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Program of Assertive Community Treatment (PACT)Review Type in QTPlace of ServiceType of ServiceBehavioral Health Outpatient99 – Other Place of ServiceAMDD PACTTimingProcedure CodeMCG Guideline Name – PA specificDiagnostic/MNC CriteriaProspective, Retrospective, Concurrent, Continued StayH0040MT PACT Initial(1) Meets SDMI criteria as described in AMDD Provider Manual;(2) The prognosis for treatment of the member at a lessrestrictive level of care is poor, because the memberdemonstrates the following due to the SDMI:(a) significantly impaired interpersonal or social functioning;(b) significantly impaired occupational functioning;(c) impaired judgment;(d) poor impulse control; or(e) lack of family or other community or social supports;(3) Inability to consistently perform the range of practical dailyliving tasks required for basic adult functioning in the communityor persistent or recurrent failure to perform daily living taskswithout significant support or assistance from others;(4) Inability to be consistently employed at a self-sustaining levelor inability to consistently carry out the homemaker role;(5) Inability to maintain a safe living situation;(6) Two or more admissions within the past 12 months intoacute psychiatric hospitals, crisis stabilization programs orpsychiatric emergency services;(7) Intractable (persistent and/or recurrent) or severe majorsymptoms which present with affective, psychotic or at risk forharm to self or others;(8) Co-occurring SUD with a duration of greater than six months;(9) High risk or recent history of criminal justice involvement;(10) Inability to meet basic survival needs or residing in subsubstandard housing, homeless or at imminent risk of beinghomelessBiopsychosocial assessment; psychiatric intake assessment;and/or psychiatric provider discharge summary from psychiatricfacility/providerYes – Electronic fields in provider portal (QT)*Faxed requests possible until 2/28/20; form available onMountain-Pacific provider portal for faxes onlyNo earlier than 5 business days prior to requested start date ofservicesMNC up to 180 daysTechnical denial for requests earlier than 5 business days;Requests received after admission will be reviewed for MNCfrom date of submission moving forward3 business days (additional 3 business days for PR)Examples of clinical documentationto support PA criteriaPA RequiredTimeframe for PA requestInitial Authorization PeriodOutcome of missing PA timeframeTAT for UM review of PACSR RequiredMCG Guideline Name – CSRspecificYes – Electronic fields in provider portal (QT)*Faxed requests possible until 2/28/20; form available onMountain-Pacific provider portal for faxes onlyMT PACT CSR7

CSR CriteriaExamples of clinical documentationto support CSR criteriaTimeframe for CSRCSR coverage periodOutcome of missing CSR timeframeTAT for CSRTimeframe for RFI for PA or CSRTAT of UM review after RFIsubmittedOutcome of missing RFI for PA orCSROutcome of UM for PA or CSRDischarge Notification Required(1) Member continues to meet SDMI criteria as described inAMDD Provider Manual.(2) The prognosis for treatment of the SDMI at a less restrictivelevel of care remains poor, because the member stilldemonstrates two or more of the following:(a) significantly impaired interpersonal or social functioning;(b) significantly impaired educational or occupationalfunctioning;(c) impaired judgment; or(d) poor impulse control.(3) As a result of the SDMI, the member exhibits an inability toperform daily living activities in a developmentally appropriatemanner without the structure of the PACT service.(4) The SDMI symptoms of the member are of a severe orpersistent nature requiring more intensive treatment and clinicalsupervision than can be provided by other outpatient or in-homemental health services.(5) The member continues to require at least three of thefollowing services:(a) medication management;(b) psychotherapy;(c) community psychiatric supportive treatment;(d) skills training;(e) vocational services; or(f) co-occurring services.(6) The member has demonstrated progress toward identifiedtreatment goals and has a reasonable likelihood of continuedprogress.Most recent treatment plan demonstrating progress towardsgoals; discharge plan including projected discharge date andprogress towards completion of the plan; medication listincluding rationale for med changes, if applicable; progressnotes or assessments detailing the following: changes toDSM/ICD diagnosis; description of Interventions and criticalincidents.Any additional clinical documentation provider sees fit to provideto demonstrate CSR criteria including justification for continuedservice at current LOC.No earlier than 5 business days prior to last covered dayMNC up to 180 daysTechnical denial if received earlier than 5 business days;Requests received after the authorized period has expired willbe reviewed for MNC from the date of submission movingforward3 business days (additional 4 business days for PR)Must be submitted to UM team within 5 business days ofrequest3 business days (additional 3 business days for PR)Technical denialApproval, Partial or DenialYes – Completed via Discharge Status Task in QT8

