specialist and the Medicaid eligible person. A peer specialist uses his or her lived experience to support the person with the following:

Achieving the goals and objectives of the person’s individualized recovery plan

Skill development

Problem solving strategies

Coping mechanisms for stressors and barriers encountered when recovering from a mental health condition or a substance use disorder

Peer specialist services can be delivered individually or in a group setting.

6.2Peer Specialist Requirements

Peer specialist services may be delivered as part of a coordinated, comprehensive, and individualized approach to treating a person’s mental health condition, substance use disorder, or both, if the peer specialist is employed by one of the following Medicaid-enrolled provider types:

Clinic/group practices that treat behavioral health conditions

Physicians (M.D.s), osteopaths (D.O.s), and nurse practitioners (NPs), clinical nurse specialists (CNSs), and physicians assistants (PAs) that treat behavioral health conditions

Psychologists, licensed clinical social workers, licensed marriage and family therapists, and licensed professional counselors

Comprehensive provider agencies of targeted case management and mental health rehabilitative services

Local mental and behavioral health authorities

Chemical dependency treatment facilities

Federally qualified health clinics (FQHCs)

Rural health clinics (RHCs)

Opioid Treatment Providers (OTPs)

Only clinic/group practices or behavioral health care individual providers (M.D., D.O., NP, CNS, and PA) with a behavioral health focus may be reimbursed for peer specialist services.

Peer specialists coordinate with all behavioral health service providers involved in the person’s care and utilize a person-centered, recovery-oriented approach to treatment planning and service delivery.

Non-Medicaid enrolled providers that employ peer specialists can contract with one of the listed Medicaid-enrolled provider types to furnish peer specialist services as part of a continuum of compre­hensive treatment services. Subcontracted peer specialist services must also be part of the coordinated, comprehensive, and individualized person-centered recovery plan.

A peer specialist must meet all of the following criteria:

Be at least 18 years of age.

Have lived experience with a mental health condition, substance use disorder, or both.

Have a high school diploma or General Equivalency Diploma (GED).

Be willing to appropriately share his or her own recovery story with the person receiving services.

Demonstrate current self-directed recovery.

Pass criminal history and registry checks as described in 1 TAC §354.3201.

A peer specialist must not:

Practice psychotherapy.

Make clinical or diagnostic assessments.

Dispense expert opinions.

Engage in any service that requires a license.

Falsify any documentation related to application, training, testing, certification, or services provided.

6.2.1Certification

A peer specialist must complete all required training and certification before providing services. To be certified as a peer specialist as specified in 1 TAC §354.3155, a candidate must complete the following training:

Required orientation

Self-assessment activities

Core training delivered by a certified training entity

Supplemental training in one of two specialty areas:

Mental health peer specialist

Recovery support peer specialist

The candidate can apply for initial certification after successful completion of core and one supple­mental training and a knowledge assessment.

A peer specialist who is initially certified may begin to deliver Medicaid billable services, if participating in a supervised internship at their place of employment. The internship consists of 250 hours of super­vised work experience to be completed within a 6-month period. An extension may be granted by the certification entity should a peer be unable to complete the required hours within the 6-month time frame.

Independent study, such as reading or watching instructional videos, does not count toward the required supervised work experience hours. Time spent receiving supervision, other than the obser­vation of the peer specialist providing services, does not count toward the required hours.

After completing the required internship hours, certified peer specialists can apply for renewed certifi­cation through the approved certification entity. Peer specialists must renew their certification every two years, which requires continuing education hours.

Certified peer specialists should only deliver services in their specialty area.

6.2.2Supervision

As defined in 1 TAC §354.3003, providers may be reimbursed for peer specialist services rendered under the supervision of one of the following:

Qualified credentialed counselor (QCC)

Licensed practitioner of the healing arts (LPHA)

Qualified mental health professional (QMHP), with a QCC or LPHA supervising the QMHP

Qualified peer supervisor (QPS), with a QCC or LPHA supervising the QPS

Supervision must focus on a peer specialist’s provision of services, including:

Review of cases and activities

Skill building

Problem resolution

Professional growth

Supervision may also include aspects specific to the organization, such as following organizational policy or other administrative matters.

Peer specialist supervision may be provided as follows:

Individually

In a group setting

Face-to-face

By teleconference

Through observation of the peer specialist providing services

Supervision must occur at least once weekly for a peer specialist with an initial certification, at least once monthly for a peer specialist with a two-year certification, or more frequently at the request of the peer specialist.

A QCC or LPHA who supervises a QMHP or QPS must provide individual or group supervision at least once monthly and conduct an observation of the QMHP or QPS supervising the peer specialist at a self-determined frequency based on the QMHP’s or QPS’s skill level.

A supervisor must successfully complete supervisory training for peer specialist services and the recovery model from a certified training entity before supervising a peer specialist. Supervisor training must include instruction about:

The distinction between peer support and therapy.

The role of peer support in building and sustaining recovery goals.

Advocacy for peer specialists and peer specialist services.

Job performance review, including strengths-based, timely, and respectful feedback.

Supervisory skills, such as how to work with a variety of personality types and communication styles.

After completing training, each candidate must successfully complete a knowledge assessment before receiving approval to supervise a peer specialist from a certified training entity. Peer specialist supervisor certification must be renewed every two years, which requires continuing education hours.

6.3Prior Authorization Requirements

Prior authorization is not required for the first 104 units of peer specialist services in a rolling 6-month period. Prior authorization is required once a person exceeds 104 units of individual or group peer specialist services in a rolling 6-month period.

Prior authorization requests for procedure code H0038 must be submitted to TMHP using the Special Medical Prior Authorization (SMPA) Request Form. Requests for continued services must demonstrate all of the following:

The person continues to meet eligibility criteria as outlined in the statement of benefits above, including current DSM diagnoses

The current person-centered recovery plan and goals

The progress made relative to the goals outlined in the person-centered recovery plan

The need for continued services

Requests must indicate how many additional units of service are being requested (up to 30 units are allowed per request) and the type (individual or group), as well as the expected time frame when services will be delivered.

Note:The requesting provider may be asked for additional information to clarify or complete a request.

Retrospective review may be performed to ensure that the documentation supports the medical necessity of the requested service.

Refer to:  Refer to: “Section 5: Fee-for-Service Prior Authorizations” (Vol. 1, General Information)for more information on submitting prior authorization methods.

6.4Documentation Requirements

The Medicaid-enrolled provider must ensure proper documentation of all peer specialist services that are rendered. Documentation of peer specialist services must:

Indicate the date, time, and place of service.

Summarize the purpose and content of the services.

Include the specific strategies and activities utilized as related to the goals of the person’s plan of care.

Peer specialist supervisors must document all supervisory sessions and maintain the records in the peer specialist’s employee personnel file.

6.4.1Reimbursement

Reimbursement for procedure code H0038 is limited to substance use disorders and mental health conditions, including, but not limited to:

Schizophrenia spectrum and other psychotic disorders.

Bipolar and related disorders.

Depressive disorders.

Anxiety disorders.

Obsessive-compulsive and related disorders.

Trauma and stressor related disorders.

Feeding and eating disorders.

Procedure code H0038 is limited to 104 units in a rolling six-month period. This limitation may be exceeded with documentation of medical necessity for the additional services.

