DHS COVID-19 PROVIDER RESOURCES // OMHSAS
Prior Authorization During the COVID-19 Disaster Emergency Declaration Period
Updated: May 18, 2020
Audience
All Behavioral Health HealthChoices (BHHC) Primary Contractors (PCs), Behavioral Health Managed Care Organizations (BH-MCOs) and Behavioral Health Providers enrolled in the Medical Assistance (MA) ProgramPurpose
Purpose
The purpose of this Memorandum is to inform BHHC PCs, BH-MCOs and behavioral health providers enrolled in the MA program that to facilitate access to services during the COVID-19 disaster emergency declaration period, OMHSAS is suspending certain prior authorization requirements for services, as described in this memorandum.
Background
As outlined in Appendix AA of the Program Standards and Requirements (PS&R) of the BH HC Agreement, BH-MCOs are permitted to require prior authorization for any service for which prior authorization is required in the Behavioral Health (BH) MA Fee-for-Service (FFS) program. The PS&R also requires BH-MCOs to submit requests for the Department’s approval to require prior authorization of services not currently required to be prior-authorized in the MA FFS Program.
The following services require prior authorization or other utilization management reviews in the MA FFS program:
- Residential Treatment Facility for Children (both accredited and non-accredited)
- Therapeutic Staff Support Services
- Program Exceptions, including Program Exceptions for Behavioral HealthRehabilitation Services (BHRS)
- Certain Intensive Behavioral Health Services (IBHS) (Behavioral Health Technician Services, Behavioral Health Technician Services – ABA, Assistant Behavior Consultation – ABA, and Group Services)
- Psychiatric Inpatient Services (concurrent and retrospective reviews)
- Drug and Alcohol American Society of Addition Medicine (ASAM) Level 4 Services (concurrent and retrospective reviews)
There will not be any changes to the prior authorization requirements in the FFS program.
Prior Authorization During the Disaster Emergency Period
It is critical that administrative and other processes be reordered to facilitate access for individuals in need of behavioral health services during this unprecedented time. Prior authorization has been identified as a high priority area for relief at both the federal and state levels. In addition, during this time of emergency and uncertainty, it is important to have consistency across the FFS and managed care delivery systems.
The following guidance applies to in-network and out-of-network services for the BH-MCOs.
For dates of service on or after the release of this guidance, OMHSAS is suspending its previous approval of BH-MCO requests to prior authorize services not prior authorized in the MA FFS program. BH-MCOs may, however, choose to continue to prior authorize services currently requiring prior authorization in the MA FFS program.
During the period that prior authorization is suspended, as specified below, BH-MCOs may apply post admission registration, notification and concurrent review practices for the purposes of supporting the provider in evaluating the ongoing medical necessity of care being provided and in coordinating care across the continuum of behavioral health services, including discharge planning. In addition, all services for which prior authorization has been suspended through this guidance will be subject to retrospective review for medical necessity by the BH-MCO and the Bureau of Program Integrity in the Department of Human Services.
If a provider submits a prior authorization request for a service that does not require prior authorization during the COVID-19 disaster emergency declaration period, the BH-MCO must review the request and issue a decision.
When the COVID-19 disaster emergency declaration period ends, providers must submit prior authorization requests for services to continue to be delivered where the prior authorization requirements were suspended. Providers must submit prior authorization requests as follows:
- Prior authorization requests must be submitted within 30 days from the date the COVID-19 emergency declaration ends for children under the age of 21 who are receiving Family Based Mental Health Services, BHRS/IBHS, and for children who are in a residential treatment facility.
- Prior authorization requests must be submitted within 15 days from the date the COVID-19 emergency declaration ends for all other adult and child services.
Obsolete
This guidance will be in effect while the Governor’s Proclamation of Disaster Emergency issued on March 6, 2020, related to COVID-19 remains in place.