Prior Authorization Required

Authorization is required for many ARMHS and CTSS services and for requests that exceed specified monthly or calendar-year thresholds. Submit required forms and supporting documentation to request authorization. Failure to provide complete authorization documentation may result in denial.

• Request authorization for ARMHS services that exceed benefit limits shown in the ARMHS Benefits chart (basic living and social skills, community intervention, functional assessment, individual treatment plan, medication education).
• Required authorization forms: MHCP Authorization Form (DHS-4695) (except when using MN-ITS) and Adult Mental Health Rehabilitative Services Authorization Form (DHS-4159A).
• Include supporting documentation of medical necessity (treatment plan, diagnostic assessment, functional assessment, level of care assessment, progress notes as applicable).
• For ARMHS provided concurrently with another mental health service, the second provider must submit the authorization request and include correspondence from the first provider describing coordination, distinct service times, goals and interventions.
• For Transition to Community Living (TCL) authorization, submit: DHS-4695 and DHS-4159A; a Letter of Referral from the higher-level provider; current documentation from the higher-level provider (diagnostic assessment, functional assessment, LOC assessment, proposed discharge plan, progress notes for past six sessions or two weeks — IRTS two weeks); the discharge goal; ARMHS provider documentation (supervisor-signed eligibility statement and proposed ARMHS TCL plan).
• TCL plans are limited to a maximum of 180 days and must include type of service, frequency and length of sessions, modality, responsible parties, and a written description of service coordination between providers and the member.

Code- and Threshold-Specific Authorization

Specific CPT/HCPCS codes and modifiers have authorization thresholds or absolute authorization requirements. Check combined totals across modifiers where thresholds apply.

• H2017 (basic living and social skills) — Units = 15 min. Authorization required for combined totals exceeding 300 hours per calendar year across H2017, H2017 HM and H2017 HQ. H2017 with TCL modifiers (U3, U3 HM) require authorization and cannot be provided concurrently with other ARMHS services.
• Environmental/community intervention codes — Authorization required for more than 10 sessions per month or 72 sessions per calendar year (applies across modifiers). TCL variants require authorization and cannot be concurrent.
• H0031 (mental health assessment by nonphysician) — Authorization required for more than 6 sessions per calendar year.
• H0032 (service plan development by nonphysician) — Authorization required for more than 4 sessions per calendar year (including follow-up).
• H0034 (medication education) — Authorization required for more than 26 hours per calendar year (individual and group combined where applicable).
• Use interactive complexity add-on code (90785) on authorization requests when services include interactive complexity; include UA modifier for CTSS when required.

CTSS Authorization / Calendar-Year Thresholds

CTSS services count toward calendar-year authorization thresholds. Monitor cumulative hours and session counts when billing and requesting authorization.

• 200 cumulative hours per calendar year for any combination of: psychotherapy (with patient or family), skills training, crisis planning, MHBA services, service plan development — these count toward the CTSS 200-hour authorization threshold.
• 52 cumulative sessions per calendar year of group psychotherapy (including outpatient group psychotherapy).
• 26 cumulative sessions per calendar year of family psychotherapy (including outpatient family psychotherapy).
• 10 cumulative sessions per calendar year of multiple family group psychotherapy.
• Up to 24 sessions per calendar year of service plan development (treatment plan development and review services count toward the 200-hour threshold).
• Children's day treatment hours are excluded from the 200-hour threshold.

Monthly Documentation Required for Reimbursement

Monthly MH-TCM reimbursement requires documentation that at least one of the four core case management components was provided and documented each month. Ensure encounter notes clearly identify the core component and link to ICSP/IFCSP goals.

• To bill monthly MH-TCM, document at least one core service component: assessment, planning, referral and linkage, or monitoring and coordination.
• Case notes must state which core component was provided, what was done, the person's response, and plan for next contact; link services to ICSP/IFCSP goals.
• Encounter-rate reimbursement requires in-person or both video and audio; counties may bill one claim per month, IHS/638 bill one claim per encounter (enter date of service).

Noncovered Services and Provider/Setting Restrictions

Certain ARMHS services and scenarios are noncovered. Do not bill for noncovered items or provide ARMHS in excluded settings or by nonqualified personnel.

• Noncovered ARMHS services include: transportation; services by providers not enrolled to provide ARMHS; volunteer-delivered ARMHS; household tasks (laundry, housekeeping, grocery shopping, moving); time 'on call' without service delivery; primarily social or recreational activities; job-specific on-the-job training; services already included in case management; outreach to potential members; room and board.
• Do not provide ARMHS (except TCL where explicitly allowed) to members residing in regional treatment centers, nursing facilities, inpatient hospitals (acute-care), or sub-acute (IRTS) settings.
• ARMHS must not duplicate or substitute for targeted case management, assertive community treatment, day treatment, residential treatment, or other covered mental health services. When provided concurrently with another mental health service, documentation must demonstrate distinct treatment goals, distinct rehabilitative interventions, and distinct service times.
• Noncovered CTSS scenarios include: CTSS components provided simultaneously by more than one provider entity without prior authorization; treatment by multiple providers within same agency at same clock time; services provided contrary to Minnesota rules; MHBA services provided by unqualified personal care assistants; service components the residential/program license holder is responsible for; consultation that is not billable within CTSS (may be billed separately as clinical care consultation).

Required Documentation Elements

Progress notes and encounter documentation must include specific elements to support billing, medical necessity, and authorization requests. Maintain separate documentation when services are concurrent to demonstrate distinct goals and interventions.

• Progress notes must document: type of service, date, session start and stop times, service location, scope of service (nature of interventions/contacts, treatment modalities, phone contacts), goals/objectives targeted, intervention delivered and methods used, member's response to interventions, plan for next sessions including planned treatment changes, service modality (group or individual), signature/printed name and credentials of the service provider, and travel documentation when applicable.
• Significant observations to include when applicable: current risk factors, emergency interventions, consultations/referrals, changes in symptoms (physical or mental).
• When ARMHS is provided concurrently with another mental health service, documentation must clearly demonstrate distinct treatment goals, distinct rehabilitative interventions, and distinct service times; include time allocation and separate goals in progress notes.

Required MH-TCM Encounter Documentation

MH-TCM encounter documentation must include a written description of each contact and identify the contact person, content, and which case management component was performed.

• Each MH-TCM encounter record must include: client name, date of service, name and relationship of the contacted person (if applicable), nature and extent of service provided, name and professional title of person providing service, type of contact (face-to-face or telephone), location of contact, and case manager signature/credentials.
• Indicate which MH-TCM core activity was performed (assessment, planning, referral and linkage, monitoring and coordination) and document how the activity linked to ICSP/IFCSP goals.
• If multiple case management components were provided during a contact, document each component separately in the note.

Family and Group Psychotherapy Session Limits

Family and group psychotherapy session limits apply on a calendar-year basis and count toward CTSS authorization thresholds.

• Family psychotherapy: 26 sessions per calendar year (including outpatient family psychotherapy).
• Multiple family group psychotherapy: 10 sessions per calendar year.
• Group psychotherapy: 52 sessions per calendar year (including outpatient group psychotherapy).
• These session counts count toward CTSS authorization thresholds (200-hour and session limits) and must be tracked when requesting authorization.