Peer specialist services will also be limited as follows:

Must not be delivered simultaneously with other behavioral health services that are delivered to the person or group of persons receiving services

Must be delivered in person and not through advanced telecommunications technology

Limited to 12 total persons per group session

6.4.2Claim Filing

Procedure code H0038 must be submitted with one of the following specialty modifiers:

Modifier HE-mental health

Modifier HF-substance use

If services are provided in a group setting, procedure code H0038 must also be submitted with modifier HQ.

Mental health rehabilitative services must be billed separately from peer specialist services.

FQHCs and RHCs should submit claims using procedure code H0038 for informational purposes only.

6.5Exclusions

The following services are not a benefit of Texas Medicaid:

Record keeping or documentation activities

Services provided without the person present

7 Inpatient Psychiatric Services

Admissions to acute care hospitals for inpatient psychiatric services are a benefit of Texas Medicaid for persons of all ages in fee-for-service Medicaid or managed care.

Admissions to psychiatric facilities, i.e. Institutions for Mental Disease (IMD), for inpatient psychiatric services are a benefit of Texas Medicaid for:

Persons 20 years of age and younger and 65 years of age and older in fee-for-service Medicaid.

Persons 21 through 64 years of age enrolled in managed care as an in lieu of service if the MCO and the person receiving services agree to an IMD as the setting for inpatient psychiatric services. The benefit is for a maximum of 15 calendar days per month, not per stay.

Note:In lieu of services are services substituted for Medicaid State Plan services or settings, as allowed by 42 CFR §438.3(e).

Refer to:  Section 3.4, “Services, Benefits, Limitations, and Prior Authorization - Inpatient Psychiatric Services” of the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks) for more information.

8 Screening, Brief Intervention, and Referral to Treatment (SBIRT)

SBIRT is a comprehensive, public health approach to the delivery of early intervention and treatment services for persons who are 10 years of age and older and who have alcohol or substance use disorders or are at risk of developing such disorders. SBIRT is used for intervention directed to a person and not for group intervention.

SBIRT services can be provided by physicians, registered nurses, advanced practice nurses, physician assistants, psychologists, licensed clinical social workers, licensed professional counselors, certified nurse midwives, outpatient hospitals, federally qualified health centers (FQHCs), and rural health clinics (RHCs). Non-licensed providers may deliver SBIRT under the supervision of a licensed provider if such supervision is within the scope of practice for that licensed provider. The same SBIRT training require­ments apply to non-licensed providers.

A person may have a maximum of two screening only sessions per rolling year, and up to four combined screening and brief intervention sessions per rolling year. Providers must refer the person to treatment if the screening results reveal severe risk of alcohol or substance use.

Refer to:  Section 9, “Substance Use Disorder (SUD) Services” in this handbook for additional infor­mation on SUD treatment.

8.1SBIRT Training

Providers that perform SBIRT must be trained in the correct practice of this method and will be required to complete at least four hours of training. Proof of completion of SBIRT training must be maintained in an accessible manner at the provider’s place of service.

Information regarding available trainings and standardized screening tools can be found through the Substance Abuse and Mental Health Services Administration.

8.2Screening

Screening persons for problems related to alcohol or substance use identifies the person’s level of risk and determines the appropriate level of intervention indicated for the person. Providers must explain the screening results to the person, and if the results are positive, be prepared to subsequently deliver, or delegate to another provider, brief intervention services. Screening must be conducted using a standardized screening tool. Standardized tools that may be used include, but are not limited to, the following:

Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)

Drug Abuse Screening Test (DAST)

Alcohol Use Disorders Identification Test (AUDIT)

Cut-down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire

Car, Relax, Alone, Forget, Family or Friends, Trouble (CRAFFT) questionnaire

Binge drinking questionnaire

Results obtained through blood alcohol content (BAC) or through toxicology screening may also be used to screen for alcohol or substance use risk.

8.3Brief Intervention

Brief intervention is performed following a positive screen or a finding of at least a mild to moderate risk for alcohol or substance use. During the session, brief intervention involves motivational interviewing techniques (such as the Brief Negotiated Interview) that is focused on raising the person’s awareness of his or her alcohol or substance use and its consequences. The session is also focused on motivating the person toward behavioral change.

Subsequent screening and brief intervention sessions within the allowable annual limitations may be indicated to assess for behavior change and further explore a person’s readiness to make behavioral changes related to their alcohol or substance use.

Note:Providers may choose to schedule multiple screening and brief intervention sessions in a rolling year in order to provide ongoing support to a person at risk for substance use who is receptive to behavior change.

8.4Referral to Treatment

If the provider determines that the person is in need of more extensive treatment or has a severe risk for alcohol or substance use, the person must be referred to an appropriate substance use treatment provider.

Referral to more extensive treatment is a proactive process that facilitates access to care for persons who require a more extensive level of service than SBIRT provides. Referral is an essential component of the SBIRT intervention because it ensures that all persons who are screened have access to the appropriate level of care.

Note:If the person is currently under the care of a behavioral health provider, the person must be referred back to that provider.

8.5Reimbursement and Limitations

SBIRT is limited to persons who are 10 years of age and older.

SBIRT is limited to up to two screening sessions per rolling year. A screening that results in a negative result does not require a brief intervention. In these instances procedure code H0049 should be used. A provider may re-screen a person within the same rolling year to determine whether their substance use behavior has changed.

Procedure code 99408 or G2011 should be used when a brief intervention follows an SBIRT screening. Procedure code 99408 is limited to once per day. SBIRT is limited to four sessions per rolling year when it constitutes a screening followed by a brief intervention.

If a person requires more than four combined screening and brief intervention sessions per rolling year, the person must be referred for substance use disorder treatment.

SBIRT is not reimbursable to providers (whether licensed or non-licensed) who have not completed the required number of training hours in SBIRT methodology.

Procedure codes 99408, G2011, and H0049 will be denied if billed for the same date of service as any of the following procedure codes:

Procedure Codes

90791

90792

90832

90833*

90834

90836*

90837

90838*

90847

90853

90865

90870

96130

96131*

96132

96133*

96136

96137*

*Add-on procedure codes must be billed with the appropriate primary code.

Procedure codes 99408 and H0049 cannot both be billed on the same date.

Physicians and other qualified health care professionals that bill an Evaluation and Management (E/M) code for a visit where SBIRT occurred must use modifier 25 to identify a significant, separately identi­fiable E/M service rendered by the same provider on the same date of service.

Note:FQHCs and RHCs should submit claims using SBIRT procedure codes for informational purposes only.

8.6Documentation Requirements

A person’s record documentation must support medical necessity for the SBIRT services provided and must be maintained by the SBIRT provider and made readily available for review when requested by the Health and Human Services Commission (HHSC) or its designee. SBIRT documentation for screening must include the following:

The provider who performed the SBIRT screening

Screening results from a standardized screening tool or laboratory results such as BAC, toxicology screen, or other measures showing risk for alcohol or substance use and the specific screening tool used.

Documentation for SBIRT brief intervention sessions must include a person-centered plan for the delivery of medically necessary services that supports the use of procedure code 99408. The plan must include all of the following:

The provider who performed the SBIRT brief intervention, if different from the provider who screened the person

Start and stop time of the session, or the total face-to-face time spent providing SBIRT services to the person

Goals established

Specific strategies to achieve the goals

The person’s support system such as family members, a legal guardian, or friends.

