PURPOSE: This rule establishes the process by which non-pharmaceutical behavioral health services will be prior authorized in order to be reimbursable by the MO Health- Net Program. The prior authorization process will serve as a utilization management measure allowing payment only for this treatment and services (interventions) that are medically necessary, appropriate and cost-effective, and to reduce over-utilization or abuse of services without compromising the quality of care to MO HealthNet participants.

PUBLISHER’S NOTE The secretary of state has determined that the publication of the entire text of the material which 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) This rule establishes a MO HealthNet non-pharmaceutical behavioral health services prior authorization advisory committee in the Department of Social Services, MO HealthNet Division. The advisory committee shall be composed of practicing clinicians who are also licensed in their respective fields. The advisory committee shall be composed of three (3) practicing psychiatrists, three (3) practicing psychologists, three (3) practicing licensed clinical social workers (LCSW), and three (3) practicing licensed professional counselors (LPC). All members shall be appointed by the director of the Department of Social Services. The members of the committee shall represent a broad spectrum of practice including, but not limited to, those providing services to adults, children, children in custody, the geriatric population, and Department of Mental Health clients. The members shall serve for a term of four
2. (4) years, except that of the members first appointed, three (3) shall be appointed for one (1) year, three (3) shall be appointed for two (2) years, three (3) shall be appointed for three (3) years, and three (3) shall be appointed for four (4) years. Members of the committee shall receive no compensation for their services but shall be reimbursed for their actual and necessary expenses incurred related to participation on the committee, as approved by the MO HealthNet Division out of appropriations made for that purpose.
3. (2) All persons eligible for MO HealthNet benefits shall have access to non-pharmaceutical behavioral health services when they are determined medically necessary when using diagnostic criteria from the current edition of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association. The services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the MO HealthNet Behavioral Health Services Provider Manual and Section 13 of the Physician Provider Manual, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, on its website www.dss.mo.gov/mhd, November 15, 2013. This rule does not incorporate any subsequent amendments or additions. The MO HealthNet non-pharmaceutical behavioral health services prior authorization advisory committee shall review and make recommendations regarding the prior authorization process to the MO HealthNet Division. The MO HealthNet non-pharmaceutical behavioral health services prior authorization advisory committee shall hold a public hearing in order to make recommendations to the department 13 CSR 70-98

prior to any final decisions by the division on the prior authorization process. The recommendations of the non-pharmaceutical behavioral health services prior authorization advisory committee shall be provided to the MO HealthNet Division, in writing, prior to the division making a final determination. The policy requirements regarding the prior authorization process for non-pharmaceutical behavioral health services shall be available through the Department of Social Services, MO HealthNet Division website at www.dss.mo.gov/mhd.

1. (3) The prior authorization requirements shall be reviewed at least every twelve (12) months by the non-pharmaceutical behavioral health services prior authorization committee.
2. (4) The prior authorization process will not apply to emergency and inpatient hospital interventions.
3. (5) The provider may bill for up to four (4) hours of service for diagnosis and testing without prior authorization. If additional services are needed the provider shall initiate the prior authorization process for up to an additional ten (10) to twenty (20) hours of service dependent on the diagnosis and type of service. The first prior authorization does not require an assessment treatment plan, or progress notes. After the first aggregate fourteen (14) to twenty-four (24) hours of service an additional prior authorization with appropriate documentation is required. The prior authorization request can be phoned, faxed, or mailed to the division designee.

AUTHORITY: section 208.201, RSMo Supp. 2013.* Original rule filed Jan. 15, 2004, effective Aug. 30, 2004. Amended: Filed Oct. 30, 2007, effective April 30, 2008. Amended: Filed Oct. 10, 2013, effective April 30, 2014.

*Original authority: 208.201, RSMo 1987, amended 2007.