(1) The department will not reimburse providers for two services that duplicate one another on the same day.

(2) Medicaid mental health services for youth requiring approval prior to treatment, prior authorization, or continued stay authorization will be reimbursed only if the following requirements are met:

(a) the youth has been determined to have a serious emotional disturbance defined in the Manual adopted and incorporated by reference in (8), 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.

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

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

(b) group outpatient therapy.

(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 an equipment failure or malfunction of the department or its designee that prevented the transmittal of the request at the required time and the provider submitted a subsequent authorization request within ten business days.

(5) 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.

(6) If 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) In addition to the requirements contained in rule, the department has developed and published a provider manual entitled Children's Mental Health Bureau, Medicaid Services Provider Manual (Manual), dated October 1, 2015, for the purpose of utilization management. The department adopts and incorporates by reference the Children's Mental Health Bureau, Medicaid Services Provider Manual, dated October 1, 2015. 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 http://dphhs.mt.gov/dsd/CMB/Manuals.aspx.

(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.