Medicaid outpatient therapy clinical review process change Nov. 1
We've simplified the outpatient behavioral health clinical review process for Medicaid members. Effective November 1, 2018, if a member is not currently receiving services from local Community Mental Health (CMH) or seeking substance use disorder services, we will approve service requests without a limit on sessions.
Priority Health continues to be responsible for providing outpatient behavioral health therapy services for Medicaid members with mild to moderate mental health needs. Priority Health's behavioral health team has established a process that allows the health plan to do an initial screen using CareConnect360 to determine if a member is currently involved with CMH receiving care management services for a severe mental illness, developmental delay, serious emotional disturbance, or seeking any level of substance use disorder services. Members who are currently receiving services are referred back to CMH to coordinate their care.
What you need to do
Initial requests for outpatient therapy services continue to be required. Providers will no longer need to request additional mental health outpatient therapy services. Priority Health will conduct outlier reviews whereby clinical documentation will be requested from providers to ensure services are clinically appropriate for coverage by the health plan. Providers are responsible for ensuring that members with a severe persistent mental illness, serious emotional disturbance or development disability are referred to CMH for ongoing care.