Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 98 - Behavioral Health Services › Section 13 CSR 70-98.020 - Prior Authorization Committee for Non-Pharmaceutical Behavioral Health Services

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment updates the incorporation by
				  reference, amends the purpose statement, and removes language in order to
				  comply with mental health parity.
PURPOSE: This rule establishes a committee to advise
				  the MO HealthNet Division on a prior authorization process for
				  non-pharmaceutical behavioral health services. The prior authorization process
				  will serve as a utilization management measure to ensure that services are
				  medically necessary, appropriate, and cost-effective.
(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 (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.
(2) All persons
				eligible for MO HealthNet benefits shall have access to non-pharmaceutical
				behavioral health services when they are determined medically necessary 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 prior authorization requirements, and the limitations under
				which services are covered shall be determined by the MO HealthNet Division and
				shall be included in the MO HealthNet Behavioral Health Services Provider
				Manual and the Physician's 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, at its
				website at
http://manuals.momed.com/manuals/
,
				October 1, 2018. 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 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 are available through
				the Department of Social Services, MO HealthNet Division website at
				https://dss.mo.gov/mhd/, October 1, 2018. This rule does not incorporate any
				subsequent amendments or additions.
(3) The prior authorization requirements
				shall be reviewed at least every twelve (12) months by the non-pharmaceutical
				behavioral health services prior authorization committee.
(4) The prior authorization process will not
				apply to emergency and inpatient hospital interventions.