gsa160

Required to use review or authorization for
mental health and substance abuse

AZBH | CO | IABH | MABH | MN | NE | ORMH | TX | VA | WI

AZBH

"Inpatient Hospital...
Service Limitations: ...
3. Prior authorization with a competed certification of need, must be obtained for inpatient hospital services prior to admission…

Inpatient Psychiatric Facility for Individuals Under Age 21...
Service Limitations...
3. Prior authorization with a competed certification of need, must be obtained for inpatient services provided in an inpatient psychiatric facility for individuals under age 21...
7. Bed Holds for Title XIX members must be prior authorized. Authorization for bed holds will be limited, for each occurrence, as follows:
- Therapeutic leave days (home pass, prepare for discharge): up to 9 days per contract year
- Short term hospitalization leave: up to 12 days per contract year...

Institutions for Mental Diseases (IMD)...
Service Limitations...
3. Prior authorization with a competed certification of need, must be obtained for inpatient psychiatric services provided in an IMD...
9. Bed Holds for Title XIX members require prior authorization. Authorization for bed holds will be limited, for each occurrence, as follows:
- Therapeutic leave days (home pass, prepare for discharge): up to 9 days per contract year
- Short Term hospitalization leave: up to 12 days per contract year…

Laboratory and radiology Services for Diagnosis and Medication Regulation...
Service Limitations: ...
2. Laboratory and radiology tests performed for diagnosis and psychotropic medication regulation must be authorized for behavioral health related illnesses only." Arizona Behavioral Health Contract, BHS Guide, pages 1-3, 18.

"EXHIBIT A
COVERED SERVICES…
A.16 Mental Health And Substance Abuse Services
Mental Health Services:
a. Inpatient or partial hospitalization - Upon admission to a health care facility for services for the diagnosis and treatment of a mental illness: the period of stay for which benefits are payable shall be at least forty-five days for inpatient care or ninety days for partial hospitalization during a Contract Year with a properly authorized Referral…." Colorado Contract, Exhibit A, page 31.

IABH

"42.2 AUTHORIZING SUBSTANCE ABUSE SERVICES...
For Medicaid enrollees, the Contractor may require authorization for substance abuse treatment services at the higher levels of service in accordance with Attachment entitled Substance Abuse services...

42.3 APPLYING, DEVELOPING, IMPLEMENTING AND UPDATING UTILIZATION MANAGEMENT GUIDELINES...
The Contractor may limit payment to only those services which the Contractor has authorized or exempted from authorization under guidelines which the Contractor has developed and the Departments have approved…" Iowa Behavioral Health Contract, pages 28-29.

"ATTACHMENT ON MENTAL HEALTH SERVICES
Covered Mental Health Services...
* In the following instances, the Iowa Plan Contractor shall monitor and reimburse non-psychiatric physicians. The Contractor may implement policies and procedures which limit both the credentialing required for non-psychiatric physicians and the scope of services for which they may be reimbursed:
     physical examinations performed for a patient being admitted for mental health reasons
     to an inpatient setting, providing such inpatient admission was authorized according to
     policies established by the Contractor…" Iowa Behavioral Health Contract, pages 79-80.

"Mental Health Services Not Requiring Authorization
Treatment authorization will not be required for the following mental health services delivered to Medicaid enrollees of the Iowa Plan: individual therapy; group therapy; medication management; initial evaluation; and targeted case management services. For all other Medicaid mental health services and supports, pre authorization through MBC of Iowa will be required. Frequency of concurrent review will depend on the level and intensity of services being provided, as well as the client's clinical and environmental history." Iowa Behavioral Health Contract, page 83.

"Payment for Emergency Room Services (Section 5.9.4 of the RFP)...
For emergency room services provided to an Iowa Plan enrollee by a network or non-network provider when psychiatric or substance abuse diagnoses are the primary condition, the Contractor may: ...
* require authorization of any services beyond those provided in the emergency room (e.g. 23-hour observation; admission to a psychiatric ward, crisis counseling or stabilization)…" Iowa Behavioral Health Contract, page 90.

