Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 306 - BEHAVIORAL HEALTH DELIVERY SYSTEM
Subchapter F - MENTAL HEALTH AND REHABILITATIVE SERVICES
Section 306.311 - Service Authorization and Recovery Plan

Universal Citation: 26 TX Admin Code ยง 306.311

Current through Reg. 49, No. 38; September 20, 2024

(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 § 306.333 of this title (relating to Guidelines); and the utilization management guidelines, which are referenced in § 306.333 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 §301,353(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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