Note:If subsequent sessions are indicated, the provider who performed the SBIRT session must document that a follow up SBIRT appointment was made and with whom, or document another mechanism established to reassess progress

The name, address, and phone number of the provider that the person has been referred to for substance use disorder treatment

Services are subject to retrospective review to ensure that the documentation in the person’s medical record supports the medical necessity of the services provided.

8.7* Claims Filing and Reimbursement

SBIRT 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).

Texas Medicaid rates for Hospitals are calculated according to 1 TAC §355.8061.

According to 1 TAC §355.8091, the 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.

The Medicaid rates for psychologists are calculated in accordance with 1 TAC §355.8085.

Texas Medicaid rates for physicians and certain other practitioners are calculated in accordance with TAC §355.8085.

Texas Medicaid rates for Nurse Practitioners and Clinical Nurse Specialists are calculated in accordance with TAC §355.8281.

[Revised] According to 1 TAC §355.8093, the Medicaid rate for PAs is 92 percent of the rate paid to a physician (MD or DO) for the same professional service and 100 percent of the rate paid to physicians for laboratory services, X-ray services, and injections. Services performed by a PA and billed under a physician’s or RHC’s NPI are reimbursed according to the Texas Medicaid Reimbursement Method­ology (TMRM) for physician services.

Note:For more information about Texas Medicaid rates for the provider types above, refer to the 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.

Note:Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column.

9 Substance Use Disorder (SUD) Services

9.1Overview

SUDs are chronic, relapsing medical illnesses that require an array of best practice medical and psycho­social interventions of sufficient intensity and duration to achieve and maintain remission and support progress toward recovery. SUD may include problematic use of alcohol, prescription drugs, illegal drugs (e.g., cannabis, opioids, stimulants, inhalants, hallucinogens, “club” drugs, other synthetic euphoriants), and other substances that may be identified in the future.

Treatment for SUD is a benefit of Texas Medicaid for persons who meet the criteria for a substance-related disorder, as outlined in the current edition of the American Psychiatric Association’s DSM.

SUD treatment services are individualized, age-appropriate medical and psychosocial interventions designed to treat a person’s problematic use of alcohol or other drugs, including prescription medication.

SUD services may include:

Withdrawal management services.

Individual and group SUD counseling in an outpatient setting.

Residential treatment services.

Medication assisted treatment.

Evaluation and treatment (or referral for treatment) for co-occurring physical and behavioral health conditions.

Level of care (e.g., outpatient, residential, inpatient hospital) and specific services provided must adhere to current evidence-based industry standards and guidelines for SUD treatment, such as those outlined in the current edition of the American Society of Addiction Medicine’s Treatment Criteria for Addictive Substance-Related and Co-Occurring Conditions, as well as the licensure requirements outlined in 25 TAC §448 pertaining to standards of care.

SUD treatment services (outpatient or residential) may only be delivered in a licensed chemical depen­dency treatment facility (CDTF). Medication assisted treatment (MAT) may also be delivered in the office setting by appropriately trained physicians, physician assistants (PAs), and advanced practice registered nurses (APRNs) who are recognized by the Texas Board of Nursing as either nurse practi­tioners (NPs), clinical nurse specialists (CNSs), nurse anesthetists (CRNAs), or nurse midwives (CNMs), provided that the APRN is a qualifying practitioner and possesses the Drug Addiction Treatment Act (DATA) waiver.

SUD withdrawal management in an inpatient hospital setting may be provided for persons who meet hospital level of care requirements as a result of the severity of their withdrawal syndrome or the severity of their co-occurring conditions. These services may be reimbursed as general hospital inpatient services.

The treatment setting and the intensity or level of services will vary depending on the severity of the person’s SUD and what is clinically appropriate. The intensity or level of services refers to the number of hours of services per week, as well as the types of services the person receives. Early Intervention services are part of the spectrum of SUD treatment and are a benefit in Texas Medicaid. Early inter­vention services target persons who are at risk of developing a substance related problem but may not have a diagnosed SUD.

Refer to:  Subsection 8, “Screening, Brief Intervention, and Referral to Treatment (SBIRT)” in this handbook for further information on early intervention services.

Upon admission into a treatment setting, a face-to-face multi-dimensional assessment (procedure code H0001) must be conducted by a qualified credentialed counselor (QCC) or intern as defined in DSHS TAC §441.101 to determine a course of treatment that is medically necessary and clinically appropriate. The assessment must be signed off by a QCC.

9.2Evaluation, Treatment, or Referral for Co-Occurring Conditions

CDTFs shall facilitate access to physical health, mental health, and ancillary services if those services are not available through the program and are necessary to meet treatment goals or needs of the person receiving services.

Persons in residential CDTFs commonly require medications unrelated to their SUD treatment for which costs are not covered in the reimbursement for SUD or MAT services. These medications, if included in the Medicaid formulary, may be obtained and reimbursed through the person’s Medicaid pharmacy benefit.

Persons in residential CDTFs also commonly require other services that are benefits of Texas Medicaid, but not included in the CDTF rate. Claims for these services can be submitted by the appropriate providers.

CDTFs should screen each person for risk for contracting tuberculosis, Hepatitis B and C, HIV antibody, and sexually transmitted infections, and if appropriate, provide access to testing and follow up. Testing may be performed on site and billed by the ordering provider if appropriate testing facilities are available that are compliant with the rules and regulations for the Clinical Laboratory Improvement Amendments (CLIA). Providers that do not comply with CLIA are not reimbursed for laboratory services.

9.3Withdrawal Management Services

Withdrawal management, formerly known as detoxification, is the medical and behavioral treatment of persons experiencing or potentially experiencing withdrawal symptoms as a result of ceasing or reducing substance use.

Withdrawal management involving opioids, alcohol, sedatives, hypnotics, or anxiolytics will vary depending on the severity of the withdrawal symptoms experienced but will typically involve medica­tions to treat symptoms in addition to supportive care, observation, and monitoring. Withdrawal management involving stimulants, inhalants, and cannabis typically involves supportive care, obser­vation and monitoring, and medications to treat withdrawal symptoms as required.

Withdrawal management may be performed in an outpatient setting for persons experiencing mild to moderate withdrawal symptoms that can be successfully, as well as safely, managed outside of a residential setting or an inpatient hospital. Withdrawal management in a residential setting may be required for persons whose multidimensional assessment indicates one or more of the following circum­stances that would make outpatient withdrawal management unsafe or unsuccessful:

A level of severity of withdrawal, medical, or mental health complication

Sufficient challenges with readiness to change, ability to stop using, or social support

Withdrawal management in an inpatient hospital setting may be required for persons whose severity of medical withdrawal (e.g., impending delirium tremens, severe withdrawal seizures), comorbid medical conditions (e.g., severe liver impairment, acute pneumonia, endocarditis, dementia), or comorbid psychiatric conditions (e.g., severe suicidality, acute and unstable psychosis or mania) requires a hospital level of care.

