(1) The therapeutic and rehabilitative portion of medically necessary TFC and TFOC services is covered if prior-authorized by the department or its designee according to the provisions of the Children's Mental Health Bureau's (CMHB) Provider Manual and Clinical Guidelines for Utilization Management incorporated in ARM 37.87.903 and this subchapter. TFC and TFOC providers are required to abide by the CMHB Provider Manual and Clinical Guidelines for Utilization Management.

(2) Medicaid reimbursement is not available for TFC or TFOC services unless the provider submits to the department or its designee in accordance with this subchapter and the CMHB Provider Manual and Clinical Guidelines for Utilization Management, a complete and accurate CON that certifies the level of care needed for the youth with a serious emotional disturbance (SED).

(3) For youth determined Medicaid eligible by the department at the time of admission to TFC or TFOC services, the CON required under (2) must be:

(a) completed, signed, and dated prior to, but no more than 30 days before, admission; and

(b) written by a team of health care professionals that has competence in diagnosis and treatment of mental illness, and that has knowledge of the youth's situation, including the youth's psychiatric condition. The team must include a physician that has competence in diagnosis and treatment of mental illness, preferably in child psychiatry, and a licensed mental health professional as defined in ARM 37.87.102.

(4) For youth determined Medicaid eligible by the department after admission to or discharge from TFC or TFOC services, the CON required under (2) is waived. A retrospective review to determine the medical necessity of the admission to the program and the treatment provided will be completed by the department or its designee at the request of the department, a provider or the youth's parent or legal guardian. Request for retrospective review must be:

(a) received within 14 days after the eligibility determination for youth determined eligible following admission, but before discharge from TFC or TFOC services; or

(b) received within 90 days after the eligibility determination for youth determined eligible after discharge from TFC or TFOC services.

(5) All CONs required under (2) must actually and personally be signed by a minimum of two team members. Two of the signatures must be:

(a) a physician who has competence in diagnosis and treatment of mental illness, preferably child psychiatry, or a board-certified/board-eligible psychiatrist and;

(b) a licensed mental health professional. If a signature stamp is used, the team member must actually and personally initial the document over the signature stamp.

(6) The therapeutic portion of moderate level TFC or TFOC, as defined in ARM Title 37, chapters 37 and 97, is covered if provided by a TFOC agency licensed by and contracted with the department to provide moderate level TFC or TFOC services.

(7) The therapeutic portion of permanency TFOC treatment, as defined in ARM Title 37, chapters 37 and 97, is covered if provided by a TFOC agency licensed by and contracted with the department to provide permanency TFOC services.