CurrentMontana Department of Public Health & Human ServicesPolicy 425

Mental Health Outpatient (OP) Therapy Coverage Criteria

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Defines coverage, provider and service requirements, and utilization management for mental health outpatient (individual, family, and group) therapy provided to members with a primary DSM or ICD mental health diagnosis.

Policy Summary

PayerMontana Department of Public Health & Human Services

PolicyMental Health Outpatient (OP) Therapy Coverage Criteria

Policy CodePolicy 425

Change TypeNo material change

Effective DateJan 1, 2024

Next Review Date

Key ActionDocument in the member's file that the member meets the medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

16maximum group members

no prior authprior authorization required

no continued stay reviewcontinued reviews required

master's-levelminimum provider qualification

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CurrentMontana Department of Public Health & Human ServicesPolicy 425

Mental Health Outpatient (OP) Therapy Coverage Criteria

Customize your policy alerts

Sign up for Montana Department of Public Health & Human Services Policy 425 alerts

Get alerted when Policy 425 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerMontana Department of Public Health & Human Services

PolicyMental Health Outpatient (OP) Therapy Coverage Criteria

Policy CodePolicy 425

Change TypeNo material change

Effective DateJan 1, 2024

Next Review Date

Key ActionDocument in the member's file that the member meets the medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

16maximum group members

no prior authprior authorization required

no continued stay reviewcontinued reviews required

master's-levelminimum provider qualification

Coverage Criteria

Initial Coverage Criteria

Covered when ALL of the following are met

Primary diagnosis: Member has any mental health diagnosis from the current DSM or ICD as the primary diagnosis.

Source: medical necessity criteria

Assessment and individualized treatment plan (ITP): Services are based on a current comprehensive assessment and are included as interventions in the member's individualized treatment plan (ITP).

Source: service requirements

MH Outpatient Therapy is not a bundled service. Providers must bill each service separately using the appropriate outpatient therapy procedure codes for the modality and unit of service provided, in accordance with the payer's billing guidelines.

Services will not meet medical necessity unless the member has a primary mental health diagnosis listed in the current version of the DSM or ICD. If the member does not have a primary DSM/ICD mental health diagnosis, the service is considered not medically necessary under this policy.

Level of Care Criteria

Treatment Modalities

Outpatient therapy (individual, family, group)

Modalities: Includes individual, family, and group therapy where diagnosis, assessment, psychotherapy, and related services are provided.

From service definition

Visit Limits

Group therapy maximum members

Maximum membersGroup therapy services may not have more than 16 members participating in the group.

Billing noteMH OP is not a bundled service and must be billed using the appropriate outpatient therapy codes.

BasisServices must be based on a current comprehensive assessment and included as an intervention in the member's individualized treatment plan (ITP).

Provider Actions & Billing

Prior Authorization

Prior authorization not required

Prior authorization is not required for MH Outpatient Therapy services.

Step Therapy

No step therapy specified

No step-therapy or other utilization-management sequencing is specified in this policy.

Documentation Required

Document medical necessity in member file

The provider must document in the member's file that the member meets the medical necessity criteria.

Definitions

MH Outpatient Therapy

DefinitionMH Outpatient Therapy services include individual, family, and group therapy in which diagnosis, assessment, psychotherapy, and related services are provided.

Required documentationServices must be based on a current comprehensive assessment and included as interventions in the member's individualized treatment plan (ITP).

BillingMH OP is not a bundled service and must be billed using the appropriate outpatient therapy codes.

Medical necessity — primary diagnosis

Primary diagnosis requirementThe member must have any mental health diagnosis from the current version of the DSM or ICD as the primary diagnosis.

Medical necessity implicationServices for which the member does not have a primary DSM or ICD mental health diagnosis would not meet the stated medical necessity criteria.

Background

MH Outpatient Therapy includes individual, family, and group therapy where diagnosis, assessment, psychotherapy, and related services are provided. Services must be based on a current comprehensive assessment and must be included as interventions in the member's individualized treatment plan (ITP).

To qualify as medically necessary for outpatient therapy, the member must have any mental health diagnosis from the current DSM or ICD recorded as the primary diagnosis. For group therapy specifically, sessions may include up to 16 members per session.