DHS Discontinues Outpatient Behavioral Health Prior Authorization Requirements

WHA work group recommended reforms to behavioral health prior authorization process

September 08, 2017

The Department of Health Services (DHS) has discontinued the prior authorization requirement in the fee-for-service Medicaid program for outpatient mental health and outpatient substance abuse treatment in excess of 15 hours or $825 per year and for outpatient mental health and outpatient substance abuse assessments in excess of eight hours per year. This change was published in the September 2017 ForwardHealth Update (2017-27) “New Prior Authorization Policy for Outpatient Behavioral Health Services” and is effective October 1, 2017.

“WHA has long supported reducing regulatory burdens on health care providers in a number of areas, including Medicaid,” said Joanne Alig, WHA senior vice president, policy and research. “WHA’s Medicaid Policy Work Group has focused on the area of mental health and substance abuse in particular, and reforming the prior authorization requirements was one of the recommendations coming out of that work group over the past year. WHA is pleased DHS is taking this step.”

In addition to the change in prior authorization requirements, the ForwardHealth Update provides several “reminders” regarding covered services, claims submission, medical necessity and documentation for outpatient mental health and substance abuse services. It also notes the Update contains fee-for-service policy and “applies to services members receive on a fee-for service basis only,” but that “[Managed Care Organizations] are required to provide at least the same benefits as those provided under fee-for-service arrangements.” 

DHS also published changes to covered services and prior authorization requirements for adaptive behavior assessment and treatment for Medicaid members with autism or other diagnoses or conditions associated with deficient adaptive or maladaptive behaviors. Those changes were contained in a second September 2017 ForwardHealth Update (2017-28), “Changes to Coverage Policy and Prior Authorization Requirements for Behavioral Treatment”. Among the changes in this Update, “behavioral treatment technicians” are now permitted to deliver “focused behavioral treatment” under certain conditions. These changes are also effective for dates of services on or after October 1, 2017.

This story originally appeared in the September 08, 2017 edition of WHA Newsletter