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

(a) the youth, defined in ARM 37.87.102, has been determined to have a serious emotional disturbance as defined in ARM 37.87.303;

(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; and

(c) for prior authorized services, the serious emotional disturbance has been verified by the department or its designee.

(2) If a youth has a mental health diagnosis designated by the department, the youth is not required to have a serious emotional disturbance to receive the following services:

(a) group outpatient therapy; and

(b) the first 24 sessions per state fiscal year of individual and family outpatient therapy.

(3) Prior authorization by the department or its designee is required for the following services for a Medicaid recipient who is a youth:

(a) 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 37.86.2207. This rule does not apply to a session with a physician or midlevel practitioner for the purpose of medication management;

(b) targeted case management in excess of 120 units of service per state fiscal year and in accordance with ARM 37.87.808;

(c) all outpatient therapy services that are provided concurrently with comprehensive school and community treatment (CSCT) described at ARM 37.86.2224, 37.86.2225, 37.106.1955, 37.106.1956, 37.106.1960, 37.106.1961, and 37.106.1965; or

(d) as provided for in other rules.

(4) 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.

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

(6) Under no circumstances may a waiver under (4) be granted more than 30 days after the initial date of service.

(7) Review of authorization requests by the department or its designee will be made with consideration of the clinical management guidelines (2008). A copy of the clinical management guidelines (2008) can be obtained from the department by a request in writing 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.

(8) 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.

(9) 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.