(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 or its designee has determined on a case by case basis, that treatment is medically necessary for early intervention and prevention of a more serious emotional disturbance:

(i) prior to treatment, (prior authorization); and

(ii) when required, (continued authorization).

(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 and when required continued authorization by the department or its designee is required for the following services:

(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 37.87.901. 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 provided on the same day as 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;

(d) therapeutic youth group home services and extraordinary needs aide services in accordance with ARM 37.87.1011, 37.87.1013, 37.87.1015, and 37.87.1017;

(e) 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;

(f) psychiatric residential treatment facility services defined in ARM 37.87.1202;

(g) psychiatric hospital and partial psychiatric hospital services defined in ARM 37.86.2901 and 37.86.3001; and

(h) as provided for in other rules.

(4) The department may waive a requirement for prior authorization or continued authorization when the provider submits documentation that:

(a) 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) 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.

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

(6) Review of authorization requests 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 January 15, 2011. A copy of the manual can 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.

(7) 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.

(8) 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.