| (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 |
