(1) The department will not reimburse providers for some Medicaid services unless the prior authorization and continued authorization requirements are met.

(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.

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

(a) concurrent with therapeutic youth group services;

(b) 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;

(c) therapeutic foster care (TFOC) services in accordance with ARM Title 37, chapter 51;

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

(e) hospital for psychiatric treatment and partial psychiatric hospital services defined in ARM 37.86.2901 and 37.86.3001; and

(f) as provided for in other rules.

(4) Medicaid mental health services for youth requiring prior authorization or continued authorization 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 defined in ARM 37.87.303, which has been verified by the department or designee; or

(b) the department or 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).

(5) Youth are not required to have a serious emotional disturbance to receive the following outpatient therapy services:

(a) the first 24 sessions of individual and/or family outpatient therapy per state fiscal year. Group outpatient therapy is not included in the 24-session limit; and

(b) group outpatient therapy.

(6) The department may waive a requirement for prior authorization or continued authorization when:

(a) the provider submits documentation that:

(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

(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.

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

(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 October 1, 2012. A copy of the manual 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.

(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 interested persons.