9.4Individual and Group SUD Counseling in an Outpatient Setting

Counseling for substance use disorders is designed to assist persons in developing a better under­standing of their SUD, help to establish treatment goals and plans for achieving those goals, and provide interventions to assist persons in accordance with the plan. The overall intent of the service is to assist persons in understanding their SUD and developing the skills and supports needed to address their SUD over time. Counseling may be done individually or in a group setting with multiple members. Group counseling sessions are limited to a total of 16 persons per session.

Outpatient counseling services are appropriate for the following:

Persons with less severe disorders

Persons who are in the early stages of change

As a step down from more intensive services

Persons who are stable but for whom ongoing monitoring is appropriate

Note:For persons unable or unwilling to access SUD treatment services at a CDTF, psychotherapy delivered by a licensed practitioner of the healing arts (LPHA) may be an alternative treatment option to address a person’s SUD.

Outpatient services may be appropriate at the start of treatment, throughout treatment, or after an episode of residential or inpatient treatment, depending on the person’s acuity, severity, comorbidity, needs, or preferences. Outpatient services can address active symptoms as well as provide ongoing treatment for persons in partial or full remission who need continuing help to maintain progress.

Abstinence should not necessarily be a requirement for participation in outpatient services.

9.5Residential Treatment Services

Residential treatment programs provide a structured therapeutic environment where persons reside with staff support and deliver comprehensive substance use disorder treatment with attention to co-occurring conditions as appropriate. The frequency and duration of services should be based on meeting the person’s needs and achieving the person’s treatment goals.

Residential services are appropriate for persons who require a structured therapeutic environment to stabilize SUD and develop coping and recovery skills. Residential treatment programs may specialize in the unique needs of a specific population such as adolescents, or pregnant or parenting women with children.

Episodes of residential treatment may be required for persons with more severe SUD, more significant medical or psychiatric comorbidities, more significant challenges with sustaining motivation, maintaining control in an outpatient setting, or a living environment that jeopardizes their current ability to be successful in outpatient treatment.

Residential SUD treatment services may only be provided by a licensed CDTF.

9.6Outpatient Treatment Services

Outpatient treatment services must be billed with procedure codes H0004 or H0005.

Procedure codes H0004 and H0005 are limited to the following diagnosis codes:

Diagnosis Codes

F1010

F1011

F10120

F10121

F10129

F10130

F10131

F10132

F10139

F1014

F10150

F10151

F10159

F10180

F10181

F10182

F10188

F1019

F1020

F1021

F10220

F10221

F10229

F10230

F10231

F10232

F10239

F1024

F10250

F10251

F10259

F1026

F1027

F10280

F10281

F10282

F10288

F1029

F10920

F10921

F10929

F10930

F10931

F10932

F10939

F1094

F10950

F10951

F10959

F1096

F1097

F10980

F10981

F10982

F10988

F1099

F1110

F1111

F11120

F11121

F11122

F11129

F1113

F1114

F11150

F11151

F11159

F11181

F11182

F11188

F1119

F1120

F1121

F11220

F11221

F11222

F11229

F1123

F1124

F11250

F11251

F11259

F11281

F11282

F11288

F1129

F1190

F11920

F11921

F11922

F11929

F1193

F1194

F11950

F11951

F11959

F11981

F11982

F11988

F1199

F1210

F1211

F12120

F12121

F12122

F12129

F1213

F12150

F12151

F12159

F12180

F12188

F1219

F1220

F1221

F12220

F12221

F12222

F12229

F1223

F12250

F12251

F12259

F12280

F12288

F1229

F1290

F1293

F12920

F12921

F12922

F12929

F12950

F12951

F12959

F12980

F12988

F1299

F1310

F1311

F13120

F13121

F13129

F13130

F13131

F13132

F13139

F1314

F13150

F13151

F13159

F13180

F13181

F13182

F13188

F1319

F1320

F1321

F13220

F13221

F13229

F13230

F13231

F13232

F13239

F1324

F13250

F13251

F13259

F1326

F1327

F13280

F13281

F13282

F13288

F1329

F1390

F13920

F13921

F13929

F13930

F13931

F13932

F13939

F1394

F13950

F13951

F13959

F1396

F1397

F13980

F13981

F13982

F13988

F1399

F1410

F1411

F14120

F14121

F14122

F14129

F1413

F1414

F14150

F14151

F14159

F14180

F14181

F14182

F14188

F1419

F1420

F1421

F14220

F14221

F14222

F14229

F1423

F1424

F14250

F14251

F14259

F14280

F14281

F14282

F14288

F1429

F1490

F14920

F14921

F14922

F14929

F1493

F1494

F14950

F14951

F14959

F14980

F14981

F14982

F14988

F1499

F1510

F1511

F15120

F15121

F15122

F15129

F1513

F1514

F15150

F15151

F15159

F15180

F15181

F15182

F15188

F1519

F1520

F1521

F15220

F15221

F15222

F15229

F1523

F1524

F15250

F15251

F15259

F15280

F15281

F15282

F15288

F1529

F1590

F15920

F15921

F15922

F15929

F1593

F1594

F15950

F15951

F15959

F15980

F15981

F15982

F15988

F1599

F1610

F1611

F16120

F16121

F16122

F16129

F1614

F16150

F16151

F16159

F16180

F16183

F16188

F1619

F1620

F1621

F16220

F16221

F16229

F1624

F16250

F16251

F16259

F16280

F16283

F16288

F1629

F1690

F16920

F16921

F16929

F1694

F16950

F16951

F16959

F16980

F16983

F16988

F1699

F1810

F1811

F18120

F18121

F18129

F1814

F18150

F18151

F18159

F1817

F18180

F18188

F1819

F1820

F1821

F18220

F18221

F18229

F1824

F18250

F18251

F18259

F1827

F18280

F18288

F1829

F1890

F18920

F18921

F18929

F1894

F18950

F18951

F18959

F1897

F18980

F18988

F1899

F1910

F1911

F19120

F19121

F19122

F19129

F19130

F19131

F19132

F19139

F1914

F19150

F19151

F19159

F1916

F1917

F19180

F19181

F19182

F19188

F1919

F1920

F1921

F19220

F192221

F19222

F19229

F19230

F19231

F19232

F19239

F1924

F19250

F19251

F19259

F1926

F1927

F19280

F19281

F19282

F19288

F1929

F1990

F19920

F19221

F19922

F19929

F19930

F19931

F19932

F19939

F1994

F19950

F19951

F19959

F1996

F1997

F19980

F19981

F19982

F19988

F1999

F551

F553

9.7Medication Assisted Treatment

MAT is the use of FDA-approved medications in combination with psychosocial treatment to treat substance use disorders, particularly alcohol and opioid use disorders.

MAT is a recognized best practice for alcohol use disorder (AUD) and opioid use disorder (OUD). All persons with AUD and OUD should be educated about the availability of MAT and the evidence supporting MAT, and have the opportunity to receive MAT regardless of where they are receiving SUD services. This could be accomplished on site or through a written agreement with a collaborating opioid treatment program (OTP) or office-based opioid treatment (OBOT) program.

Initiation or induction of MAT can appropriately occur in lieu of withdrawal management for opioid use disorders, may begin early in withdrawal management for either AUD or OUD, and can be initiated as appropriate at any point in time during the course of treatment. Duration of MAT is determined on an person basis, depending on the person’s unique needs and treatment goals.

