| Behavioral Health Evaluation and Therapy |
- Benefits are limited to two routine therapy sessions per week; more frequent visits require additional authorization.
- Each beneficiary is allowed eight routine therapy sessions per fiscal year without a medical necessity review; sessions beyond the initial eight require a medical necessity review and prior authorization. Active duty service members (ADSMs) are not eligible for the initial eight visits. He or she must have a referral from his or her MTF or from their Service Point of Contact (SPOC).
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| Notes: |
- Routine outpatient behavioral health does not require a PCM referral; beneficiaries may self-refer. (ADSMs may not self-refer, as noted above.)
- An LMHC, LPC, or pastoral counselor requires a physician referral and ongoing physician supervision in order to be paid. This does not have to be from the beneficiary’s PCM. This information must be included on the CMS-1500 claim form in blocks #17 and #19.
- Providers are allowed one initial evaluation (90801) per beneficiary per year with no authorization. The 90801 does not count as a therapy session within the initial eight visits.
- Crisis intervention (90808, 90809) always requires authorization; request as soon as possible after services are rendered.
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| Substance Use Disorders |
- Benefits are limited to 60 group therapy sessions and 15 family therapy sessions per benefit period.
- Individual therapy is not a covered benefit for beneficiaries with a primary diagnosis of substance use disorder.
- Benefit period begins with the first day of covered treatment and ends 365 days later, regardless of the total services actually used within the year.
- Services must be rendered by institutional providers and always require prior authorization.
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| Other Outpatient Services |
- Psychological testing is generally limited to six hours per year and requires a medical necessity review and prior authorization.
- Medication management checks (90862) do not require medical necessity review or authorization.
- ECT always requires medical necessity review and prior authorization.
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