Charlene Toten, Division Director
Mental Health Services offered by Medicaid include:
Psychiatric Facilities–provide acute services for children under
21, with an average length of stay of 7-10 days. Prior authorization is required.
Therapeutic and Evaluative Mental Health Services for Children–provide
the Expanded Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program
for children under 21 years of age, which includes therapeutic and evaluative services.
All services must be medically necessary and require prior authorization from the
Division of Medicaid. Service standards apply but can be over-ridden.
Record Review Process
Services Record Review
Evaluation Record Review
Find a mental health provider in
Billing Guidelines for
Therapeutic & Evaluative Mental Health Services for Children
(Formerly Billing Guidelines for Community-Based Mental Health Services)
Community Mental Health Center Services –
mental health services provided for children and adults by one of the regional Community
Mental Health Centers or Community Services Division of a State Hospital.
Community Mental Health
Center Billing Guidelines
Health Center and Rural Health Clinics–provide mental health
services in the community, but are based on visits. Each person is allowed a medical
visit and a separate mental health visit. All visits count against the service limits
for adults. Children under the age of 21 may receive more visits, if medically necessary,
with prior authorization.
Geriatric Psychiatric services are
for Chemical Dependency –limited to detoxification. Medicaid
does not cover alcohol and drug treatment; however, with a primary mental health
diagnosis, the rules for psychiatric units apply.
Intellectual Disabilities/Developmental Disabilities
The ID/DD Waiver provides services to individuals who, but for the
provision of home and community-based services, would require placement in an Intermediate
Care Facility for the Mentally Retarded (ICF/MR). Individuals in this program must
qualify for one of the following eligibility categories: SSI, TANF, Disabled Child
Living at Home, or income up to 300% of the SSI Federal Benefit Rate. The ID/DD
waiver is administered by the Department of Mental Health, Bureau of Intellectual
and Developmental Disabilities. The Department, through its regional centers,
provides support coordination and, through an assessment process, makes referrals
for the following services: Behavior Support, Day Services-Adult, Home and Community
Supports, Occupational Therapy,
Physical Therapy, Speech Therapy, Supervised Living,
Community Respite, Host Homes, Crisis Support, Crisis Intervention, In-Home Nursing
Respite, Support Living, Transition Assistance, Support Coordination, Supported Employment,
Prevocational Services, Job Discovery and Specialized
Approved 1915(c) Waiver (full content)
ID/DD Waiver On-Site Compliance Review Process
DMH Document Review
Regional Center Document Review
Individual Record Review
ID/DD Waiver Fee Schedule Effective 7/1/2013
Outpatient Hospital Services
– mental health services are covered when provided in an outpatient department of
a general hospital. They are not covered at acute freestanding psych facilities.
Pre-Admission Screening and Resident Review (PASRR)
–an administrative activity, which determines if applicants for nursing facility
placement meet the criteria for needed specialized mental health services due to
an indication of Mental Illness or Mental Retardation. The screening is performed
by Community Mental Health Centers (CMHC) and Regional Centers around the State.
If determined necessary, CMHCs may provide specialized mental health services to
the resident in the nursing facility.
Fees for PASRR Administrative Services
Resident Review Summary Level II
PreAdmission Screening Resident Review Summary Level II for MR form
Psychiatric Residential Treatment Facilities–residential
services for children under 21, with an average length of stay of 6 months. Prior
authorization is required.
Psychiatry Services by Physician or Nurse Practitioner–limited
to 12 visits per fiscal year, which do not affect the 12 physician office visits
for medical issues. Children under the age of 21 may receive more visits, if medically
necessary, with prior authorization.
Billing Guidelines for Mental Health/Psychiatry
Psychiatric Units at General Hospitals–provide acute psychiatric
services for both children and adults, with an average length of stay of 7-10 days.
There is a limit of 30 days per fiscal year for adults. Children may have more days,
if medically necessary. Prior authorization is required.
Fee Schedule by individual procedure
code and service date through Envision
Find a mental health provider in
Plug into your Medicaid Services