Determination of which MAT medication to use is also an individualized treatment decision based on provider assessment and the person’s needs and treatment goals. Providers are encouraged to offer as many treatment options as possible (within the parameters of their licensing and scope of practice) to maximize the person’s choice and access to care.

MAT may be utilized as appropriate, as part of the service array delivered by outpatient providers or residential treatment services programs at CDTFs.

Opioid treatment programs (also referred to as narcotic treatment programs) are the only settings permitted by law to provide methadone for OUD and must comply with additional federal and state requirements, rules on licensure and scope of practice, including physician delegation, supervision, and prescriptive authority. Opioid treatment programs can also provide or administer other forms of MAT.

CDTFs, physicians, NPs, and PAs may prescribe and provide for the administration of long acting injectable naltrexone (Vivitrol) to treat cravings associated with either opioid use disorder or alcohol use disorder.

Physicians, PAs, and APRNs who are recognized by the Texas Board of Nursing as either NPs, CNSs, APRNs, or CNMs who have received a federal waiver to dispense buprenorphine may choose to incor­porate this form of MAT into their medical practice while also providing or referring for other types of treatment services (also referred to as OBOT).

Certain MAT medications to treat alcohol and opioid use disorders (such as buprenorphine, disulfiram, acamprosate, and naltrexone), are available as a pharmacy benefit and may be prescribed to a person by their physician or other qualified health care professional. Providers may refer to the Vendor Drug Program Formulary for additional information on covered medications.

Prescribing of certain MAT medications may be done via telemedicine presuming all other applicable state and federal laws are followed.

A prescription for an opioid antagonist (e.g., naloxone) should be given to all persons receiving treatment for opioid use disorder, and instruction should be provided on how to administer if needed.

Claims for urinalysis drug screens ordered by a physician, NP, or CNS to monitor compliance with MAT may be submitted by the individually-enrolled physician or APRN.

The following MAT procedure codes may be separately reimbursed from withdrawal management and treatment services in the outpatient or residential setting:

Procedure Codes

H0020

H0033

J0570

J2315

Q9991

Q9992

9.7.1Opioid Treatment Providers

Substance Abuse and Mental Health Services Administration certified (SAMHSA-certified) opioid treatment providers (OTPs) that are also licensed as narcotic treatment programs in Texas are required to enroll in Medicare before enrolling with Texas Medicaid as OTPs. Providers billing claims for persons who have dual eligibility for Medicaid and Medicare must first submit their claims to Medicare.

The following procedure codes may be reimbursed to Opioid Treatment Providers:

Procedure Codes

H0001

H0004

H0005

H0020

H0033

J0570

J2315

Q9991

Q9992

Important:CDTFs cannot bill for OTP services through Medicare, as CDTFs are not Substance Abuse and Mental Health Services Administration certified (SAMHSA-certified) OTPs.

A comprehensive assessment (procedure code H0001) is limited to once per day, any provider. An assessment is also limited to once per episode of care and should be performed at the start of each new episode of care.

9.8Exclusions

SUD treatment services for tobacco use disorder as the primary diagnosis are not a covered benefit, although a comprehensive SUD treatment approach should address tobacco use if reducing or elimi­nating this substance is part of the person’s treatment goal.

With the exception of prescribing MAT medications via telemedicine, SUD treatment services may not be delivered via telemedicine or telehealth.

9.9Prior Authorization

The following services do not require prior authorization:

Assessment

Outpatient treatment services

MAT

Exception:Outpatient treatment services require prior authorization if the calendar year hours/units are exceeded. Those limits are 135 units of group services and 26 hours of individual services per calendar year.

The following services require prior authorization:

Outpatient withdrawal management services

Outpatient treatment for persons who exceed the benefit limitation

Residential withdrawal management services

Residential treatment services

Providers must submit the appropriate prior authorization request form for the initial or continuation of outpatient or residential withdrawal management treatment and residential treatment services. A QCC (as defined by the DSHS licensure standard) must complete and sign the prior authorization request forms.

Providers must submit one of the following forms to obtain prior authorization:

Outpatient Withdrawal Management Authorization Request Form

Outpatient Substance Use Disorder Counseling Extension Request Form

Residential Withdrawal Management Authorization Request Form

Residential Substance Use Disorder Treatment Request Form

Prior authorization will be considered for the least restrictive environment appropriate to the person’s medical need as determined in the person’s plan of care (POC), based on national standards.

Prior authorization requests for services beyond the limitations outlined in this section, may be considered with documentation supporting the medical necessity for continuation of the treatment.

9.9.1Prior Authorization to Persons with Fee-For-Service Benefits

Prior authorization requests for persons with fee-for-service benefits may be submitted to the TMHP Prior Authorization Unit online at www.tmhp.com, by fax at 1-512-514-4211, or by mail to:

Texas Medicaid & Healthcare Partnership
TMHP Prior Authorization Department
12357-B Riata Trace Parkway, Suite 100
Austin, TX 78727

To complete the prior authorization process electronically, the provider must complete the prior autho­rization requirements through any approved electronic methods. Providers must retain a copy of the signed and dated prior authorization form in the person’s medical record.

Providers may contact the TMHP Prior Authorization Unit by telephone at 1-800-213-8877, Option 2, to obtain information about substance use disorder benefits, the prior authorization process, or the status of a prior authorization request. Prior authorization for substance use disorder services cannot be obtained through this line.

Prior authorization for outpatient withdrawal management, residential treatment, or residential withdrawal management services will be considered when requested within three business days after the date of admission.

Prior authorization may be considered for persons who are enrolled in a Medicaid MCO when they are admitted to SUD services and whose eligibility changes to fee-for-service during treatment. Requests must be submitted within three business days of the date on which the fee-for-service eligibility started.

9.9.2Prior Authorization for Outpatient Withdrawal Management Treatment Services

Outpatient withdrawal management services may be prior authorized for up to 21 days. The level of service and number of days that are prior authorized will be based on the substances that are used, level of intoxication and withdrawal potential, and the person’s medical needs. Providers may submit requests for services using the Outpatient Withdrawal Management Authorization Request Form.

9.9.2.1Admission Criteria for Outpatient Withdrawal Management Treatment Services

The admission criteria for outpatient withdrawal management treatment services follow the existing Texas Department of Insurance licensure requirements and standards that are specified in 28 TAC §3.8001–§3.8030.

To be considered eligible for treatment for outpatient withdrawal management services, the person must meet the following conditions:

Chemical Substance Withdrawal—The person must meet all of the following criteria with regard to chemical substance withdrawal:

The person is expected to have a stable withdrawal from alcohol or drugs.

The diagnosis must meet the criteria for the definition of substance use disorder or the most current revision of the DSM accompanied by evidence that some of the symptoms have persisted for at least one month or have occurred repeatedly over a longer period of time.

Medical Functioning—The person must meet all of the following criteria with regard to medical functioning:

No history of recent seizures or past history of seizures during withdrawal.

No clinical evidence of altered mental state as manifested by disorientation to self, alcoholic hallucinations, toxic psychosis, or altered level of consciousness (clinically significant obtun­dation, stupor, or coma).

