SECTION 354.2607. Assessment and Service Authorization

(a) Assessment.

(1) A QMHP-CS with appropriate supervision and training must perform an assessment of an individual in accordance with the requirements of the Texas Medicaid Provider Procedures Manual (TMPPM), including all updates and revisions, and all the handbooks, standards, and guidelines as determined by HHSC or a managed care organization (MCO) with which they contract.

(2) An assessment of an individual may be performed as a telemedicine medical service or a telehealth service, including via an audio-only platform, in accordance with the requirements and limitations of Subchapter A, Division 33 of this chapter (relating to Advanced Telecommunications Services).

(b) Documentation. The assessment must be documented and must include:

(1) the individual's identifying information;

(2) completion of the appropriate uniform assessment(s) and assessment guideline calculations;

(3) the individual's present status and relevant history, including education, employment, housing, legal, military, developmental, and current available social and support systems;

(4) the individual's co-occurring substance use, intellectual or developmental disability, or physical health condition, if any;

(5) the individual's relevant past and current medical and psychiatric information, which may include trauma history;

(6) information from the individual and LAR, if applicable, regarding the individual's strengths, needs, natural supports, community participation, responsiveness to previous treatment, as well as preferences for and objections to specific treatments;

(7) the need or desire of the individual for family member involvement or other identified natural supports in treatment and mental health community services, if the individual is an adult without an LAR;

(8) the identification of the LAR's or family members' need for education and support services related to the individual's mental illness or emotional disturbance and the plan to facilitate the LAR's or family members' receipt of the needed education and support services;

(9) recommendations and conclusions regarding treatment needs;

(10) the mode of delivery; and

(11) date, signature, and credentials of the staff member completing the assessment.

(c) Diagnostics. The diagnosis of a mental illness must be:

(1) rendered by an LPHA, acting within the scope of his license, who has interviewed the individual;

(2) based on diagnostic criteria from the latest edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders;

(3) documented in writing, including the date, signature, and credentials of the person making the diagnosis; and

(4) supported by and included in the uniform assessment.

(d) Provision of services. The comprehensive provider agency and staff members must provide services in accordance with the requirements of the TMPPM, including all updates and revisions, and all handbooks, standards, and guidelines as determined by HHSC or an MCO with which they contract.

(e) A service described in this subsection may be delivered as a telemedicine medical service or a telehealth service, including via an audio-only platform, in accordance with the requirements and limitations of Subchapter A, Division 33 of this chapter. The comprehensive provider agency and staff members must implement procedures to ensure that each individual is provided mental health services based on:

(1) the assessment conducted under subsection (a) of this section;

(2) medical necessity as determined by an LPHA; and

(3) when available, physical health care needs as determined by a physician, physician assistant, or advanced practice registered nurse.

(f) Prerequisites to provision of services. Except for crisis intervention services provided under §354.2707 of this subchapter (relating to Crisis Intervention Services), before providing services to an individual under this subchapter a comprehensive provider agency must:

(1) if required by the managed care organization, submit authorization requests to the MCO with which the individual is enrolled for the type(s), amount, and duration of services to be provided to the individual in accordance with the uniform assessment and the utilization management guidelines; and

(2) in collaboration with the individual and his LAR, if applicable, develop a recovery/treatment plan for the individual that complies with the requirements of this subchapter.

Source Note: The provisions of this §354.2607 adopted to be effective October 17, 2018, 43 TexReg 6819; amended to be effective January 23, 2023, 48 TexReg 209