(1) Mental health services for a medicaid recipient under the Montana medicaid program will be reimbursed only if the following requirements are met:

(a) the recipient is a youth who has been determined to have a serious emotional disturbance as defined in ARM 37.86.3702;

(b) the department has determined prior to treatment on a case by case basis that treatment is medically necessary for early intervention and prevention of a more serious emotional disturbance;

(c) prior authorization has been obtained for outpatient therapy services that are provided concurrently with comprehensive school and community treatment (CSCT) program services described at ARM 37.106.1955, 37.106.1956, 37.106.1960, 37.106.1961, 37.106.1965 and 37.86.2225; or

(d) the recipient is 18 or more years of age and has been determined to have a severe disabling mental illness as defined in ARM 37.86.3502.

(2) For all mental health services provided to a medicaid recipient under the age of 18, prior authorization is not required for the first 24 sessions of an individual or family outpatient service in the state fiscal year. Limitations for outpatient services are set forth in the fee schedule dated July 1, 2005. This rule does not apply to a session with a physician for the purpose of medication management.

(3) For all mental health services provided to an adult medicaid recipient under the Montana medicaid program, prior authorization is not required for the first 16 visits in the 12-month period beginning July 1, 2003 and each 12-month period thereafter for outpatient mental health counseling services billed under Current Procedure Terminology 4th Edition (CPT4) codes 90804, 90806, 90810, 90812, 90846 and 90847 only.

(4) Adult intensive outpatient therapy services may be medically necessary for a person with safety and security needs who has demonstrated the ability and likelihood of benefit from continued outpatient therapy. The person must meet the requirements of (4) (a) or (b) . The person must also meet the requirements of (4) (c) . The person has:

(a) a DSM-IV diagnosis with a severity specifier of moderate or severe of mood disorder (293.83, 295.70, 296.2x, 296.3x, 296.4x, 296.5x, 296.6x, 296.7, 296.80, 296.89, 296.90, 396.40) ; or

(b) a DSM-IV diagnosis borderline personality disorder (301.83) , personality disorder (NOS) (301.9) with prominent features of 301.83; and

(c) ongoing difficulties in functioning because of mental illness for a period of at least six months or for an obviously predictable period over six months, as indicated by:

(i) dysregulation of emotion, cognition, behavior and interpersonal relationships;

(ii) resulting in recurrent suicidal, parasuicidal, serious self-damaging impulsive behaviors, or serious danger to others;

(iii) a history of treatment at a higher level of care, and

(iv) evidence that lower levels of care are inadequate to meet the needs of the client.

(5) The department may waive a requirement for prior authorization when the provider can document that:

(a) there was a clinical reason why the request for prior authorization could not be made at the required time; or

(b) a timely request for prior authorization was not possible because of a failure or malfunction of equipment that prevented the transmittal of the request at the required time.

(6) The prior authorization requirement shall not be waived except as provided in this rule.

(7) Under no circumstances may a waiver under (5) be granted more than 30 days after the initial date of service.

(8) Review of authorization requests by the department or its designee will be made with consideration of the clinical management guidelines (2004) . A copy of the clinical management guidelines (2004) can be obtained from the department by a request in writing to the Department of Public Health and Human Services, Addictive and Mental Disorders Division, 555 Fuller, P.O. Box 202905, Helena, MT 59620-2905, or to the Department of Public Health and Human Services, Health Resources Division, Children's Mental Health Bureau, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951 or can be viewed on the department's website at www.dphhs.mt.gov/aboutus/divisions/ addictivementaldisorders/index.shtml.

(9) The department may review the medical necessity of services or items at any time either before or after payment in accordance with the provisions of ARM 37.85.410. If the department determines that services or items were not medically necessary or otherwise in compliance with applicable requirements, the department may deny payment or may recover any overpayment in accordance with applicable requirements.

(10) The department or its designee may require providers to report outcome data or measures regarding mental health services, as determined in consultation with providers and consumers.