In an effort to improve access to care for clients and administrative burden for providers, effective June 1, 2014, Smoky Mountain LME/MCO will no longer require prior authorization for individual, family or group therapy services. As a result of this change, providers will no longer need to submit authorization requests beyond the previously unmanaged limits of eight (8) visits for Adults (ages 21 and up) and sixteen (16) visits for ages for Children and Adolescents below age 21.

Evidenced- based practice indicates that individual and family therapy should be provided no more than 1-3 times time a week, with titration to bi-weekly and/or monthly. Episode of care and desired treatment outcomes for this level of care is typically obtained within six months. Group therapy may be indicated 1-2 times a week for 8-12 weeks. Outpatient services are expected to be short term and recovery focused. Any combination of these services at a higher intensity may trigger clinical review.

While prior authorization is not required for these basic benefit services, utilization of basic benefits will be monitored. Higher utilization may be subject to post payment reviews for medical necessity and paybacks as indicated. Post service monitoring may include desk review, on site visits, paid claims review or a combination. Basic benefits are typically not indicated for clients receiving enhanced services except in specific circumstances outlined in Clinical Coverage Policies. SM LME/MCO will monitor for stacked services where exclusionary criteria apply.

Psychological testing remains limited to 16 unmanaged visits per calendar year for clients under the age of 21, and 8 unmanaged visits per calendar year for clients ages 21 and over. Visits beyond the calendar year limits will continue to require prior authorization. Although authorization is not required for the individual and family therapy, these services will still count toward the basic benefit unmanaged limit that will be applied when testing services are requested.

Providers are responsible for understanding billing edits and limitations of services as indicated in the National Correct Coding Initiative Policy Manual for Medicaid Services (Coding Policy Manual) and Clinical Coverage Policy 8C. Currently, Clinical Coverage policy limits testing to 5 units/sessions per day.

This change in management of basic benefit therapy will streamline administrative responsibility for providers and enable additional time for treatment and coordination of care. Providers continue to be responsible for maintaining documentation as specified in the Records and Documentation manual and may be subject to routine monitoring. These items include:

• Written consent for treatment
• Comprehensive clinical assessment/update
• Individualized treatment plan with client and provider signatures. (Parent must also sign for minors when the services are not provided under the direction and supervision of a physician)
• Individual Service/Progress Notes
• Clients under age 21: Verbal or written individual referral. Copy of the written order for service after the 16th visit (N/A for physician or PhD psychologists)
• Clients aged 21 and over: Copy of the written order for service after the 8th visit (N/A for physician or PhD psychologists)

Note that state-funded individual and family therapy services will remain a basic benefit subject to the 8/16 unmanaged visit rules.

Should you have any questions or wish to discuss further, please contact a Care Manager at 1-866-990-9712 option 5.

Print this article