Reminder of precertification requirements for behavioral health services, including psychotherapy and applied behavior analysis (ABA)
Effective immediately, all ABA services require precertification. Submitted claims for ABA services without a precertification will be denied.
Precertification is required for family, individual, and group psychotherapy (beyond the first fourteen hours) for children and youth, ages 3 through 20 years, who are not in state custody and for fee-for-service covered children and youth in foster care (ME Codes 07, 08, 37, and 38), not residing in a residential treatment facility. With the exception of diagnostic evaluation, precertification is required for all covered services (i.e., psychological testing and family therapy) provided to children age birth through 2 years, regardless of the ME code or placement of the child. Submitted claims for these services without a precertification will be denied.
Telemedicine is subject to the same precertification requirements. Claims submitted for behavioral health telemedicine services without a required precertification will be denied.
Services that require precertification, but were performed without a precertification are nonallowable services and submitted claims for such services will be denied.
Exceptions to precertification requirements are limited to the following:
- Medicare crossovers when Medicare makes the primary reimbursement and MO HealthNet pays only the coinsurance and deductible. This applies to Medicare QMB Part C but does not apply to Medicare non-QMB Part C. (Precertification is required for non-QMB Part C).
- Services performed on an emergency basis. See the definition of emergency in Section 11 of the provider manuals.
- The participant was not eligible for MO HealthNet at the time of service, but eligibility was made retroactive to that time.
Providers may contact MHD Education & Training at MHD.Education@dss.mo.gov with questions or for assistance with one of the exceptions to precertification noted above.