MABH

"3.2 Delivery and Coordination of Services
The Contractor shall: ...
G. require that Providers file prior authorization requests for continuing outpatient services sufficiently in advance of the requested start date for services…" Massachusetts MH/SAP Contract, Appendix A, pages 21-22.

"Section 6.1.1. Care Management Services… At a minimum, the HEALTH PLAN's Care Management system must incorporate the following elements…
G. For MinnesotaCare Enrollees who are hospitalized, the HEALTH PLAN's responsibility for certifying the inpatient admission must include a Medical Necessity review of the entire confinement, not just the portion covered by the HEALTH PLAN." Minnesota Contract, pages 49-50.

"13.49.1 Emergency Room Services for MH/SA Services:
At the time a MH/SA provider initiates an evaluation and/or treatment for the client, the medical/surgical plan is no longer responsible for MH/SA related service. Authorization for MH/SA services from that point forward must be obtained from the MH/SA plan.

13.49.2 Admissions for 24-Hour Observation: ...
Authorization for the admission must be obtained from the MH/SA plan...

13.49.3 Chemical Detoxification Services and Substance Abuse Treatment: ...
Authorization for hospital admissions must be obtained from the MH/SA plan, if the client is participating in the MH/SA component of the NHC...
Allowable substance abuse services for a client must be authorized by the MH/SA plan, if the client is participating in the MH/SA component of the NHC.

13.49.4 History and Physical (H&P) Exams for Inpatient Admissions for MH/SA Services: ...The physician completing the H&P must obtain authorization from the MH/SA plan, if the client is participating in the MH/SA component of the NHC." Nebraska Contract, page 98.

ORMH

"i. Long Term Psychiatric Care (LTPC)
(1) If Contractor believes that an OMAP Member is Appropriate for LTPC, Contractor shall request a LTPC determination from the applicable Division. The Division staff member shall render a determination within three working days of receiving a completed request if the OMAP Member is 18 or more years of age or within seven working days of receiving a completed request if the OMAP Member is under age 18." Oregon Mental Health Contract, page 19.

"6.6 BEHAVIORAL HEALTH CARE SERVICES - SPECIFIC REQUIREMENTS...
6.6.11.1 HMO cannot deny, reduce or controvert the medical necessity of any court ordered inpatient psychiatric service for Members under age 21. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination...
6.6.12 HMO must comply with 28 TAC §§3.8001 et seq., regarding utilization review of chemical dependency treatment." Texas Contract, pages 38, 40.

"28. Psychiatric Hospitals
For Medicaid Enrollees...
All inpatient mental health admission for individuals of any age to general acute care hospitals shall be approved by the Contractor using its own prior authorization criteria as approved by the Department or the Department's criteria. All inpatient psychiatric admissions for individuals under twenty-one (21) and over sixty-four (64) years of age to freestanding psychiatric facilities shall also be approved by the Contractor using its own prior authorization criteria as approved by the Department." Virginia Contract, page 51.

"ADDENDUM II
POLICY GUIDELINES FOR MENTAL HEALTH/SUBSTANCE ABUSE AND COMMUNITY
HUMAN SERVICE PROGRAMS...

2. MENTAL HEALTH/SUBSTANCE ABUSEASSESSMENT REQUIREMENTS - The HMO shall further assure that authorization for mental health/substance abuse treatment to its enrollees shall be governed by the findings of an assessment performed promptly by the HMO upon request of a client or referral from a physician. Such assessments shall be conducted by qualified staff in certified programs, who are experienced in mental health/substance abuse. All denials of service and the selection of particular modalities of service shall be governed by the findings of this assessment and the medical necessity of treatment. The lack of motivation of an enrollee to participate in treatment shall not be considered a factor in determining medical necessity and may not be used as a rationale for withholding or limiting treatment of a client/enrollee." Wisconsin Contract, Addendum II, pages 79-80.