The symptoms are due to withdrawal and not due to a general medical condition. Absence of any presumed new asymmetric or focal findings (i.e., limb weakness, clonus, spasticity, unequal pupils, facial asymmetry, eye ocular movement paresis, papilledema, or localized cerebellar dysfunction, as reflected in asymmetrical limb coordination).

Stable vital signs as interpreted by a physician. The person must also be without a previous history of complications from acute chemical substance withdrawal and judged to be free of a health risk as determined by a physician.

No evidence of a coexisting serious injury or systemic illness either newly discovered or progressive in nature.

Absence of serious disulfiram-alcohol (Antabuse) reaction with hypothermia, chest pains, arrhythmia, or hypotension.

Clinical condition that allows for a comprehensive and satisfactory assessment.

Family, Social, or Academic Dysfunction—The person must meet at least one of the following criteria with regard to family, social, or academic dysfunction:

The person’s social system and significant others are supportive of recovery to the extent that the person can adhere to a treatment plan and treatment service schedules without substantial risk of reactivating the person’s substance use disorder.

The person’s family or significant others are willing to participate in the outpatient withdrawal management treatment program.

The person may or may not have a primary or social support system to assist with immediate recovery, but the person has the social skills to obtain such a support system or to become involved in a self-help fellowship.

The person does not live in an environment where licit or illicit mood altering substances are being used. A person living in an environment where licit or illicit mood altering substances are being used may not be a candidate for this level of care.

Emotional and Behavioral Status—The person must meet all of the following criteria with regard to emotional and behavioral status:

The person is coherent, rational, and oriented for treatment.

The mental state of the person does not preclude the person’s ability to comprehend and under­stand the materials presented, and the person is able to participate in the outpatient withdrawal management treatment process.

Documentation exists in the medical record that the person expresses an interest to work toward outpatient withdrawal management treatment goals.

The person has no neuropsychiatric condition that places the person at imminent risk of harming self or others (e.g. pathological intoxication or alcohol idiosyncratic intoxication).

The person has no neurological, psychological, or uncontrolled behavior that places the person at imminent risk of harming self or others (depression, anguish, mood fluctuations, overreac­tions to stress, lower stress tolerance, impaired ability to concentrate, limited attention span, high level of distractibility, negative emotions, or anxiety).

The person has no documented DSM condition or disorder that, in combination with alcohol or drug use, compounds a pre-existing or concurrent emotional or behavioral disorder and presents a major risk to the person.

The person has no mental confusion or fluctuating orientation.

Chemical Substance Use—The person must meet the criteria in at least one of the following condi­tions with regard to recent chemical substance use:

The person’s chemical substance use is excessive, and the person has attempted to reduce or control it but has been unable to do so (as long as chemical substances are available).

The person is motivated to stop using alcohol or drugs and is in need of a supportive, structured treatment program to facilitate withdrawal from chemical substances.

9.9.2.2Continued Stay Criteria for Outpatient Withdrawal Management Treatment Services

A person is considered eligible for continued stay in the outpatient withdrawal management treatment service when the person meets at least one of the conditions for either chemical substance withdrawal or psychiatric or medical complications. Requests for extension of services must be received on or before the last date authorized or denied. The prior authorization unit will notify the provider by fax or electronic portal. If the date of the prior authorization unit determination letter is on or after the last date authorized or denied or if the last date falls on a holiday or weekend, the request for extension of services is due by 5 p.m. of the next business day. Documentation in the person’s medical record must support either Chemical Substance Withdrawal or Psychiatric or Medical Complications.

Chemical Substance Withdrawal

The person must meet at least one of the following conditions with regard to chemical substance withdrawal complications:

The person, while physically abstinent from chemical substance use, is exhibiting incomplete stable withdrawal from alcohol or drugs, as evidenced by psychological and physical cravings.

The person, while physically abstinent from chemical substance use, is exhibiting incomplete stable withdrawal from alcohol or drugs, as evidenced by significant drug levels.

Psychiatric or Medical Complications

The person must meet both of the following psychiatric or medical complication conditions:

The intervening medical or psychiatric event was serious enough to interrupt the outpatient withdrawal management treatment.

Evidence that the person is progressing in treatment again.

9.9.3Prior Authorization for Residential Withdrawal Management Treatment Services

Withdrawal management services may be prior authorized for up to 21 days. The level of service and number of prior authorized days will be based on the substances that are used, level of intoxication and withdrawal potential, and the person’s medical needs. Providers may submit requests for services using the Residential Withdrawal Management Authorization Request form.

Requests for withdrawal management services for persons who need more than 21 days of residential withdrawal management require review of documentation of medical necessity from a provider who is familiar with the person.

9.9.3.1Admission Criteria for Residential Withdrawal Management Treatment Services

The admission criteria for residential withdrawal management treatment services follow the existing Texas Department of Insurance licensure requirements and standards that are specified in 28 TAC §3.8001–§3.8030.

A person is eligible for admission to a residential withdrawal management service when they have failed two previous individual treatment episodes of outpatient withdrawal management or when they have a diagnosis that meets the criteria for the definition of substance use disorder or the most current revision of the DSM.

The person must also meet at least one of the following criteria for admission to residential withdrawal management treatment:

Chemical Substance Withdrawal—The person must have impaired neurological functions as evidenced by:

Extreme depression (e.g., suicidal).

Altered mental state with or without delirium as manifested by disorientation to self; alcoholic hallucinosis, toxic psychosis, altered level of consciousness, as manifested by clinically signif­icant obtundation, stupor, or coma.

History of recent seizures or past history of seizures on withdrawal.

The presence of any presumed new asymmetric or focal findings (i.e., limb weakness, clonus, spasticity, unequal pupils, facial asymmetry, eye ocular movement paresis, papilledema, or localized cerebellar dysfunction, as reflected in asymmetrical limb incoordination).

Unstable vital signs combined with a history of past acute withdrawal syndromes that are inter­preted by a physician to be indication of acute alcohol or drug withdrawal.

Evidence of coexisting serious injury or systemic illness, newly discovered or progressive.

Clinical condition (e.g., agitation, intoxication, or confusion) that prevents satisfactory assessment of the above conditions and indicates placement in residential withdrawal management service may be justified.

Neuropsychiatric changes of such severity and nature that they put the person at imminent risk of harming self or others (e.g., pathological intoxication or alcohol idiosyncratic intoxication).

Serious disulfiram-alcohol (Antabuse) reaction with hypothermia, chest pains, arrhythmia, or hypotension.

Major Medical Complications—The person must present a documented condition or disorder that, in combination with alcohol or drug use, presents a determined health risk (e.g., gastrointestinal bleeding, gastritis, severe anemia, uncontrolled diabetes mellitus, hepatitis, malnutrition, cardiac disease, hypertension).

Major Psychiatric Illness—The person must meet at least one of the following conditions with regard to major psychiatric illness:

Documented DSM condition or disorder that, in combination with alcohol or drug use, compounds a pre-existing or concurrent emotional or behavioral disorder and presents a major risk to the person.

Severe neurological and psychological symptoms: (e.g., anguish, mood fluctuations, overreac­tions to stress, lowered stress tolerance, impaired ability to concentrate, limited attention span, high level of distractibility, extreme negative emotions, or extreme anxiety).

Danger to others or homicidal.

Uncontrolled behavior that endangers self or others, or documented neuropsychiatric changes of a severity and nature that place the person at imminent risk of harming self or others.

