(1) The therapeutic and rehabilitative portion of medically necessary TGH service 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. TGH providers are required to abide by the CMHB Provider Manual and Clinical Guidelines for Utilization Management.

(2) Medicaid reimbursement is not available for TGH 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 certificate of need (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 the TGH, 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.

(4) For youth determined Medicaid eligible by the department after admission to or discharge from the TGH, 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 the TGH; or

(b) received within 90 days after the eligibility determination for youth determined eligible after discharge from the TGH.

(5) All CONs required under (2) must be actually and personally 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 as defined in ARM 37.87.102. If a signature stamp is used, the team member must actually and personally initial the document over the signature stamp.