Psychology/Counseling Prior Authorization

1. Psychology/CounselingPrior Authorization A Brief Overview

2. Prior Authorization PA must be obtained regardless of age, ME code or placement when providing… • Any service for a child under the age of 3 • Family Therapy without the Patient Present • Interactive Assessment or Interactive Therapy

3. No PA Required… • Testing and Assessment • The initial 4 hours of therapy • Medicare is primary payer BUT, • PA is required when there is a primary insurance

4. Authorized Hours Authorized hours are based on • The age of the participant • The type of therapy requested • ME code • Diagnosis

5. 4 Non-PA Hours • The initial 4 hours of therapy are allowed one time • These hours are not given at the start of each PA cycle • There must be at least 365 days since the provider last saw the participant to receive the 4 non-PA hours again

6. Adults • Prior Authorization (PA) was implemented for MO HealthNet eligible adults November01, 2004 • Adult PAs are authorized on a calendar year beginning January 01 and ending December 31

7. Non-State Custody Children • The PA process for all MO HealthNet eligible children not in state custody was implemented May 01, 2005 • PAs for these children are authorized August 01 through July 31

8. State Custody Children • The PA process for children in state custody with a Medical Eligibility (ME) code 07, 08, 37, 38 was implemented January 02, 2008 • PAs for these children are authorized on a calendar year January 01 through December 31

9. Medical Eligibility Codes • ME codes 29, 30, 35, 36, 50, 51, 52, 53, 54, 56, 57, 63, 64, 66, 68, 69, and 70 are state custody codes and do not require PA • If the ME code is anything other than one of those noted above PA is required.

10. Residential Care • Children in state custody residing at a residential care facility do not require PA for their psychology/counseling services when the services are provided at the facility.

11. Services off the Residential Facility Site • Services provided to a child residing at or under the care and management of a residential facility do not require PA when performed off site IF the ME code is 07, 08, 37, or 88. The services must be billed with a TJ modifier. PA is required for all other ME codes and the TJ modifier must not be used.

12. Notification of PA • Providers are notified through a bulletin, an email blast, or both approximately 4-6 weeks prior to the PA period ending. • At that time providers may begin calling the Psych Help Desk (866) 771-3350 to obtain a new authorization. Documentation may not be required at this time.

13. Documentation • Documentation must always be submitted for: • Any service for a child under the age of 3 (clinical justification) • Family Therapy without the Patient Present • Interactive Assessment or Interactive Therapy • Continued therapy requests after the initial authorization

14. Documentation Consists of: • the Prior Authorization Request form • the current Assessment • the current Treatment Plan • the last 3 Progress Notes for the therapy being requested

15. Current is: • 6 months old or less when the child is 12 years of age or younger • 1 year old or less when the participant is 13 years of age or older

16. Who Requests the PA • Independent providers must request the PA under their individual NPI • Providers performing services through a group practice should obtain the PA under the group’s NPI • FQHCs and RHCs utilizing the services of an LPC should obtain the PA under a non-FQHC or non-RHC group NPI

17. Submitting the PA Request • Call the Psych Help Desk before using all of the 4 non-PA hours • (866) 771-3350 • Fax or mail documentation for continued therapy before all authorized hours have been used • Call before the next PA cycle period starts

18. A PA is not required for: Testing Assessment Pharmacologic management (90862) Inpatient services Crisis Intervention Medicare Primary Services Not Requiring PA

19. Non-Covered ME codes • Some ME codes have limited coverage • Even with an authorization therapy services will not pay • ME codes – 58, 59, 80, 82, 89

20. Thank you Provider Education Unit (573) 751-6683