Section 306.261 - Authorization for MH Case Management Services(a) A provider must: (1) ensure that a QMHP-CS administers the uniform assessment to the individual at intervals specified by the department and obtain a recommended LOC for the individual;(2) evaluate the clinical needs of the individual to determine if the amount of MH case management services associated with the recommended LOC described in the utilization management guidelines is sufficient to meet those needs; and(3) ensure that an LPHA reviews the recommended LOC and verifies whether the services are medically necessary.(b) If the provider determines that the type of MH case management services associated with the recommended LOC is sufficient to meet the individual's needs, the provider must submit to the department or its designee a request for service authorization according to the recommended LOC.(c) If the provider determines that the type of MH case management services associated with the recommended LOC is not sufficient to meet the individual's needs, the provider must submit to the department or its designee: (1) a request for an authorization of an LOC that is sufficient to meet the individual's need or a request for authorization of additional units of service; and(2) the clinical justification for the request.(d) The department or its designee makes the initial determination of an individual's LOC using the uniform assessment which is referenced in § 306.281 of this title (relating to Guidelines) and the utilization management guidelines, which are referenced in § 306.281 of this title. If the LOC includes MH case management services, the department or its designee will authorize the individual to receive either routine or intensive case management services.(e) Upon receipt of a request submitted according to subsection (c) or (d) of this section, the department or its designee will:(1) review the documentation submitted by the provider;(2) based on the review of documentation and an evaluation of available resources, authorize or deny an LOC for the individual, and if authorized, it authorizes the individual to receive either routine or intensive MH case management services; and(3) communicate to the individual or LAR, no longer than seven business days after the determination has been made, whether the service has been authorized or denied.26 Tex. Admin. Code § 306.261
Adopted to be effective February 14, 2013, 38 TexReg 647Transferred from T. 25, § 412.406 by Texas Register, Volume 45, Number 03, January 17, 2020, TexReg 469, eff. 2/15/2020.