PURPOSE: This rule establishes the regulatory basis for the program requirements of the MO HealthNet behavioral health services program.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

1. (1) Administration. The MO HealthNet behavioral health services program shall be administered by the Department of Social Services, MO HealthNet Division (MHD). The services covered and not covered, the prior authorization requirements, and the limitations under which services are covered shall be determined by MHD and shall be included in the MO HealthNet Behavioral Health Services Provider Manual, September 1, 2023, and the Physician Provider Manual, September 1, 2023, which are incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at https://mydss.mo.gov/mhd/provider-manuals. This rule does not incorporate any subsequent amendments or additions. Behavioral health services shall include only those which are clearly shown to be medically necessary.

2. (2) Persons Eligible. The MO HealthNet Program pays for approved MO HealthNet behavioral health services when furnished within the provider’s scope of practice. The participant must be eligible on the date the service is furnished. Participants may have specific limitations for behavioral health services according to the type of assistance for which they have been determined eligible. It is the provider’s responsibility to determine the coverage benefits for a participant based on their type of assistance as outlined in the provider manual. The provider shall ascertain the patient’s MO HealthNet and managed care or other lock-in status before any service is performed. The participant’s MO HealthNet eligibility shall be verified in accordance with methodology outlined in the provider manual. Eligible participants shall have access to non-pharmaceutical behavioral health services when they are determined medically necessary using the appropriate diagnostic criteria as follows:

   1. (A) For individuals aged six (6) years and over, providers shall use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TRTM), which is incorporated by reference in this rule as published by American Psychiatric Association Publishing, 800 Maine Avenue SW, Suite 900, Washington, DC 20024, March 16, 2022. A copy of the DSM-5- TRTM is available for review at the MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109. This rule does not incorporate any subsequent amendments or editions;
   2. (B) For individuals under the age of six (6) years, it is recommended and preferred that providers use the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-5TM), which is incorporated by reference in this rule as published by Zero to Three, 1255 23rd Street NW, Suite 350, Washington, DC 20037, December 8, 2016. A copy of the DC:0-5TM is available for review at the MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109. This rule does not incorporate any subsequent amendments or editions; and
   3. (C) Use of the DSM-5-TRTM will be allowed when assessing children zero through five (0–5) years of age until January 1, 2029, at which time the DC:0-5TM will become required.

3. (3) Provider Participation. To be eligible to participate as a MO HealthNet provider of behavioral health services, a provider must meet the qualifications specified by the state agency for his or her profession and be an enrolled MO HealthNet provider.

   1. (A) The enrolled MO HealthNet provider shall comply with the following requirements:

      1. 1. Maintain adequate documentation and adequate re-

cords in accordance with 13 CSR 70-3.030(2)(A); and

1. 2. On request furnish to the MO HealthNet agency, the

Medicaid Audit and Compliance Unit, or State Medicaid Fraud Control Unit any information regarding payments claimed by the provider for furnishing services under the plan.

1. (4) The prior authorization requirements for behavioral health services shall be reviewed at least every twelve (12) months by the MO HealthNet Division.
2. (5) The prior authorization process will not apply to emergency and inpatient hospital interventions.

AUTHORITY: sections 208.201 and 660.017, RSMo 2016.* Original rule filed Nov. 14, 2003, effective June 30, 2004. Amended: Filed Oct. 30, 2007, effective April 30, 2008. Amended: Filed June 2, 2008, effective Nov. 30, 2008. Amended: Filed Oct. 31, 2008, effective May 30, 2009. Amended: Filed Sept. 26, 2013, effective March 30, 2014. Amended: Filed Oct. 1, 2018, effective May 30, 2019. Amended: Filed Aug. 16, 2024, effective April 30, 2025. *Original authority: 208.201, RSMo 1987, amended 2007, and 660.017, RSMo 1993, amended 1995.