Mental confusion or fluctuating orientation.

9.9.3.2Continued Stay Criteria for Residential Withdrawal Management Treatment Services

Eligibility for continued stay for residential withdrawal management services is based on the person meeting at least one of the criteria for chemical substance withdrawal, major medical complications, or major psychiatric complications.

Chemical Substance Withdrawal

The person must exhibit one of the following conditions with regard to chemical substance withdrawal complications:

Incomplete medically stable withdrawal from alcohol or drugs, as evidenced by documentation of at least one of the following conditions:

Unstable vital signs

Continued disorientation

Abnormal laboratory findings related to chemical dependency

Continued cognitive deficit related to withdrawal so that the person is unable to recognize alcohol or drug use as a problem

Laboratory finding that, based on the judgment of a physician, indicates that a drug has not suffi­ciently cleared the person’s system

Major Medical Complications

For major medical complications, the person must have documentation in the medical record that indicates that a medical condition or disorder (e.g., uncontrolled diabetes mellitus) continues to present a health risk and is being actively treated.

Major Psychiatric Complications

The person must meet at least one of the following with regard to major psychiatric complications:

Documentation in the medical record that a psychiatric condition or disorder that, in combination with alcohol or drug use, continues to present a major health risk, is actively being treated.

Documentation in the medical record that severe neurological or psychological symptoms have not been satisfactorily reduced but are actively being treated.

9.9.4Prior Authorization for Residential Treatment Services

Residential treatment may be prior authorized for up to 35 days per episode of care, with a maximum of two episodes of care per rolling six-month period and four episodes of care per rolling year.

Providers can use the Residential Substance Use Disorder Treatment Request form to submit authori­zation requests for persons who require additional episodes within the 6- or 12-month time frame.

9.9.4.1Admission Criteria for Residential Treatment Services

The admission criteria for residential treatment services follow the existing Texas Department of Insurance licensure requirements and standards that are specified in 28 TAC §3.8001-§3.8030.

The diagnosis must meet the criteria for the definition of substance use disorder or the most current version of the DSM.

All persons must meet the following conditions in order to receive treatment in a residential treatment service program:

Medical Functioning—The following must be present with regard to medical functioning:

Documented medical assessment following admission (except in instances where the person is being referred from an inpatient service) indicates that the person is medically stable and not in acute withdrawal.

The person is not bed-confined and has no medical complications that would hamper partici­pation in the residential service.

Family, Social, or Academic Dysfunction and Logistic Impairments—At least one of the following must be present with regard to family, social, or academic dysfunction and logistic impairments:

The person manifests severe social isolation or withdrawal from social contacts.

The person lives in an environment (social and interpersonal network) in which treatment is unlikely to succeed (e.g., a chaotic family dominated by interpersonal conflict, which under­mines person’s efforts to change).

The person’s family or significant others are opposed to the person’s treatment efforts and are not willing to participate in the treatment process.

Family members or significant others living with the person manifest current substance use disorders and are likely to undermine treatment.

Logistic impairments (e.g., distance from treatment facility or mobility limitations) preclude participation in an outpatient treatment setting.

Emotional and Behavioral Status—The person must meet all three of the following criteria with regard to emotional and behavioral status:

The person is coherent, rational, and oriented for treatment.

Mental state of the person does not preclude the person’s ability to comprehend and understand the materials presented and participate in rehabilitation or the treatment process.

The medical record contains documentation that with continued treatment the person will be able to improve or internalize the person’s motivation toward recovery within the recommended length of stay time frames (e.g., becoming less defensive, verbalizing, and working on alcohol or drug related issues). Interventions, treatment goals, or contracts are in place to help the person deal with or confront the blocks to treatment (e.g., family intervention or employee counseling confrontation).

Chemical Substance Use—The person must meet at least one of the following criteria with regard to chemical substance use:

The person’s chemical substance use is excessive, and the person has attempted to reduce or control it but has been unable to do so (as long as chemical substances are available).

Virtually all of the person’s daily activities revolve around obtaining, using, or recuperating from the effects of chemical substances, and the person requires a secured environment to control the person’s access to chemical substances.

9.9.4.2Residential Treatment Services for Adolescents

Adolescents who are 13 through 17 years of age must meet all above conditions and the following condi­tions in order to receive treatment in an adolescent residential treatment service program:

At the maturation level, the adolescent must meet both of the following criteria:

The adolescent is assessed as manifesting physical maturation at least in middle adolescent range (i.e., post-pubescent).

The history of the adolescent reflects cognitive development of at least 11 years of age.

The adolescent must display at least one of the following with regard to developmental status:

Documented history of inability to function within the expected age norms despite normal cognitive and physical maturation (e.g., refusal to interact with family members, overt prosti­tution, felony, or other criminal charges).

A recent history of moderate to severe conduct disorder, as defined in the DSM, or impulsive disregard for social norms and rights of others.

Documented difficulty in meeting developmental expectations in a major area of functioning (e.g., social, academic, or psychosexual) to an extent that interferes with the capacity to remain behaviorally stable.

9.9.4.3Continued Stay Criteria for Residential Treatment Services

At least one of the following conditions must be present for continued stay in a residential treatment program:

Chemical Dependency Rehabilitation or Treatment Complications:

The person recognizes or identifies with the severity of the alcohol or drug problem but demon­strates minimal insight into the person’s defeating the use of alcohol or drugs. However, documentation in the medical record indicates that the person is progressing in treatment.

The person identifies with the severity of the alcohol or drug problem and manifests insight into the person’s personal relationship with mood-altering chemicals, yet does not demonstrate behaviors that indicate the development of problem-solving skills that are necessary to cope with the problem.

The person would predictably relapse if moved to a lesser level of care.

Psychiatric or Medical Complications:

Documentation in the medical record indicates an intervening medical or psychiatric event that was serious enough to interrupt rehabilitation or treatment, but the person is again progressing in treatment.

Documentation in the medical record indicates that the person is being held pending an immediate transfer to a psychiatric, acute medical service, or inpatient withdrawal management alcohol or drug service.

9.9.5Prior Authorization for Outpatient Treatment Services

Prior authorization for outpatient treatment services beyond the annual limitation of 135 units of group services and 26 hours of individual services per calendar year, may be considered with documentation supporting medical necessity for continued treatment services. Providers may submit requests requiring additional services using the Outpatient Substance Use Disorder Counseling Extension request form.

Requests must be submitted before providing the extended services. The documentation must include the following information:

The person is meeting treatment goals.

The person demonstrates insight and understanding into relationship with mood altering chemicals, but continues to present with issues addressing the life functions of work, social, or primary relationships without the use of mood-altering chemicals.

The person is physically abstinent from chemical substance use, but remains mentally preoccupied with such use to the extent that the person is unable to adequately address primary relationships, or social or work tasks, but there are indications that, with continued treatment, the person will effec­tively address these issues.

Although other psychiatric or medical complications exist that affect the person’s treatment, there is documentation to support the person continues to show treatment progress and there is evidence to support the benefits of continued treatment.

9.10Documentation Requirements

To facilitate determination of medical necessity and avoid unnecessary denials, the provider must provide correct and complete information, including documentation for medical necessity for the services requested. The provider must maintain documentation of medical necessity in the person’s medical record.

