CurrentTexas Children's Health PlanPolicy 6671

Outpatient Psychotherapy Visits Greater than 30 per Calendar Year

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This guideline governs prior authorization for additional individual, group, or family outpatient psychotherapy visits after a member reaches the annual limit of 30 visits. It applies to providers serving Texas Children's Health Plan members.

Policy Summary

PayerTexas Children's Health Plan

PolicyOutpatient Psychotherapy Visits Greater than 30 per Calendar Year

Policy CodePolicy 6671

Change TypeNo material change

Effective DateJun 21, 2024

Next Review DateN/A

Key ActionObtain prior authorization for outpatient psychotherapy visits beyond 30 visits per member per calendar year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30Annual visits before prior authorization

Up to 10Additional visits per request

7 daysPost-service consideration window

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CurrentTexas Children's Health PlanPolicy 6671

Outpatient Psychotherapy Visits Greater than 30 per Calendar Year

Customize your policy alerts

Sign up for texaschildrenshealthplan Policy 6671 alerts

Get alerted when Policy 6671 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

PayerTexas Children's Health Plan

PolicyOutpatient Psychotherapy Visits Greater than 30 per Calendar Year

Policy CodePolicy 6671

Change TypeNo material change

Effective DateJun 21, 2024

Next Review DateN/A

Key ActionObtain prior authorization for outpatient psychotherapy visits beyond 30 visits per member per calendar year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30Annual visits before prior authorization

Up to 10Additional visits per request

7 daysPost-service consideration window

3Medical necessity pathways

Coverage Criteria

Additional Psychotherapy After Annual Limit

Additional outpatient psychotherapy visits beyond the 30-visit annual limit may be authorized when ALL of the following requirements are met:

ALL of the following

The member has reached or is approaching the limit of 30 individual, group, or family psychotherapy visits per person per calendar year, and additional psychotherapy services are needed to accomplish the goals of treatment.
Prior authorization is requested through the Utilization Management Department via online submission, fax, phone, or mail during normal business hours.
For established members, the provider requests prior authorization when the member is approaching 30 psychotherapy encounters or visits and additional visits are needed. If the member changes providers and the new provider cannot obtain complete information about the member's encounters or visits, the provider is encouraged to obtain prior authorization before rendering services.
The request is for no more than 10 additional encounters or visits per authorization request.
The request is submitted no sooner than 30 days before the requested date of service and no later than the requested date of service. A request received up to 7 days after the 31st visit may be considered when medical-necessity criteria are met.
The request includes all required information
- A completed Outpatient Mental Health Services Request Form.
- Member demographics.
- Provider name and NPI.
- A complete list of diagnoses as listed in the current edition of the DSM.
- History of substance abuse, if applicable.
- Current medications list.
- Psychosocial barriers.

Medical Necessity for Ongoing Treatment

The number of encounters or visits authorized depends on the member's symptoms and response to past treatment. Ongoing treatment may be considered medically necessary when ANY of the following pathways applies:

ANY of the following

The member has not achieved the discharge goals necessary to conclude treatment, but the member's progress indicates that treatment can be concluded within a short period of time.
The member's psychiatric condition has not responded to a trial of short-term outpatient therapy, and there is potential for serious regression or admission to a more intensive setting without ongoing outpatient management, requiring several months or longer of outpatient therapy.
The member's condition includes long-standing, pervasive symptoms or patterns of maladaptive behavior.

Preauthorization is based on medical necessity and is not a guarantee of benefits or eligibility. Even when preauthorization is approved for treatment or a particular service, the authorization applies only to the medical necessity of that treatment or service. All services remain subject to applicable benefit limitations and exclusions. Providers must comply with state and federal regulatory requirements; failure to comply may result in retrospective audit and potential financial recoupment.

Requests that do not meet the guideline criteria are referred to a Physician Reviewer, and the Denial Policy will be followed.

Authorization and Submission Requirements

Prior Authorization

Authorization Required After 30 Annual Visits

Prior authorization is required for individual, group, or family outpatient psychotherapy beyond 30 visits per person per calendar year. Providers with established members should request authorization when the member is approaching the 30-visit limit and additional visits are needed to accomplish treatment goals.

If a member changes providers and the new provider cannot obtain complete information about the member’s encounters or visits, providers are encouraged to obtain prior authorization before rendering services.

Prior Authorization

Request Timing and Authorization Increments

Prior authorization requests are considered in increments of up to 10 additional psychotherapy encounters or visits. Submit the request no sooner than 30 days before, and no later than, the requested date of service so the most current information is available.

