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    v1.0.30
    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthTexas Children's Skills Training Prior Auth | Open…
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    CurrentTexas Children's Health PlanPolicy 6364

    Skills Training Request for CHIP Members

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    This guideline governs prior authorization and medical-necessity review for skills training requested for Texas Children's Health Plan CHIP members. Targeted Case Management is not a CHIP benefit.

    Policy Summary
    PayerTexas Children's Health Plan
    PolicySkills Training Request for CHIP Members
    Policy CodePolicy 6364
    Change TypeNo material change
    Effective DateFeb 20, 2020
    Next Review DateNot specified
    Key ActionSubmit prior authorization for skills training using the completed Texas Standard Prior Authorization Request Form for Health Care Services.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    CHIP onlyApplicable product
    3Submission channels
    6Required clinical topics
    Not a benefitTargeted Case Management

    Coverage Criteria

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Initial Skills Training Authorization

    Initial skills training requests require prior authorization and medical-necessity review.

    ALL of the following

    • Requests for prior authorization for Skills Training must be submitted to the Utilization Management Department by fax, phone, or mail during normal business hours.

    • The Texas Standard Prior Authorization Request Form for Health Care Services must be completed in its entirety for CHIP members requesting Skills Training.

      • Check the Mental Health/Substance Abuse box; do not check the SB58 box.
      • Do not provide a Level of Care (LOC).
      • Document the service code for Skills Training.
      • Provide the member's diagnosis.
      • Include the name of the person providing Skills Training, if known.

      • Section VI must include the clinical reason for requesting Skills Training and the clinical information required by InterQual.

        • Current behavior and symptoms during the last 7 days.
        • Current symptoms reported by the member and/or family.
        • Interpersonal problems.
        • School problems, including risk for suspension, failure, or expulsion.
        • Legal issues, including whether the member is on probation.
        • Illegal drug use or positive drug screens.
    • Utilization Management professionals will use the most recent available version of InterQual criteria to establish medical necessity for Skills Training.
    • Preauthorization is based on medical necessity and is not a guarantee of benefits or eligibility; approved authorization applies only to the medical necessity of the treatment or service, which remains subject to benefit limitations and exclusions.

    Targeted Case Management is not a benefit for CHIP members. Texas Children's Health Plan will issue a denial letter to any provider requesting Targeted Case Management for a CHIP member.

    Requests for Skills Training that do not meet the guideline requirements or applicable InterQual criteria will be referred to a TCHP Medical Director/Physician Reviewer for review, and the Denial Policy will be followed.

    Authorization and Submission Requirements

    Prior Authorization

    Obtain prior authorization for Skills Training

    Prior authorization is required for Skills Training for TCHP CHIP members. Submit the completed Texas Standard Prior Authorization Request Form for Health Care Services.

    Documentation Required

    Complete the standard prior-authorization form

    Complete the Texas Standard Prior Authorization Request Form for Health Care Services in its entirety and check the Mental Health/Substance Abuse box. Do not check the SB58 box or provide a Level of Care (LOC).

    • Document the Skills Training service code.
    • Provide the member’s diagnosis.
    • Include the name of the person providing Skills Training, if known.
    • In Section VI, provide the clinical reason for requesting Skills Training.
    Documentation Required

    Submit required clinical information

    Include the required current clinical information in Section VI to support the Skills Training request.

    • Current behavior and symptoms during the last 7 days.
    • Current symptoms reported by the member and/or family.
    • Interpersonal problems.
    • School problems, including risk of suspension, failure, or expulsion.
    • Legal issues or probation.
    • Illegal drug use or positive drug screens.
    Prior Authorization

    Submit through Utilization Management

    Submit prior-authorization requests to the Utilization Management Department by fax, phone, or mail. Requests are received and processed during normal business hours.

    • Accepted channels: fax, phone, or mail.
    • Department: Utilization Management.
    Denial Risk

    Targeted Case Management is not a CHIP benefit

    A request for Targeted Case Management for a CHIP member will be denied because the service is not a benefit.

    Denial Risk

    Failure to meet medical-necessity criteria

    Utilization Management professionals use the most recent available InterQual criteria to establish medical necessity for Skills Training. Requests that do not meet the applicable guideline or InterQual criteria are referred to a TCHP Medical Director or Physician Reviewer, and the Denial Policy is followed.

    Note

    Authorization is not a guarantee of payment

    Preauthorization is based on medical necessity and does not guarantee benefits or eligibility. Even when treatment or a particular service is approved, services remain subject to benefit limitations and exclusions; regulatory noncompliance may result in retrospective audit and potential financial recoupment.

    Guideline Scope

    This guideline addresses skills training for CHIP members who require the service. Utilization Management professionals determine medical necessity by applying the most recent available InterQual criteria. Requests that do not meet the applicable requirements are referred to a TCHP Medical Director or Physician Reviewer for review.

    Policy Summary
    PayerTexas Children's Health Plan
    PolicySkills Training Request for CHIP Members
    Policy CodePolicy 6364
    Change TypeNo material change
    Effective DateFeb 20, 2020
    Next Review DateNot specified
    Key ActionSubmit prior authorization for skills training using the completed Texas Standard Prior Authorization Request Form for Health Care Services.
    SourceLink
    On This Page
    Coverage CriteriaAuthorization and Submission RequirementsGuideline Scope