BEFORE THE DEPARTMENT OF PUBLIC
HEALTH AND HUMAN SERVICES OF THE
STATE OF MONTANA
In the matter of the amendment of ARM 37.87.903 pertaining to changing prior authorization requirements and adopting a new utilization review manual
NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT
TO: All Concerned Persons
1. On August 29, 2012, at 10:00 a.m., the Department of Public Health and Human Services will hold a public hearing in Room 207 of the Department of Public Health and Human Services Building,111 North Sanders, Helena, Montana, to consider the proposed amendment of the above-stated rule.
2. The Department of Public Health and Human Services will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process or need an alternative accessible format of this notice. If you require an accommodation, contact the Department of Public Health and Human Services no later than 5:00 p.m. on August 22, 2012, to advise us of the nature of the accommodation that you need. Please contact Kenneth Mordan, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; telephone (406) 444-4094; fax (406) 444-9744; or e-mail firstname.lastname@example.org.
3. The rule as proposed to be amended provides as follows, new matter underlined, deleted matter interlined:
37.87.903 MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, AUTHORIZATION REQUIREMENTS (1) remains the same.
(2) The department will not reimburse providers for two services that duplicate one another on the same day. The department adopts and incorporates by reference the Medicaid Mental Health Plan and Mental Health Services Plan for Youth Services Excluded from Simultaneous Reimbursement (Service Matrix) effective August 1, 2011. A copy of the service matrix may be obtained from the department
or at www.mt.medicaid.org.
(3) Prior authorization and continued authorization by the department or its designee is required for the following services:
individual or family outpatient therapy services in excess of 24 sessions per state fiscal year, subject to such additional limitations for outpatient therapy services as may be set forth in the Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted at ARM 37.87.901. This rule does not apply to a session with a physician or midlevel practitioner for the purpose of medication management concurrent with therapeutic youth group services;
(b) remains the same.
therapeutic family care (TFC) and therapeutic foster care (TFOC) services in accordance with ARM 37.87.1021, 37.87.1023, and 37.87.1025 and ARM Title 37, chapter 51;
(d) remains the same.
psychiatric hospital for psychiatric treatment and partial psychiatric hospital services defined in ARM 37.86.2901 and 37.86.3001; and
(f) and (4) remain the same.
(5) Prior authorization and continued authorization by the department or its designee is not required for targeted case management.
(6) remains the same, but is renumbered (5).
(7)(6) The department may waive a requirement for prior authorization or continued authorization when the provider submits documentation that:
(a) the provider submits documentation that:
(a)(i) there was a clinical reason why the request for prior authorization or continued authorization could not be made at the required time, and the provider submitted a subsequent authorization request within ten business days; or
(b)(ii) a timely request for prior authorization or continued authorization was not possible because of a failure or malfunction of the department's or its designee's equipment that prevented the transmittal of the request at the required time and
the provider submitted a subsequent authorization request within ten business days.
(b) computing the time for any request provided for in this subchapter includes weekends and holidays. If a deadline falls on a weekend or holiday, the deadline is the next business day.
(c) the department finds exceptional circumstances that reasonably justify a provider's failure to timely request prior authorization or continued authorization, it may extend the deadline for meeting the requirement.
(8) remains the same, but is renumbered (7).
(9)(8) Review of authorization requests and retrospective reviews by the department or its designee will be made with consideration of the department's clinical management guidelines. The department adopts and incorporates by reference the Children's Mental Health Bureau's Provider Manual and Clinical Guidelines for Utilization Management dated August 1, 2011 October 1, 2012. A copy of the manual can may be obtained from the department by a request in writing to the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604-4210 or at www.dphhs.mt.gov/mentalhealth/children/index.shtml.
(10) remains the same, but is renumbered (9).
(11)(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 interested persons.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-111, MCA
4. STATEMENT OF REASONABLE NECESSITY
The department is proposing to amend ARM 37.87.903 pertaining to Medicaid authorization for mental health services for youths. The Children's Mental Health Bureau (CMHB) recently completed the procurement of a new Medicaid utilization review (UR) contract. These proposed amendments are necessary to align the rule with the new utilization review contract, which becomes effective October 1, 2012, CMHB is proposing to update the current provider manual, "Children's Mental Health Bureau's Provider Manual and Clinical Guidelines for Utilization Management" dated August 1, 2011 and the administrative rule language. The proposed changes to ARM 37.87.903 are described below.
Effective October 1, 2012, the CMHB will no longer require prior authorization for some of the children's mental health services provided through Medicaid funding. In order to give providers clear guidance in documenting medical necessity in the record, which is subject to retrospective reviews, the CMHB has worked with the UR contractor and providers to review and update the medical necessity criteria. The updated medical necessity criteria and prior authorization requirements will be adopted and incorporated by reference, in the proposed provider manual, "Children's Mental Health Bureau's Provider Manual and Clinical Guidelines for Utilization Management" dated October 1, 2012. This manual may be found at the following web site: www.dphhs.mt.gov/mentalhealth/children/index.shtml.
The department is proposing to add language in the rule defining deadlines for submission of authorizations and continued authorizations that fall on weekends or holidays. The new language will also allow the department more discernment when determining the deadline for submission of requests for authorizations and continued authorizations for which extenuating circumstances exist.
The CMHB has also rewritten the appeal process in the proposed provider manual in order to be in compliance with administrative rule. The proposed language aligns the department's current appeal process with administrative rule.
There is no fiscal impact due to this proposed rulemaking.
5. The department intends the proposed rule changes to be applied effective October 1, 2012. There will be no detrimental effects if the amendments are applied retroactively.
6. Concerned persons may submit their data, views, or arguments either orally or in writing at the hearing. Written data, views, or arguments may also be submitted to: Kenneth Mordan, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; fax (406) 444-9744; or e-mail email@example.com, and must be received no later than 5:00 p.m., September 6, 2012.
7. The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing.
8. The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency. Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices. Notices will be sent by e-mail unless a mailing preference is noted in the request. Such written request may be mailed or delivered to the contact person in 6 above or may be made by completing a request form at any rules hearing held by the department.
9. An electronic copy of this proposal notice is available through the Secretary of State's web site at http://sos.mt.gov/ARM/Register. The Secretary of State strives to make the electronic copy of the notice conform to the official version of the notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the notice and the electronic version of the notice, only the official printed text will be considered. In addition, although the Secretary of State works to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems.
10. The bill sponsor contact requirements of 2-4-302, MCA do not apply.
/s/ John Koch /s/ Anna Whiting Sorrell
Rule Reviewer Anna Whiting Sorrell, Director
Public Health and Human Services
Certified to the Secretary of State July 30, 2012.