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Reminder of Limitations on Outpatient Mental Health Services

Date: 08/01/19

This news announcement is a reminder to all MHS Behavioral Health professional service providers that MHS has implemented limitations on certain Outpatient Mental Health Services.  On 11/1/18 MHS released a news announcement under the Provider News section of our website.

Please refer to the following link for details: https://www.mhsindiana.com/newsroom/limitations-on-outpatient-mental-health-services.html

This article is meant to provide a reminder to our BH providers as well as provide updated information for clarification.

The Indiana Health Coverage Programs Mental Health and Addiction Provider Reference Module (May 2017) outlines a coverage policy for the following CPT [1] codes that, in combination, are limited 20 units per member, per provider, per rolling 12-month period:

Code

Description

90832 - 90834

Individual Psychotherapy

90837 - 90840

Psychotherapy, with patient and/or family member & Crisis Psychotherapy

90845 - 90853

Psychoanalysis & Family/Group Psychotherapy with or without patient

Please Note: CPT codes 90833, 90836, and 90838 for psychotherapy with medical evaluation and management are medical services. Therefore, the IHCP does not reimburse clinical social workers, clinical psychologists, or any mid-level practitioners (excluding nurse practitioners and clinical nurse specialists) for these codes.

Effective 12/15/18, Managed Health Services (MHS) has begun applying this limitation for claims with dates of service (DOS) on or after 12/15/18. Claims exceeding the limit will deny EX Mb: Maximum Benefit Reached.

If the member requires additional services above the 20 unit limitation, providers may request prior authorization for additional units.  Approval will be given based on the necessity of the services as determined by the review of medical records.

Additional Information on this implementation is provided as follows:

  • As of 12/15/18, any member who has utilized 20 units with a single provider within a 12-month-rolling period, will require an authorization OTR submission for continued services.  Providers will need to determine if they have provided 20 units to the member in the past rolling 12 months (starting with DOS 12/15/18) to determine if a prior authorization request is needed.  DOS prior to 12/15/18 are not counted towards the 20 unit limitation.
  • “Per Provider” is defined by MHS as per individual rendering practitioner NPI being billed on the CMS-1500 claim form (Box 24J).
  • This change is related to professional services being billed on CMS 1500 claims only.
  • For submission of prior authorization:
    • Please use the BH prior authorization outpatient treatment request (OTR) forms;
    • The treating provider requesting the auth completes and signs the OTR (PA Form), as in any other OTR request for services for MHS. Please note:
      • The treatment plan would require signatures by the MD or Supervising HSPP related to the services.
      • The NPI# entered on the OTR form, for professional services that will be provided and billed by practitioners, needs to match the NPI of the billing supervising MD or HSPP.  Mid-Level practitioner NPI should not be entered here.  This may result in claim and auth not connecting within our system once your claim is billed.
        • Also do not enter your group NPI in the “Rendering Provider Information” field of the OTR.  You must enter the rendering practitioner NPI that will be billed in box 24J of the CMS 1500 form.
    • Listed on the OTR form you will find the Fax number for submission at the top: 1-866-694-3649;
    • It is best to include all service codes, duration/units/frequency requests on one OTR form per member;
    • MHS typical approved authorization date span is 3-6 months depending on medical necessity determination;
    • MHS internal turn-around time on OTR request is 7 days, while our contractual turnaround time is 14 days;
    • Decision letters, referred to either as a Notice of Coverage or Denial Letter is sent as a response to every request;
    • If upon submission of provider OTR request MHS determines that additional information is needed, MHS will call out to the provider using the contact information provided on the OTR form.  Providers are typically given 23-48 hours to call us back. If a denial is issued, providers have 30 days to appeal that decision and provide additional documentation.
    • Behavioral Health Practitioners who disagree with a determination based on medical necessity may request a medical necessity appeal.  All member or provider appeals of an MHS decision as to medical necessity must include a statement from the provider supporting the appeal and the need for the service. Each medical necessity appeal will be reviewed by an MHS Medical Director or Pharmacist. The reviewer may reverse the original decision and grant the appeal in whole or in part, or will uphold the original denial.
      • The appeal must be received by MHS within 60 calendar days of the date listed on the denial determination letter. The monitoring of the appeal timeline will begin the day MHS receives and receipt-stamps the appeal. Medical necessity behavioral health appeals should be mailed or faxed to:

MHS Behavioral Health
ATTN: Appeals Coordinator
12515 Research Blvd, Suite 400
Austin, TX 78701
FAX: 1-866-714-7991

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Last Updated: 08/01/2019