(1) To be reimbursed, targeted case management services for youth with SED must be authorized by the department or its designee via an authorization process as outlined below.

(2) A case manager may request up to 120 units in an initial request for authorization.

(a) A unit of targeted case management services is equal to 15 minutes.

(3) An initial request for authorization must also include:

(a) demographic information about the youth;

(b) the name and mailing address of a responsible party, if any;

(c) the name of the provider and other provider information; and

(d) the youth's DSM-IV diagnosis code.

(4) A case manager may submit an unscheduled revision (continued stay) requesting authorization for continued services of up to 120 units more than the initial number of authorized units. The department or its designee will determine if further targeted case management services are medically necessary. The unscheduled revision request must include:

(a) documentation of an SED diagnosis and functional impairment;

(b) documentation of the need for continued targeted case management services;

(c) a case formulation that includes measurable case management goals and objectives;

(d) a complete list of other services currently in place; and

(e) a discharge plan.

(5) Targeted case management services requested in excess of 240 units in a single state fiscal year (July 1 – June 30) must be reviewed by the department or its designee to determine medical necessity. All the requirements of (4) also apply.