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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 therapyMedicare 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 participantThe type of therapy requestedME codeDiagnosis

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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 (866) 771-3350 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 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

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Submitting the PA Request

Call the Psych Help Desk before using all of the 4 non-PA hours

(866) 771-3350Fax 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 coverageEven with an authorization therapy

services will not payME codes – 58, 59, 80, 82, 89

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Thank you

Provider Education Unit

(573) 751-6683