Requests received up to 7 days after the 31st visit may be considered for approval if medical necessity criteria are met.

Clinical Background

Psychotherapy is treatment for mental illness and behavioral disturbances through professional therapeutic communication or interactions. It is intended to alleviate emotional disturbances, change maladaptive behavior patterns, and support personality growth and development.

Key Definitions

Psychotherapy

DefinitionTreatment for mental illness and behavioral disturbances.

Therapeutic relationshipThe clinician establishes a professional contract with the member.

Therapeutic approachDefinitive therapeutic communication or therapeutic interactions are used to alleviate emotional disturbances, change maladaptive behavior patterns, and encourage personality growth and development.

Outpatient Level of Care

Eligible Psychotherapy Modalities

Individual, Group, or Family Psychotherapy

Covered psychotherapy modalities include the following when continuation beyond the annual limit is medically necessary:

Psychotherapy continuation: Individual, group, or family psychotherapy beyond 30 visits per person per calendar year requires prior authorization and supporting medical necessity documentation.>30 visits per calendar year

Authorization is considered in increments of up to 10 additional encounters or visits per request.

Annual and Incremental Visit Limits

Annual Visit Limit

Annual limit30 visits per person, per calendar year.

Covered modalitiesIndividual, group, or family outpatient psychotherapy visits.

After the limitAdditional psychotherapy services must be prior authorized.

Additional Visits Per Request

Authorization incrementUp to 10 additional encounters or visits per request.

Submission windowSubmit no sooner than 30 days before the requested date of service and no later than the date of service.

Late requests

Policy Summary

PayerTexas Children's Health Plan

PolicyOutpatient Psychotherapy Visits Greater than 30 per Calendar Year

Policy CodePolicy 6671

Change TypeNo material change

Effective DateJun 21, 2024

Next Review DateN/A

Key ActionObtain prior authorization for outpatient psychotherapy visits beyond 30 visits per member per calendar year.

SourceLink

On This Page

Number and type of services requested, and the dates services will be provided based on the requested frequency of encounters or visits.

Date on which current treatment is to begin.

Indication of court-ordered or DFPS-directed services.

Clinical documentation of specific symptoms and response to past treatment.

A treatment plan containing measurable short-term goals, specific therapeutic interventions, measurable expected outcomes, anticipated treatment length, and planned frequency of encounters or visits.

An assessment explaining why the member was unable to achieve the expected treatment objectives within the original treatment timeframe.

Note

Submit Through Utilization Management

Requests for outpatient psychotherapy beyond 30 visits per calendar year are received by the Utilization Management Department during normal business hours through the following channels:

Online submission
Fax
Phone
Mail

Documentation Required

Required Request Form Information

Requests for psychotherapy beyond the 30-visit limit must include a completed Outpatient Mental Health Services Request Form with the following information:

Member demographics
Provider name and NPI
Complete diagnoses as listed in the current edition of the DSM
History of substance abuse, if applicable
Current medications list
Psychosocial barriers
Number and type of services requested, and the dates and frequency of the requested encounters or visits
Date the current treatment is to begin
Whether services are court-ordered or DFPS-directed

Documentation Required

Clinical Documentation and Treatment Plan

Submit clinical documentation supporting the need for continued psychotherapy, including specific symptoms, response to past treatment, and a treatment plan. The assessment must explain why the member was unable to achieve the expected treatment objectives within the original treatment timeframe.

Treatment plan must include measurable short-term goals.
Identify the specific therapeutic interventions to be used.
Document measurable expected outcomes.
State the anticipated length of treatment and planned frequency of encounters or visits.

Denial Risk

Medical Necessity Review and Denial Risk

The number of encounters or visits authorized depends on the member’s symptoms and response to past treatment. Ongoing treatment may be medically necessary when the member has not achieved discharge goals but can conclude treatment within a short period, has not responded to short-term outpatient therapy with potential for serious regression or admission to a more intensive setting without ongoing management, or has long-standing, pervasive symptoms or maladaptive behavior patterns.

Requests that do not meet these guidelines are referred to a Physician Reviewer, and the Denial Policy is followed.

Note

Authorization Does Not Guarantee Payment

Preauthorization is based on medical necessity only and does not guarantee benefits, eligibility, or payment. Even when treatment or a particular service is authorized, the authorization applies only to medical necessity; all services remain subject to benefit limitations and exclusions.

Providers must comply with applicable state and federal regulations.
Failure to comply may result in a retrospective audit and potential financial recoupment.

Requests received up to 7 days after the 31st visit may be considered when medical necessity criteria are met.