ModifiedTexas Children's Health PlanPolicy 12419

Targeted Case Management & Mental Health Rehabilitation Policy

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Governs authorization activities for Mental Health Targeted Case Management and Mental Health Rehabilitative Services for STAR/CHIP and STAR Kids members, following applicable Texas Medicaid requirements.

Policy Summary

PayerTexas Children's Health Plan

PolicyTargeted Case Management & Mental Health Rehabilitation Policy

Policy CodePolicy 12419

Change TypeModified

Effective DateOct 6, 2025

Next Review DateNot specified

Key ActionPerform authorizations for Targeted Case Management and Mental Health Rehabilitation services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Service categories

2Product groupings

CANS or ANSAAssessment tools

Age-basedUtilization management

HHSC-approved

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ModifiedTexas Children's Health PlanPolicy 12419

Targeted Case Management & Mental Health Rehabilitation Policy

Customize your policy alerts

Sign up for texaschildrenshealthplan Policy 12419 alerts

Get alerted when Policy 12419 changes without checking for updates manually.

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Policy Summary

PayerTexas Children's Health Plan

PolicyTargeted Case Management & Mental Health Rehabilitation Policy

Policy CodePolicy 12419

Change TypeModified

Effective DateOct 6, 2025

Next Review DateNot specified

Key ActionPerform authorizations for Targeted Case Management and Mental Health Rehabilitation services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Service categories

2Product groupings

CANS or ANSAAssessment tools

Age-basedUtilization management

HHSC-approved

Authorization and Medical Necessity

Authorization and medical necessity framework

Authorization and coverage are governed by medical necessity, age-appropriate utilization management guidance, and applicable Texas Medicaid requirements.

ALL of the following

Mental Health Targeted Case Management eligibility is based on a standardized Child and Adolescent Needs and Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA) and other diagnostic criteria used to establish medical necessity.
Mental Health Rehabilitative Services must be medically necessary under HHSC and federally approved protocols to reduce disability and restore the member to the best possible functioning level in the community; services that maintain functioning may qualify when necessary to help the member achieve a rehabilitation goal defined in the member's rehabilitation plan.
Apply the Texas Resilience and Recovery Utilization Management Guidelines for Child and Adolescent Services or Adult Mental Health Services, as appropriate for the member's age.
Follow the Texas Medicaid Provider Procedures Manual, Behavioral Health and Case Management Services Handbook, for applicable prior authorization, coverage, coding, and reimbursement requirements, including benefit limitations and restrictions.

Authorization Requirements

Prior Authorization

Authorization required

Obtain authorization for all Targeted Case Management and Mental Health Rehabilitation services before providing them.

Prior Authorization

Use age-appropriate utilization management guidelines

Apply the utilization management guideline appropriate to the member’s age: the Texas Resilience and Recovery Utilization Management Guidelines for Child and Adolescent Services or the Adult Mental Health Services guidelines.

Billing Rule

Service Definitions

Mental Health Targeted Case Management

DefinitionServices designed to assist Members with gaining access to needed medical, social, educational, and other services and supports.

EligibilityMembers are eligible based on a standardized assessment—the Child and Adolescent Needs and Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA)—and other diagnostic criteria used to establish medical necessity.

Mental Health Rehabilitative Services

DefinitionAge-appropriate services determined by HHSC and federally approved protocol as medically necessary to reduce a Member's disability and restore the Member to his or her best possible functioning level in the community.

Age-specific applicationServices address disability resulting from severe mental illness for adults, or serious emotional, behavioral, or mental disorders for children.

Maintaining functioning