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 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 non-allowable services and submitted claims for such services will be denied.
Precertification for psychotherapy services for adults are issued for a maximum of ten (10) hours per rolling year for adjustment disorder, Z-code, or unspecified current version ICD diagnostic codes. For all other covered diagnosis codes, refer to the table below for the maximum hours issued for a twelve-month period.
Adults: Maximum Hours Precertified per 12 months
|
|
Individual* 90832 / 90834/90837 |
Family* 90847 |
Family without patient 90846 |
Group 90849/90853 |
|---|---|---|---|---|
|
Max Hours First 12 months |
15 |
10 |
10 |
25 |
|
Max Hours Continued Tx |
20 |
10 |
10 |
30 |
*Note: For first 12 months, provider may precertify up to 25 hours of individual, or family, or a combination. For continued treatment, provider may precertify up to 30 hours of individual, or family, or a combination.
Precertification for psychotherapy services for children and youth are issued for a maximum of ten (10) hours per rolling year for adjustment disorder, Z-code, or unspecified current version ICD diagnostic codes. For all other covered diagnosis codes, refer to the table below for the maximum hours issued for a twelve month period.
Children Not In State Custody: Maximum Hours Precertified per 12 Months: Each Cell Shows First 12 months / Continued Treatment
|
Age |
Testing* |
Individual |
Family |
Family without Patient 90846 |
Group |
|---|---|---|---|---|---|
|
0-2 |
4 |
N/A |
20 / 20 |
10 / 10 |
N/A |
|
3 |
N/A |
5/ 10 |
15 / 20 |
10 / 10 |
N/A |
|
4 |
N/A |
15/ 20 |
15 / 20 |
10 / 10 |
N/A |
|
5-12 |
N/A |
16/ 20 |
37 / 40 |
10 / 10 |
13 / 16 |
|
13-17 |
N/A |
27/ 30 |
26 / 30 |
10 / 10 |
13 / 16 |
|
18-20 |
N/A |
37/ 40 |
16 / 20 |
10 / 10 |
13 / 16 |
*Note: Precertification not required for testing unless under age 3. Annual limit for testing is listed.
Children in Foster Care: Maximum Hours Precertified per 12 Months
Age |
Testing* |
Individual |
Family |
Family without Patient 90846 |
Group |
|---|---|---|---|---|---|
|
0-2 |
4 |
N/A |
50 / 50 |
10 / 10 |
N/A |
|
3 |
N/A |
15 / 20 |
35 / 40 |
10 / 10 |
N/A |
|
4 |
N/A |
35 / 40 |
35 / 40 |
10 / 10 |
N/A |
|
5-12 |
N/A |
37 / 40 |
37 / 40 |
10 / 10 |
36 / 40 |
|
13-17 |
N/A |
37 / 40 |
37 / 40 |
10 / 10 |
36 / 40 |
|
18-20 |
N/A |
37 / 40 |
37 / 40 |
10 / 10 |
36 / 40 |
|
21-25 |
N/A |
37 / 40 |
37 / 40 |
10 / 10 |
36 / 40 |
*Note: Precertification not required for testing unless under age 3. Annual limit for testing is listed.
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 does not apply to Medicare Advantage Plans (Medicare Part C).
- Services performed on an emergency basis. See the definition of emergency in the General Sections Manual.
- 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.