(a) A provider must:
(1) ensure that a QMHP-CS administers the uniform assessment
to the individual at intervals specified by the department and obtain
a recommended LOC for the individual;
(2) evaluate the clinical needs of the individual to
determine if the amount of MH case management services associated
with the recommended LOC described in the utilization management guidelines
is sufficient to meet those needs; and
(3) ensure that an LPHA reviews the recommended LOC
and verifies whether the services are medically necessary.
(b) If the provider determines that the type of MH
case management services associated with the recommended LOC is sufficient
to meet the individual's needs, the provider must submit to the department
or its designee a request for service authorization according to the
recommended LOC.
(c) If the provider determines that the type of MH
case management services associated with the recommended LOC is not
sufficient to meet the individual's needs, the provider must submit
to the department or its designee:
(1) a request for an authorization of an LOC that is
sufficient to meet the individual's need or a request for authorization
of additional units of service; and
(2) the clinical justification for the request.
(d) The department or its designee makes the initial
determination of an individual's LOC using the uniform assessment
which is referenced in §412.416 of this title (relating to Guidelines)
and the utilization management guidelines, which are referenced in
§412.416 of this title. If the LOC includes MH case management
services, the department or its designee will authorize the individual
to receive either routine or intensive case management services.
(e) Upon receipt of a request submitted according to
subsection (c) or (d) of this section, the department or its designee
will:
(1) review the documentation submitted by the provider;
(2) based on the review of documentation and an evaluation
of available resources, authorize or deny an LOC for the individual,
and if authorized, it authorizes the individual to receive either
routine or intensive MH case management services; and
(3) communicate to the individual or LAR, no longer
than seven business days after the determination has been made, whether
the service has been authorized or denied.
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Source Note: The provisions of this §306.261 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469 |