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Welcome  » September 30, 2022 11:36 PM
Program Name: BadgerCare Plus and Medicaid Handbook Area: Behavioral Treatment Benefit
09/30/2022  

Prior Authorization : Services Requiring Prior Authorization

Topic #19059

Prior Authorization Requirements for Behavioral Treatment Services

Comprehensive behavioral treatment, focused behavioral treatment, behavioral treatment with protocol modification, family treatment guidance, and team meetings all require PA.

Only licensed supervisors may be listed as the billing or rendering provider on a PA request. The renderer listed on the PA/RF must match the supervising professional in the POC.

Providers should submit a POC consistent with their clinical recommendations for the member. The treatment hours requested on the PA/RF should reflect the number of weekly treatment hours that will be provided, based on member and staff availability. ForwardHealth may approve the plan as requested or may approve a lesser level of service than requested based on the documentation submitted. ForwardHealth will deny PA requests that do not meet approval criteria or that do not establish medical necessity for the requested service.

PA requirements for covered services within the following categories are included below.

Comprehensive Behavioral Treatment

All comprehensive treatment activities require an approved PA request. The comprehensive treatment approach must have adequate research evidence indicating its effectiveness for individuals comparable to the member (e.g., age, diagnostic status, behavioral and cognitive characteristics). For members with autism, current evidenced-based comprehensive treatment modalities include ABA and ESDM. Comprehensive treatment may continue to be authorized as long as the provider demonstrates the medical necessity of the proposed services for the member via the PA request process.

Focused Behavioral Treatment

All focused treatment activities require an approved PA request. The focused treatment approach must have adequate research evidence indicating its effectiveness for individuals comparable to the member (e.g., age, diagnostic status, behavioral and cognitive characteristics) and must fall within the scope of practice of the requesting provider's training and credentials. Focused treatment will typically not be authorized for more than 12 continuous months per episode of treatment for the goals specified in the member's POC. Through the PA process, the provider is required to document the rationale for continued treatment beyond 12 months for a single treatment goal or set of treatment goals for a member. Focused treatment may be authorized for additional episodes of treatment for a different set of goals, as long as the provider demonstrates medical necessity for the proposed services via the PA approval process.

Team Meetings

Team meetings must be prior authorized by ForwardHealth. Team meeting services are requested on the PA/RF with procedure code 97156 and modifier AM on a separate line item.

Family Treatment Guidance

Family treatment guidance must be prior authorized by ForwardHealth. Family treatment guidance is requested on the PA/RF with procedure code 97156 and modifier TG or TF, as appropriate on a separate line item.

 
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