Montana Administrative Register Notice 37-597 No. 19   10/11/2012    
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In the matter of the amendment of ARM 37.87.903 pertaining to changing prior authorization requirements and adopting a new utilization review manual







TO: All Concerned Persons


1. On August 9, 2012, the Department of Public Health and Human Services published MAR Notice No. 37-597 pertaining to the public hearing on the proposed amendment of the above-stated rule at page 1609 of the 2012 Montana Administrative Register, Issue Number 15.


2. The department has amended the above-stated rule as proposed.


            3. The department has thoroughly considered the comments and testimony received. A summary of the comments received and the department's responses are as follows:


COMMENT #1One commenter asked why case management and community-based psychiatric rehabilitation services (CBPRS) does not have an "x" in the box under CON (certificate of need) on page 8 of the UR manual, since neither of these services requires a CON.


RESPONSE #1: The boxes referenced should have an "x".  The department will correct this typographical error.


COMMENT #2: A commenter refers to the title Medical Necessity Criteria on pg. 1 of the UR manual and asked the department to define what is meant by Medical Necessity Criteria.


RESPONSE #2: The general definition of medical necessity or medically necessary service is defined in ARM 37.82.102(18). Medical necessity is further defined for children's mental health services using specific criteria. For children's mental health services, the terms medical necessity criteria, clinical management guidelines, and clinical guidelines mean the same thing. The medical necessity criteria are used as a guideline in determining whether or not children's mental health services are clinically indicated to treat the youth and for how long. The criteria are separated into admission and continued stay criteria; both are used as guidelines in determining whether services are medically necessary and will be reimbursed by Medicaid. The purpose of the Children's Mental Health Bureau Provider Manual and Clinical Guidelines for Utilization Management (UR manual) is to define the medical necessity criteria for children's mental health services for Medicaid reimbursement and the process for requesting a review.


COMMENT #3: A commenter asked for clarification of the apparent disparity in the UR manual between the CON criteria for therapeutic group home (TGH) which includes:  e) Lack of family and other community social networks and the medical necessity criteria (MNC) for continued stay in a TGH which includes "2. The youth and family/legal representative are engaged in treatment and making progress."


RESPONSE #3: The department appreciates the commenter's recommendations; however, the comment is outside the scope of the proposed changes to the UR manual. The department did not propose changes to the TGH CON criteria.


COMMENT #4: On pg. 28 of the UR manual, a commenter suggested that the department should consider the chronicity of symptoms and behaviors in addition to their severity, stating that the interval between episodes of severe behaviors may increase when the youth is in an intensive level of care, but the risk of the behavior returning increases when the person returns to a lower level of care.


RESPONSE #4: The department appreciates the commenter's recommendations; however, the comment is outside the scope of the proposed changes to the UR manual.


COMMENT #5: A commenter suggested adding Dialectical Behavioral Therapy (DBT) as an example of specialized outpatient therapy to be allowed concurrent with Comprehensive School and Community Treatment (CSCT), and disagreeed with the statement that continuation of an existing relationship with the previous outpatient therapist does not constitute a specific clinical need.  The commenter also asked what constitutes adequate documentation regarding the coordination of care between the outpatient therapist and the CSCT therapist.


RESPONSE #5: The department appreciates the commenter's recommendations; however, the comment is outside the scope of the proposed changes to the UR manual.


COMMENT #6:  In section 5.8.2 of the UR manual one of the criteria for providing outpatient therapy in excess of 24 sessions is "SED diagnosis and currently global assessment of functioning (GAF)." A commenter asked if there is a limit or cut-off GAF score that is expected for support of additional sessions.


RESPONSE #6: The department appreciates the commenter's recommendations; however, the comment is outside the scope of the proposed changes to the UR manual.


COMMENT #7: A commenter asked for clarification of the continued stay criteria for therapeutic family care (TFC) in the UR manual.


RESPONSE #7: The department appreciates this question.  Since TFC services will not require prior authorization after October 1, 2012, TFC providers must use the TFC admission criteria in assessing whether or not to provide TFC services to youth.


COMMENT #8: One commenter asked for a copy of the proposed October 1, 2012 UR manual and wondered if it was complete. The commenter wanted to make sure they had an opportunity to review the proposed manual changes before it became final and wanted to be reassured that the department could not modify the manual after the adoption of the rule.


RESPONSE #8: The MAR notice was published on August 9, 2012 and provided the web site address where the proposed manual was posted for review during the rulemaking process.  The manual contained the revisions the department was proposing to make.  The department cannot modify the manual outside of the rulemaking process as it is adopted and incorporated into the rule.


COMMENT #9: Two commenters commented on Section 4, Appeal process of the UR manual requesting language revision based upon actual practice of the Utilization Management Contractor and the Office of Fair Hearings.


RESPONSE #9: The department has made the requested language revisions to the UR manual based upon these comments. Both commenters are well versed in actual practice of the two entities mentioned above and the revisions ensure the UR manual is correct. The revisions may be viewed at our web site at: www.dphhs.mt.gov/mentalhealth/children/ or at www.dphhs.mt.gov/dsd/adminrules.shtml during the rulemaking process.


The revisions made include the following:


In 4.1, language is removed that references the ten calendar day timeframe before an initial recommendation becomes a final determination. Language had also been added to clarify that parents or legal representatives maintain their right to request a fair hearing.


In 4.2, the department added language which better describes peer-to-peer reviews and desk reviews.


COMMENT #10: One commenter asked a question, "in the clinical management guidelines under 5.8.5 who will be authorizing outpatient therapy services concurrent with TGH, the department or the UR contractor."


RESPONSE #10: The department researched this and in the new utilization review contract the UR contractor is responsible for authorizing outpatient therapy services concurrent with Therapeutic Group Home.  The department has corrected this in section 5.8.5 of the UR manual.


COMMENT #11: One comment noted that there was a clerical error regarding the effective date on the cover of the UR manual.


RESPONSE #11: The department has corrected the error and the effective date on the manual now states October 1, 2012.


            4. The department intends to apply these rules retroactively to October 1, 2012. A retroactive application of the proposed rules does not result in a negative impact to any affected party.



/s/ John Koch                                               /s/ Anna Whiting Sorrell                            

Rule Reviewer                                             Anna Whiting Sorrell, Director

                                                                        Public Health and Human Services


Certified to the Secretary of State October 1, 2012.


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