(a) Except as
provided in (b) and (c) of this section and
7
AAC 105.130(d), the department will
not pay for behavioral health services unless the department has given prior
authorization for those services.
(b) A community behavioral health services
provider or mental health physician clinic may provide the following behavioral
health clinic services without prior authorization from the department:
(1) a combination of individual, group, and
family psychotherapy, not to exceed 30 hours for each recipient in a state
fiscal year;
(2) psychiatric
assessments under
7
AAC 135.110(e), not to exceed four
per recipient in a state fiscal year;
(3) psychological testing and evaluation
under 7 AAC 135.110(g),
not to exceed six hours per recipient in a state fiscal year, except that
neuropsychological testing and evaluation is limited to 12 hours per recipient
in a state fiscal year if the provider has documentation validating the
provider's qualifications to provide neuropsychological testing and evaluation
services;
(4) pharmacologic
management services, not to exceed one visit per recipient per week during the
first four weeks after the recipient begins receiving pharmacologic management
services, and, thereafter, not to exceed one visit per recipient per month as
long as the recipient is receiving a service under this chapter, unless more
frequent monitoring is required because of
(A) the requirements of the specific
medication; or
(B) a recipient's
unusual clinical reaction to a medication;
(5) if the individual is not already
receiving services under this chapter at the time the assessment is provided
under this paragraph, one integrated mental health and substance use intake
assessment under
7
AAC 135.110, or a combination of one mental health
intake assessment and one substance use intake assessment under
7
AAC 135.110; the assessment or combination of
assessments must consist of
(A) one or more
face-to-face sessions; and
(B) a
review of collaterally connected information;
(6) based on a current behavioral health
treatment plan, one integrated mental health and substance use intake
assessment under
7
AAC 135.110, or a combination of one mental health
intake assessment and one substance use intake assessment under
7
AAC 135.110, every six months;
(7) short-term crisis intervention services
under 7 AAC 135.160, or a combination of
behavioral health clinic service, rehabilitation service, and intervention
service under
7
AAC 135.010 that are included in the crisis plan, that
do not exceed 22 hours of the total short-term crisis intervention services
provided to a recipient during a state fiscal year;
(8) screening and brief intervention
services, with no limit.
(c) A community behavioral health services
provider may provide the following behavioral health rehabilitation services
without prior authorization by the department:
(1) case management, not to exceed 180 hours
per recipient per state fiscal year; no more than one hour per week per
recipient may be used in monitoring by the directing clinician of the provision
of services;
(2) individual
therapeutic behavioral health services for children under
7
AAC 135.220, or a combination of individual
therapeutic behavioral health services for children and peer support services
under 7 AAC 135.210 and
7
AAC 135.220; the services or combination of services
may not exceed 100 hours per recipient per state fiscal year;
(3) group therapeutic behavioral health
services for children under
7
AAC 135.220, not to exceed 140 hours per recipient per
state fiscal year;
(4) family
therapeutic behavioral health services for children under
7
AAC 135.220, or a combination of family therapeutic
behavioral health services for children and peer support services under
7
AAC 135.210 and
7
AAC 135.220; the services or combination of services
may not exceed 180 hours per recipient per state fiscal year;
(8) medication administration services as
provided in the recipient's behavioral health treatment plan;
(9) one medical evaluation of a recipient in
an opioid use disorder treatment program per admission for that opioid use
disorder treatment program, including
(A)
consultation and referral;
(B)
verification of one year of addiction; and
(C) establishing dosage for methadone or
another agonist or partial agonist;
(10) methadone or antabuse administration as
prescribed by a physician;
(11)
withdrawal management services, with no limit;
(12) behavioral health screening in
accordance with
7
AAC 135.100, to determine eligibility for admission to
a treatment program, limited to one screening per program admission for new or
returning recipients;
(13) medical
evaluation for a recipient not receiving methadone, limited to one medical
evaluation per recipient per admission to withdrawal management
treatment;
(14) behavioral health
treatment plan review for a recipient in an opioid use disorder treatment
program, limited to one review per admission;
(15) day treatment services for children
under 7 AAC 135.250, not to exceed 180
hours per state fiscal year; day treatment services may not be provided more
than six hours per school day;
(16)
Repealed 11/10/2019;
(17)
residential substance use disorder treatment services under
7
AAC 135.280, with no limit;
(18) short-term crisis stabilization services
under 7 AAC 135.170 that
(A) do not exceed 22 hours of the total
short-term crisis stabilization services provided to a recipient during a state
fiscal year; and
(B) are provided
during a psychiatric emergency that is documented in the recipient's clinical
record.
(19) autism
services provided in accordance with
7
AAC 135.350 that do not exceed more than
(A) a total of 1,040 hours in a six-month
period for either
(i) adaptive behavior
treatment by protocol;
(ii) group
adaptive behavior treatment by protocol; or
(iii) a combination of adaptive behavior
treatment by protocol and group adaptive behavior treatment by
protocol;
(B) 52 hours of
adaptive behavior treatment by protocol modification in a six-month
period;
(C) 12 family adaptive
behavior treatment guidance sessions in a 12- month period of time;
(D) one behavior identification reassessment
in a six-month period; and
(E) the
initial behavior identification assessment conducted by a licensed behavior
analyst in accordance with
7
AAC 135.350(b) for a new or returning
recipient.
(d)
A provider request for prior authorization of an extension of a service beyond
service limitations or a provider request for a change in the level of the
service that a recipient previously received must be made in writing on a form
approved by the department. The request must
(1) be documented in the clinical record
prepared under
7
AAC 105.230 and
7
AAC 135.130;
(2) include a listing of all Medicaid
reimbursable services and the expected duration of these services as set out in
the recipient's behavioral health treatment plan; and
(3) affirm that the recipient's treatment
team for a recipient under 18 years of age, in accordance with
7
AAC 135.120, has reviewed the behavioral health
treatment plan and recommended the requested services as medically necessary
and clinically appropriate.
(e) An extension made under (d) of this
section is valid through the date set by the director of the division
responsible within the department for behavioral health services, or the
director's designee.
(f) The
department will not pay for more than one service episode per day of a
detoxification service. In this subsection, "service episode" means the
completion of all services identified in this section for which a single
payment is made in accordance with
7
AAC 145.580.
(g) After considering the area of the state
where the service is provided, the provider's location, and whether other
providers are available to a recipient, the director of the division
responsible within the department for behavioral health services, or the
director's designee, shall extend a behavioral health clinic service limitation
under 7 AAC 135.010 -
7
AAC 135.280 if the director or director's designee
determines that
(1) the recipient's
circumstances are exceptional; and
(2) the extension is necessary to protect the
recipient's health.
(h)
In this section, "state fiscal year" has the meaning given "fiscal year" in
AS
37.05.920 and
37.05.990.
