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    v1.0.28
    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthNew Mexico HCA Behavior Management Services Covera…
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    CurrentNew Mexico Health Care AuthorityPolicy N/A

    Behavior Management Services (BMS) - Coverage Criteria

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    Defines Medicaid-covered Behavior Management Services (BMS) for children and youth within New Mexico’s Medicaid program, describing purpose, basic elements, provider inputs, utilization trends, and future development considerations. Affects providers delivering behavioral management as part of comprehensive treatment for Medicaid-enrolled children and adolescents.

    Policy Summary
    PayerNew Mexico Health Care Authority
    PolicyBehavior Management Services (BMS) - Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument a relevant clinical assessment and an individualized treatment plan specifying BMS and record caregiver involvement and monitoring.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    part of EPSDTprogram inclusion
    tot-to-teenage range referenced for screening
    1st 6 monthsutilization period
    increased

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    utilization direction

    Coverage and Medical Necessity Criteria

    General Coverage Criteria for BMS

    Covered when ALL of the following are met:

    BMS coverage prerequisites: BMS must be part of a comprehensive treatment plan (not a stand-alone service); be provided to children and youth who need behavioral management to avoid hospitalization, residential care, separation from family, require continued intensive treatment following hospitalization, or need transition to avoid return to a more restrictive environment; must be based on a relevant clinical assessment; and must be specified in an individualized treatment plan.

    Source: service definition, basic elements, provider inputs

    Behavior Management Services (BMS) are not intended to be provided as a stand‑alone service. BMS must be delivered as part of a comprehensive treatment approach for children and youth who need behavioral management intervention to avoid hospitalization, residential treatment, or separation from families; to provide continued intensive treatment following hospitalization; or to support transition to less restrictive settings. BMS includes development and implementation of a behavior management plan, caregiver assistance and monitoring, and use of basic techniques such as reinforcement, redirection, voluntary time‑outs, and verbal redirection.

    Providing BMS solely because a child is "misbehaving" is not supported. Misbehaving is explicitly stated as not a diagnosis; coverage requires a relevant clinical assessment and a current, individualized treatment plan documenting clinical need and specifying BMS as part of comprehensive care.

    Provider Requirements, Documentation, and Authorization

    Prior Authorization

    Prior Authorization Not Required

    No prior authorization is required for Behavior Management Services (BMS); the policy does not specify any prior authorization requirements.

    Step Therapy

    No Step Therapy Specified

    The policy does not impose any step therapy requirements for BMS; no sequencing or trial-of-therapy rules are specified.

    Documentation Required

    Assessment, Treatment Plan, and Monitoring Required

    Document a relevant clinical assessment, an individualized treatment plan that specifies Behavior Management Services (BMS), and ongoing monitoring including caregiver involvement and plan implementation.

    Background and Purpose

    Behavior Management Services are intended for children and youth who require behavioral management intervention as part of comprehensive treatment to prevent hospitalization, residential placement, or separation from family, to continue intensive treatment after hospitalization, or to support transitions to less restrictive environments. BMS comprises development and implementation of a behavior management plan, assisting caregivers with implementation, monitoring plan adherence, and use of basic techniques such as reinforcement, redirection, voluntary time‑outs, and verbal redirection. Successful provision requires assessment of the child’s whole environment and a current assessment and treatment plan for every child.

    Definitions and Program Context

    Behavior Management Services (BMS)
    DefinitionA set of services for children and youth that includes development and implementation of a behavior management plan, assisting caregivers with implementation, monitoring the plan, and use of basic techniques such as reinforcement, redirection, voluntary time-outs, and verbal redirection.
    Primary purposeProvided as part of a comprehensive treatment approach to avoid hospitalization, residential treatment, separation from families, provide continued intensive treatment after hospitalization, or to support transition to less restrictive settings.
    Service elementsDevelopment of a behavior management plan; implementation of the plan; caregiver assistance with implementation; and monitoring of plan implementation.
    Techniques usedReinforcement; redirection; voluntary time-outs; verbal redirection; plus teaching, training, coaching, and a regimen of positive intervention and reinforcement.
    Service setting limitationNot intended to be provided as a stand-alone service—must be part of a comprehensive treatment plan.

    Settings and Level-of-Care Criteria

    Behavioral Management Techniques and Modalities

    Behavioral management techniques

    Techniques: Use of reinforcement, redirection, voluntary time-outs, and verbal redirection as basic techniques, along with teaching, training, coaching, and a regimen of positive intervention and reinforcement to support the child's functioning in home and community.

    Basic elements

    Policy Summary
    PayerNew Mexico Health Care Authority
    PolicyBehavior Management Services (BMS) - Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument a relevant clinical assessment and an individualized treatment plan specifying BMS and record caregiver involvement and monitoring.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaProvider Requirements, Documentation, and AuthorizationBackground and PurposeDefinitions and Program ContextSettings and Level-of-Care CriteriaBehavioral Management Techniques and Modalities
    • Assessment: Must be based on a relevant clinical assessment (e.g., identified in a tot-to-teen health check screen or other diagnostic evaluation).
    • Treatment plan: Every child must have a current, individualized treatment plan that specifies BMS and uses teaching, training, coaching, and a regimen of positive intervention and reinforcement.
    • Monitoring and caregiver involvement: Providers must assist caregivers with implementation and monitor the plan's implementation; consider the child’s whole environment and involve schools as appropriate.
    Denial Risk

    Risk of Denial Without Assessment & Plan

    Failure to maintain a current clinical assessment and an individualized treatment plan for each child risks noncompliance with policy and potential denial of BMS.

    • Note that 'misbehaving' alone is not a diagnosis or justification for BMS; documentation must demonstrate clinical need.
    EPSDT (Early Periodic Screening, Diagnosis & Treatment)
    Program inclusionBMS is provided as part of the Medicaid Early Periodic Screening, Diagnosis & Treatment (EPSDT) program.
    Trigger for BMSWhen need is identified in a tot-to-teen health check screen or other diagnostic evaluation.
    Assessment requirementMust be based on a relevant clinical assessment.
    Treatment plan requirementMust be specified in an individualized treatment plan.
    Intervention approachUses teaching, training, and coaching activities to help a child function successfully in home and community; includes a regimen of positive intervention and reinforcement.