HAR §17-1737-21. Outpatient psychiatric care

(a) Outpatient psychiatric care shall be provided by authorized psychiatric providers. (b) Prior authorization is required for outpatient psychiatric care for: (1) All eligible recipients in need of outpatient psychiatric care; (2) Non-Medicaid patients who become eligible for medical assistance and whose outpatient visits may be covered retroactively. The prior authorization form shall be submitted by the provider immediately upon learning that the patient became eligible for retroactive coverage; and (3) Medicaid patients with third party coverage or any other available resources except for Medicare. (c) The appropriate department of human services form for prior medical authorization shall be used to request authorization for outpatient psychiatric care. The following procedure shall be taken: (1) The form shall be completed, signed, and dated by the psychiatrist or psychologist; (2) The form shall be received in the medical assistance program (Medicaid) office of the department within five working days from the time of the patient's first visit. The postmarked date shall be accepted provided it is within the five working days requirement from the time of patient's first visit; (3) Subsequent requests shall be submitted to the medical assistance program (Medicaid) office within five working days from the date of the last visit authorized. The postmarked date shall be accepted provided it is within the five working days requirement; and UNOFFICIAL 1737-23 (4) Reimbursements to the physician or psychologist shall be denied when forms are not received within the specified time. (d) Outpatient visits for psychiatric care shall be as follows: (1) Emergency room service in a licensed general hospital may be provided to patients with psychiatric problems. Services shall consist of examination for clinical impression and treatment; and Office or clinic visits shall be a face to face, personal contact between the patient and the authorized therapist for therapy or for a diagnostic purpose. (e) Outpatient visits shall not be reimbursed for time spent beyond one hour for individual therapy; or two hours for group therapy. (f) The number of visits shall be as follows: (1) The maximum number of visits for the primary mode of therapy is twenty-four one hour individual visits or twenty-four one and one- half to two hour group visits within a twelve month period; (2) For a combination of group and individual psychotherapy, the maximum for the primary modality is twenty-four visits and the maximum for the secondary modality (when twenty-four of the primary modality is approved) is six visits within a twelve month period; (3) Any combination of group and individual psychotherapy is allowed, provided the total of thirty visits and the maximum for the primary modality are not exceeded; (4) One-half hour (twenty to thirty minutes), or one quarter hour (ten to fifteen minutes), as well as one hour (forty-five to fifty minutes) individual psychotherapy visits are allowed. Any combination of visits is allowed, provided the total does not exceed twenty-four one hour visits within a twelve month period; and (5) One inpatient day can be exchanged for two outpatient hours. (g) Approval of a second request and subsequent requests shall be based on the severity of the patient's illness. (1) Severe cases shall be allowed a maximum of twenty-four visits within a twelve month period; UNOFFICIAL 1737-24 (2) Moderate cases shall be allowed a maximum of eighteen visits within a twelve month period; (3) Maintenance cases shall be allowed a maximum of twelve visits within a twelve month period; and (4) Personality disorders without acute crisis shall be eligible for extension after one year of treatment, with sufficient justification. (h) Visits not used in the authorized twelve month period shall not be added to the outpatient visits allowed for the following twelve month period. (i) A summary of the patient-therapist relationship may be requested at any interval after the onset of treatment: (1) The summary should include such information as a justification for said diagnosis, a logical expressed treatment plan and observed changes since the onset of patient-therapist relationship; and (2) The summary shall be utilized by the department's psychiatric consultant or by the department's established peer review committee to determine the number of subsequent out-patient visits that shall be authorized. (j) Patients who have been under continuous psychiatric treatment for longer than a year may have their records reviewed by the department's psychiatric consultant for progress towards rehabilitation and general productivity of therapy before further outpatient visits are approved. If the provider is in disagreement with the department's psychiatric consultant's determination, the case shall be referred to the department's established peer review committee for review. (k) Psychiatric outpatient visits available through third party coverage shall be counted as part of a patient's authorized visits under Medicaid. It shall be the provider's responsibility to apply the number of visits available from the third party coverage to the authorized number of visits under Medicaid. [Eff 08/01/94; am 06/19/00; am 02/16/02 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §440.20) §17-1737-22 Exclusions to the psychiatric program. Excluded from the psychiatric program are: Partial hospitalization, day, evening, and night care; UNOFFICIAL 1737-25 (1) Residential treatment centers; (2) Skilled nursing facilities; (3) Intermediate care facilities; (4) Consortiums; and (5) Home visits to a residence, care home, boarding home, or other living arrangement, except in an emergency situation. [Eff 02/16/02 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §456.3) §