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RULE §301.335Utilization Management

(a) Utilization management plan. The LMHA and MCO must develop a written utilization management plan that includes:

  (1) the utilization management program plan description and work plan;

  (2) requirements relating to the utilization management committee credentials, job functions, meetings, and training;

  (3) how the utilization management program's effectiveness in meeting goals will be evaluated;

  (4) how improvements will be made on a regular basis;

  (5) the oversight and control mechanisms to ensure that UM activities meet required standards when they are delegated to an administrative services organization or a DSHS-approved entity; and

  (6) approval by the LMHA or MCO governing body.

(b) Utilization management program. The LMHA and MCO must implement a utilization management program under the direction of a psychiatrist licensed in Texas as required by its contract with the department, and in accordance with the utilization management guidelines, as updated and amended.

(c) Authorization of services. The LMHA and MCO must ensure that it has a timely authorization system in place to ensure medically necessary services are delivered without delay and with prior authorization, except that the delivery of crisis services does not require prior authorization but rather must be authorized subsequent to delivery. The LMHA and MCO will review requests for authorization of services, determine if services should be authorized and if so which services to authorize. Services must be authorized using the department's utilization management guidelines and based on the uniform assessment, diagnosis, additional clinical information submitted by the requestor, and clinical judgment. The determination and documentation of services to be authorized will occur according to the following timeframes:

  (1) crisis intervention services--within two business days of the date of service;

  (2) inpatient services--within sufficient time to ensure medically necessary services are delivered without delay;

  (3) all other mental health community services, including outpatient and add-on services upon receipt but no later than three business days and prior to service delivery; and

  (4) reauthorization for continuing services according to established timeframes in the utilization management guidelines, as updated and amended.

(d) Appeal and Medicaid fair hearing procedures. The LMHA and MCO must implement procedures to give notice of the right to a timely and objective appeal process for all individuals receiving community mental health services, in accordance with §401.464 of this title (relating to Notification and Appeals Process). For individuals eligible for Medicaid, the LMHA and MCO must implement procedures that provide notice of the right to request a fair hearing, as described in Title 1, Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules for the Medicaid, TANF, and Food Stamp Programs), to an individual whose service or benefits are denied, reduced, suspended, or terminated. The procedures regarding notice of the right to a Medicaid fair hearing must comply with department policy, which may be included in contract provisions.

(e) Waiting list maintenance requirements. The LMHA must comply with the department's policy on waiting list maintenance requirements, which may be included in contract provisions and is subject to the requirements set forth in §412.314(d)(2) of this title (relating to Access to Mental Health Community Services).

Source Note: The provisions of this §301.335 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237

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