The requesting provider may be asked for additional information to clarify or complete a request.

Retrospective review may be performed to ensure documentation supports the medical necessity of the requested services.

9.11Reimbursement and Limitations

9.11.1Withdrawal Management Services

Inpatient hospital-based withdrawal management is reimbursed by the reimbursement methodology specific to the inpatient hospital. Separate reimbursement may be provided for physician services performed during an inpatient stay.

Residential withdrawal management and treatment services are considered outpatient services for the purposes of reimbursement and should be billed accordingly.

Residential withdrawal management services (procedure codes H0012, H0031, S9445, and T1007) are limited to once per day, any provider.

Residential withdrawal management services (procedure codes H0031, H0047, S9445, or T1007) will be denied if billed without lead procedure code H0012 on the same day, same provider.

Room and board for residential withdrawal management and treatment (procedure code H0047) is limited to once per date of service, any provider. Procedure code H0047 is reimbursed for persons who are 21 years of age and older as an access-based fee and as an informational detail for persons who are 20 years of age and younger.

Outpatient withdrawal management (procedure codes H0016, H0050, and S9445) is limited to once per day, any provider and may be reimbursed on the same date of service as outpatient SUD treatment by the same or different provider when medically necessary and identified in the person’s treatment plan.

Outpatient withdrawal management (procedure codes H0050 and S9445) will be denied if billed without lead procedure code H0016 on the same day, same provider.

Separate reimbursement may be provided for physician services during a residential stay.

9.11.1.1Treatment Services

Outpatient treatment services are limited to 135 units of group counseling and 26 hours of individual counseling per calendar year when provided by a CDTF. Providers may submit requests requiring additional services using the Outpatient Substance Use Disorder Counseling Extension request form.

Residential treatment services (procedure code H2035) are limited to one per day and are allowed up to a maximum of 35 days.

Outpatient treatment (procedure codes H0004 and H0005) will be denied if billed on the same date of service as residential withdrawal management (procedure codes H0012, H0031, H0047, S9445, and T1007) or residential treatment (procedure code H2035).

Procedure code H0047 will be denied if billed without lead procedure code H2035 or H0012 on the same day, same provider.

Refer to:  Subsection 6.4.1, “National Correct Coding Initiative (NCCI) Guidelines” in “Section 6: Claims Filing” (Vol. 1, General Information) for information about NCCI MUE guidelines.

9.11.2MAT Services

Claims billed for MAT must include the person’s substance use disorder diagnosis. MAT billing may include billing for induction as well as maintenance.

Methadone administration (procedure code H0020) for opioid disorder must be submitted with the following modifiers:

When methadone is administered with supervision in a facility the provider must submit claims using the UA modifier to indicate the facility administered doses

When methadone is dispensed without supervision as a take home dose the provider must submit claims using the U1 modifier to indicate take home doses

Methadone provided in an outpatient setting (procedure code H0020) is limited to once per date of service, by any provider and is reimbursed at a fixed daily rate. Reimbursement for procedure code H0020 with modifier U1 is limited to a quantity of 30 per 30 days, any provider.

Providers that allow take-home doses must submit procedure code H0020 with modifier U1 for each date of service for which a take-home dose is dispensed. Methadone that is dispensed for unsupervised take-home use should be dispensed in alignment with the federal opioid treatment standards in Title 42 Code of Federal Regulations (CFR) §8.12.

Methadone administration (procedure code H0020) submitted without a modifier will be denied.

Non-methadone (e.g., buprenorphine) administration (procedure code H0033) for opioid disorder must be submitted with the following modifiers:

When non-methadone is administered with supervision in a facility the provider must submit claims using the modifier UA to indicate opioid disorder treatment facility doses or claims will be denied

When non-methadone is dispensed without supervision as a take home dose the provider must submit claims using the modifier U1 to indicate opioid disorder take home doses or claims will be denied

Non-methadone provided in an outpatient setting (procedure code H0033) is limited to once per date of service, by any provider. Reimbursement for procedure code H0033 with modifier U1 is limited to a quantity of 30 per 30 days, any provider.

Providers that allow take-home doses must submit procedure code H0033 with modifier U1 for each date of service for which a take-home dose is dispensed. Non-methadone that is dispensed for unsuper­vised take-home use should be dispensed in alignment with the federal opioid treatment standards in Title 42 Code of Federal Regulations (CFR) §8.12.

When non-methadone is administered in a facility for a non-opioid treatment, providers must use procedure code H0033 to indicate non-opioid treatment in a facility.

Non-methadone administration (procedure code H0033) submitted without a modifier will be denied. Physician and physician extenders may be reimbursed separately using the appropriate evaluation and management procedure codes.

Injectable administration is considered part of MAT and is not reimbursed separately. Procedure code 96372 will be denied when billed for the same date of service by any provider as procedure code H0020 or H0033.

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.

Note:Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column.

9.12Claims Filing

Claims for SUD 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 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).

10 Collaborative Care Model (CoCM)

The Collaborative Care Model (CoCM) is a systematic approach to the treatment of behavioral health conditions (mental health or substance use) in primary care settings. The model integrates the services of behavioral health care managers (BHCMs) and psychiatric consultants with primary care provider (PCP) oversight to proactively manage behavioral health conditions as chronic diseases, rather than treating acute symptoms.

CoCM services are benefits of Texas Medicaid for persons of all ages who have a mental health or substance use condition to include a pre-existing or suspected mental health or substance use condition, as determined by the PCP, i.e., physician, physician assistant, or nurse practitioner.

CoCM services must be provided under the direction of the PCP and are benefits when provided in an office, outpatient hospital, inpatient hospital, skilled nursing facility or intermediate care facility, extended care facility or other locations.

Refer to:  Subsection 9.3, “Collaborative Care Model (CoCM)” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information.

11 Claims Resources

Refer to the following sections or forms when filing claims:

Resource

Location

Acronym Dictionary

“Appendix C: Acronym Dictionary” (Vol. 1, General Information)

Automated Inquiry System (AIS)

Subsection A.10, “TMHP Telephone and Fax Communication” in “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information)

CMS-1500 Paper Claim Filing Instructions

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

State, federal, and TMHP contact information

“Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information)

TMHP Electronic Data Interchange (EDI) information

“Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information)

12 Contact TMHP

Providers can call the TMHP Contact Center at 1-800-925-9126 from Monday through Friday, 7 a.m. to 7 p.m., Central Time.

13 Forms

The following linked forms can also be found on the Forms page of the Provider section of the TMHP website at www.tmhp.com:

Forms

Outpatient Withdrawal Management Authorization Request Form

Outpatient Substance Use Disorder Counseling Extension Request Form

Outpatient Mental Health Services Request Form

Residential Withdrawal Management Authorization Request Form

Residential Substance Use Disorder Treatment Request Form

14 Claim Form Examples

The following linked claim form examples can also be found on the Claim Form Examples page of the Provider section of the TMHP website at www.tmhp.com:

Claim Form Examples

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

Case Management for Children and Pregnant Women

Licensed Clinical Social Worker (LCSW)

Licensed Marriage and Family Therapist (LMFT)

Licensed Professional Counselor (LPC)

Mental Health Case Management

Psychologist

Psychotherapy with Evaluation and Management (E/M)