Section 7 AAC 135.040 - Service authorization and limitation(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.Eff. 10/1/2011, Register 199; am 4/9/2017, Register 222, July 2017; am 7/1/2018, Register 226, July 2018; am 11/10/2019, Register 232, January 2020; am 4/24/2020, Register 234, April 2020; am 6/30/2021, Register 238, July 2021; am 12/23/2022, Register 244, January 2023Authority:AS 47.05.010
AS 47.07.030