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Medical Assistance Bulletin DRAFT
Commonwealth of Pennsylvania
Department of Public Welfare
Issue Date: December 1, 2000
Effective Date: March 1, 2001

Prior Authorization of Therapeutic
Staff Support (TSS) Services

Number 01-00-03, 29-00-04, 33-00-03, 41-00-01, 48-00-01, 49-00-01, 50-00-02

Purpose

The purpose of this bulletin is to:
1. Inform providers that the Department will require prior authorization of all Therapeutic Staff Support (TSS) services rendered on or after March 1, 2001, to eligible children under 21 years of age enrolled in the Medical Assistance (MA) Program fee-for-service (FFS) delivery system;
2. Issue handbook pages that contain instructions on how to request prior authorization of TSS services, including the type of medical information needed to evaluate requests for TSS services.

Scope

This bulletin applies to all qualified enrolled providers approved to render TSS services to MA enrolled children under 21 years of age and paid through the FFS delivery system.

This bulletin does not apply to services provided by managed care organizations under contract with the Department. Information on managed care behavioral health services can be obtained from the individual managed care organization.

Background

On January 1, 1994, the Department added certain behavioral health rehabilitation services, including TSS services, to the MA Program Fee Schedule for children under 21 years of age. Providers were permitted to bill for TSS services from the MA Program Fee Schedule for the first four months of service when those services did not exceed $10,000 per month. The Department also issued policies, procedures, and time frames for submission of and response to requests for medically necessary behavioral health rehabilitative services not on the MA Program Fee Schedule (including TSS services that exceeded the four month limitation or fee limitation).

Before developing TSS and the other behavioral health rehabilitation services, the Department in 1992 paid $29,059,156 for the traditional clinic-based outpatient and partial hospitalization services, which were virtually the only behavioral health services available to children and adolescents with serious emotional disturbances. Since that time, the behavioral health services delivery system in Pennsylvania has expanded to the point that, in 1999, the Department paid a total of $280,090,978 for the entire continuum of nonresidential behavioral health services in the fee-for-service and mandatory managed care systems, of which $222,170,026 was expended on mobile therapy, behavioral specialist consultation and therapeutic staff support to serve 19,095 children and adolescents. TSS services in the fee-for-service program alone accounted for $91,941,117 in expenditures in 1999.

TSS services are delivered in the home and community in the context of a child's or adolescent's daily routines. They are, by design, intended to provide active, individualized treatment to the child or adolescent and require careful and constant review to determine their effectiveness and the need, if any, for modification to meet the ever changing individualized needs of the child and the family.

When TSS was introduced in 1994, there was a lack of history or experience regarding its prescription and effectiveness. Since then, the Department has obtained six years of experience in reviewing requests for medically necessary TSS services. That experience, along with reports of overutilization and misutilization, has prompted the Department to now require that the service be subject to prior authorization at the outset of a prescription as opposed to beginning after four months of continuous receipt of the service.

Discussion

Effective with dates of service on or after March 1, 2001, the Department will require prior authorization of all TSS services rendered in the MA FFS delivery system.

The documentation submitted to request prior authorization of TSS services must include sufficient detail for the Department's reviewers to determine medical necessity for the requested services. The documentation described in the attached provider handbook section, Procedures To Request Prior Authorization and Submit Claims for Therapeutic Staff Support (TSS) Services, includes the information that experience has shown to be most effective in reflecting the medical need for, and the extent of the need for, TSS services. Evaluation of the documentation for medical necessity will take the following three criteria into account:

1. Level of Care
2. Documentation supporting the need for services
3. Active Treatment

Procedure

Providers should place the accompanying handbook pages in their provider handbooks. As described in 55 Pa. Code § 1101.67(a), the procedure described within the handbook pages must be followed in order to ensure timely processing of prior authorization requests for TSS services.

Effective with dates of service on or after March 1, 2001, ALL TSS SERVICES WILL REQUIRE PRIOR AUTHORIZATION IN ORDER FOR PROVIDERS TO BE PAID BY THE MA FFS PROGRAM FOR SERVICES RENDERED.

For TSS services that were approved before March 1, 2001 through the 1150 Administrative Waiver Process to include dates of service on or after March 1, 2001:

TSS services approved for a child/adolescent through the 1150 Administrative Waiver Process prior to March 1, 2001, may include authorized periods of services that extend past March 1, 2001. The Department will recognize the approval granted through the Waiver Process until the end of the authorization period. The Program Exception authorization number is the number that should be used to bill through the end of the authorization period. All subsequent requests must be processed through the prior authorization process as described in the attached provider handbook section.

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