PURPOSE: This rule establishes the process by which non-pharmaceutical mental health services will be prior authorized in order to be reimbursable by the Missouri Medicaid 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 Missouri Medicaid recipients.

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. Therefore, the material which is so incorporated is on file with the agency who filed this rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the rule is printed here. This note refers only to the incorporated by reference material. (1) This rule establishes a Medicaid nonpharmaceutical mental health services prior authorization advisory committee in the Department of Social Services, Division of Medical Services. 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 (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 Division of Medical Services out of appropriations made for that purpose.

1. (2) All persons eligible for medical assistance benefits shall have access to non-pharmaceutical mental health services when they are determined medically necessary when using diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders— Fourth Edition (DSM-IV), published by the American Psychiatric Association, or the most currently published version of the DSM manual. 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 Division of Medical Services and shall be included in the Medicaid Psychology/Counseling Provider Manual and Section 13 of the Physician Provider Manual, which are incorporated by reference in this rule and available through the Department of Social Services, Division of Medical Services website at www.dss.mo.gov/dms. The Medicaid nonpharmaceutical mental health services prior authorization advisory committee shall review and make recommendations regarding the prior authorization process to the Division of Medical Services. The Medicaid nonpharmaceutical mental health services prior authorization advisory committee shall hold a 13 CSR 70-98

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

1. (3) The prior authorization requirements shall be reviewed at least every twelve (12) months by the non-pharmaceutical mental 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 2000.* Original rule filed Jan. 15, 2004, effective Aug. 30, 2004. *Original authority: 208.201, RSMo 1987.