Psychology/Counseling Prior Authorization A Brief Overview 1
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 2
No PA Required… Testing and Assessment l The initial 4 hours of therapy l Medicare is primary payer BUT, l PA is required when there is a primary insurance l 3
Authorized Hours Authorized hours are based on l The age of the participant l The type of therapy requested l ME code l Diagnosis 4
4 Non-PA Hours l l l 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 5
Adults Prior Authorization (PA) was implemented for MO Health. Net eligible adults November 01, 2004 l Adult PAs are authorized on a calendar year beginning January 01 and ending December 31 l 6
Non-State Custody Children The PA process for all MO Health. Net eligible children not in state custody was implemented May 01, 2005 l PAs for these children are authorized August 01 through July 31 l 7
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 l PAs for these children are authorized on a calendar year January 01 through December 31 l 8
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 l If the ME code is anything other than one of those noted above PA is required. l 9
Residential Care l 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. 10
Services off the Residential Facility Site l 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. 11
Notification of PA l l 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. 12
Documentation l l l 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 13
Documentation Consists of: l l the Prior Authorization Request form the current Assessment the current Treatment Plan the last 3 Progress Notes for therapy being requested 14
Current is: 6 months old or less when the child is 12 years of age or younger l 1 year old or less when the participant is 13 years of age or older l 15
Who Requests the PA l l l 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 16
Submitting the PA Request l Call the Psych Help Desk before using all of the 4 non-PA hours l (866) 771 -3350 Fax or mail documentation for continued therapy before all authorized hours have been used l Call before the next PA cycle period starts l 17
Services Not Requiring PA A PA is not required for: § Testing § Assessment § Pharmacologic management (90862) § Inpatient services § Crisis Intervention § Medicare Primary 18
Non-Covered ME codes Some ME codes have limited coverage l Even with an authorization therapy services will not pay l ME codes – 58, 59, 80, 82, 89 l 19
Thank you Provider Education Unit (573) 751 -6683 20
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