Psychology/Counseling Prior Authorization

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Psychology/CounselingPrior Authorization

• A Brief Overview

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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

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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

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Authorized Hours

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

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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

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Adults

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

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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

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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

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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.

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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.

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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.

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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 [phone] to obtain a new
  authorization. Documentation may not be required
  at this time.

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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

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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

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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

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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 groups
  NPI
• FQHCs and RHCs utilizing the services of an LPC
  should obtain the PA under a non-FQHC or non-RHC
  group NPI

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Submitting the PA Request

• Call the Psych Help Desk before using all of the
  4 non-PA hours
• [phone]
• Fax or mail documentation for continued therapy
  before all authorized hours have been used
• Call before the next PA cycle period starts

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Services Not Requiring PA

• A PA is not required for
• Testing
• Assessment
• Pharmacologic management (90862)
• Inpatient services
• Crisis Intervention
• Medicare Primary

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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

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Thank you

• Provider Education Unit
• [phone]