Mo. Code Regs. tit. 13 § 70-98.020

Current through Register Vol. 49, No.12, June 17, 2024

Section 13 CSR 70-98.020 - Prior Authorization Committee for Non-Pharmaceutical Behavioral Health Services

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.

13 CSR 70-98.020

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 Apr 30, 2014.

Amended by Missouri Register April 1, 2019/Volume 44, Number 7, effective 5/31/2019