| (a) Prerequisites to providing services. With the exception
of crisis intervention services:
(1) the provider must obtain prior authorization from
the department or its designee for the MH rehabilitative services
to be provided in accordance with the uniform assessment, which is
referenced in §416.17 of this title (relating to Guidelines);
and the utilization management guidelines, which are referenced in §416.17
of this title; and
(2) an LPHA must determine whether the need for MH
rehabilitative services meets the definition of medical necessity.
(b) Recovery planning.
(1) In collaboration with the individual or LAR, develop
a recovery plan in accordance with §412.322(e) of this title
(relating to Provider Responsibilities for Treatment Planning and
Service Authorization) that also includes a list of the type(s) of
MH rehabilitative services authorized in accordance with subsection
(a)(1) of this section.
(2) A provider must develop the recovery plan required
by paragraph (1) of this subsection within 10 days after the authorization
date.
(c) Documenting medical necessity for crisis intervention
services.
(1) An LPHA must, within two business days after crisis
intervention services are provided:
(A) determine whether the crisis intervention services
met the definition of medical necessity; and
(B) if the crisis intervention services were determined
to meet medical necessity, document the medical necessity for such
services.
(2) A provider is not required to develop a recovery
plan for providing crisis intervention services.
(d) Reauthorization of MH rehabilitative services.
(1) Prior to the expiration of the authorization period
or depleting the amount of services authorized:
(A) the provider must make a determination of whether
the individual continues to need MH rehabilitative services; and
(B) an LPHA must determine whether the continuing need
for MH rehabilitative services meets the definition of medical necessity.
(2) If the determination is that the individual continues
to need MH rehabilitative services and that such services are medically
necessary, the provider must:
(A) request another authorization from the department
or its designee for the same type and amount of MH rehabilitative
service previously authorized; or
(B) submit a request to the department or its designee,
with documented clinical reasons for such request, to change the type
or amount of MH rehabilitative services previously authorized if:
(i) the provider determines that the type or amount
of MH rehabilitative services previously authorized is inappropriate
to address the individual's needs; and
(ii) the criteria described in the utilization management
guidelines for changing the type or amount of MH rehabilitative services
has been met.
(e) Recovery plan review.
(1) In collaboration with the individual or LAR or
primary caregiver, the provider must, review the recovery plan to
determine if the plan adequately assists the individual in achieving
recovery through the identified goals, objectives, and needs:
(A) at intervals set forth in the utilization management
guidelines;
(B) as clinically indicated; and
(C) at the request of the individual, LAR, or primary
caregiver.
(2) At the time the recovery plan is reviewed, the
provider must:
(A) solicit active participation of the individual
and LAR or primary caregiver of a child or adolescent regarding the
services received to date and whether the services received have led
to improvement and/or if there are other services to address unmet
needs; and
(B) document such input.
(f) Revisions to the recovery plan. If, after review
of the recovery plan, the provider in collaboration with the individual
or LAR determines that the recovery plan does not adequately address
the needs of the individual, the provider must, as appropriate:
(1) revise the content of the recovery plan; or
(2) must document medical necessity if there is a
change in an LOC; and
(3) request authorization for a change in the type
or amount of the MH rehabilitative services authorized consistent
with subsection (d)(2) of this section.
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| Source Note: The provisions of this §306.311 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239 |
