Medicaid outpatient behavioral health therapy process for over 30 visits
Originally published Dec. 20, 2017. Updated Feb. 22, 2018, to clarify the processes for requesting the initial 30 outpatient visits and requesting additional visits.
Effective October 1, 2017, the 20 outpatient session limit on behavioral health outpatient therapy services provided by Medicaid Health Plans was eliminated.
Priority Health: Outpatient care for mild to moderate mental health needs
Priority Health continues to be responsible for providing outpatient behavioral health therapy services for Medicaid members with mild to moderate mental health needs. This includes members experiencing or demonstrating mild to moderate psychiatric symptoms or signs of sufficient intensity to cause subjective distress or mildly disordered behavior, with minor or temporary functional limitations or impairments (self-care/daily living skills, social/interpersonal relations, educational/vocational role performance, etc.) and minimal clinical (self/other harm risk) instability.
Community Mental Health: Care for severe needs
Members with a severe mental illness, serious emotional disturbance (children and adolescents) or those with a development disability should be referred to Community Mental Health (CMH) for all behavioral health services. Members appropriate for CMH services often have substantial impairment in their ability to perform daily living activities including; bathing, dressing, personal hygiene, preparing meals, housework and employment, etc. For children and adolescents, this includes interference in achievement or maintenance of developmentally appropriate social, behavioral, cognitive, communicative or adaptive skills.
New methodology for authorizing 30 visits
Our Behavioral Health team reviews cases of mild to moderate symptoms for clinical appropriateness for services. Starting Jan. 1, 2018, they will enter authorizations for an initial 30 visits that will expire at the end of the calendar year. Since treatment for mild to moderate conditions is generally short-term in nature, those 30 visits could span over any length of time, so the health plan uses end of the calendar year as the authorization expiration to allow claims to process correctly.
Substance abuse treatment
All substance abuse treatment services continue to be the responsibility of CMH providers. The Priority Health behavioral health team has established a process to review clinical appropriateness for services and determine the amount and duration of outpatient services needed to address behavioral health concerns effectively. Requests for outpatient therapy services continue to be required.
If functional impairment of the member is significant and needs are substantial and long-term in nature, or the member is already receiving case management, supports coordination, or home-based services from CMH, members should be referred to their local CMH provider.
Members already in outpatient therapy
Medicaid members already receiving outpatient therapy services will need to have an updated Behavioral Health Outpatient Authorization Request Form submitted to Priority Health by February 1, 2018. Behavioral Health staff will create a new authorization that will allow claims to process correctly. This form is currently being created and will be posted to the Provider Center soon.
Treatment beyond 30 visits
We follow a clinical review process when additional outpatient services are requested beyond the initial threshold of 30 visits. The purpose of this process is to review the clinical needs of the member and determine if specialty mental health services from CMH would be more appropriate.
When the member has completed at least 26 sessions and is determined to meet medical necessity criteria for outpatient therapy services, providers must fax us the following clinical information with the request for additional sessions:
- Behavioral Health Outpatient Clinical Review form (Soon to be created)
- Initial assessment
- Treatment plan
- Summary of progress
Behavioral Health clinical staff will follow up with providers if additional information is needed or will assist with coordinating on-going treatment with the local CMH provider as necessary.
Medicaid Provider Manual Go to the "Behavioral Health and Intellectual & Developmental Disability Supports and Services" section, then Section 1.6, Beneficiary Eligibility