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BHRS Medical Necessity Documentation
April 2, 2002

The Department of Public Welfare (DPW) has issued a Medical Assistance Bulletin on documentation of medical necessity criteria. The Bulletin applies to all enrolled Medical Assistance (MA) providers who prescribe BHRS to MA enrolled children under 21 years of age and who are paid through the fee-for-service or behavioral health managed care delivery systems.

The purpose of the Bulletin is to remind prescribing providers, i.e., psychiatrists and licensed psychologists, of the requirement that they must provide appropriate medical information and documentation in order for DPW to evaluate the medical necessity for Behavioral Health Rehabilitation Services (BHRS) and that when documentation fails to justify the medical necessity of the MA recipient's need for these services, a prospective denial of services or retrospective restitution of payment to the Department will occur.

DPW has monitored the documentation received as part of the prior authorization process for Therapeutic Staff Support Services over the past year. Deficiencies have been identified in psychological and psychiatric evaluations, treatment history, mental status exams, child and family strengths, current services being utilized, new services being requested, and information related to active treatment and coordination of care.

Providers are encouraged to review the Bulletin and take appropriate action.

The Bulletin is available on the DPW web site at www.dpw.state.pa.us/omap/provinf/mabull/010207.asp

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