Crisis Stabilization Program (a.k.a., crisis intervention facility)Review Type in QTPlace of ServiceType of ServiceBehavioral Health Inpatient99 – Other Place of ServiceAMDD Crisis StabilizationTimingProcedure CodeMCG Guideline Name – PA specificDiagnostic/MNC CriteriaRetrospective, Concurrent, Continued StayS9485MT Crisis Stabilization Initial(1) Any mental health DSM V diagnosis as primary;(2) Danger to self as evidenced by behaviors as described in theAMDD Provider Manual;(3) Danger to others, as evidenced by behaviors as described inthe AMDD Provider Manual;(4) Grave disability as exhibited by ideas or behaviors, asdescribed in the AMDD Provider Manual;*Not unless in need of CSR – Electronic fields in providerportal (QT)Must be submitted prior to or same day as CSR requestUp to 5 days (No PA needed for first 5 days)Yes – Electronic fields in provider portal (QT)*Faxed requests possible until 2/28/20; form available onMountain-Pacific provider portal for faxes onlyMT Crisis Stabilization CSRPA RequiredTimeframe for PA requestInitial Authorization PeriodCSR RequiredMCG Guideline Name – CSRspecificCSR CriteriaExamples of clinical documentationto support CSR criteriaTimeframe for CSR(1) Any mental health diagnosis from the current version of theDSM as the primary diagnosis and both the following:(a) active treatment is occurring, which is focused on stabilizingor reversing symptoms that meet the admission criteria; and(b) a lower level of care is inadequate to meet the member’streatment or safety needs.(2) Either (a), (b) or (c) below:(a) There is reasonable likelihood of a clinically significantbenefit resulting from medical intervention requiring theinpatient setting;(b) There is a high likelihood of either risk to the member’ssafety, clinical well-being, or further significant acutedeterioration in the member’s condition without continuedcare and lower levels of care inadequate to meet theseneeds; or(c) The appearance of new impairments meeting admissionguidelines.Most recent treatment plan demonstrating progress towardsgoals; discharge plan including projected discharge date andprogress towards completion of the plan; medication listincluding rationale for med changes, if applicable; progressnotes or assessments detailing the following: changes toDSM/ICD diagnosis; description of Interventions and criticalincidents.Any additional clinical documentation provider sees fit to provideto demonstrate CSR criteria including justification for continuedservice at current LOC.Prior to last covered day9

CSR coverage periodOutcome of missing CSR timeframeTAT for UM review of CSRTimeframe for RFI for CSROutcome of missing RFI for CSRMNC up to 3 daysTechnical denial if received earlier than 3 business days;Requests received after the authorized period has expired willbe reviewed for MNC from the date of submission movingforward3 business days (additional 4 business days for PR)Must be submitted to UM team within 5 business days ofrequestTechnical denialTAT of UM review after RFIsubmittedOutcome of UM for PA or CSR3 business days (additional 4 business days for PR)Discharge Notification RequiredYes – Completed via Discharge Status Task in QTApproval, Partial or Denial10

Adult Group Home (AGH)Review Type in QTPlace of ServiceBehavioral Health Residential99 – Other Place of ServiceType of ServiceTimingProcedure CodeMCG Guideline Name – PA specificDiagnostic/MNC CriteriaAMDD Adult Group HomeProspective, Retrospective, Concurrent, Continued StayS5102MT Adult Group Home Initial(1) Meets SDMI criteria as described in AMDD Provider Manual;(2) The prognosis for treatment of the member at a lessrestrictive level of care is poor because the memberdemonstrates 3 or more of the following due to the SDMI:(a) significantly impaired interpersonal or social functioning;(b) significantly impaired occupational functioning;(c) impaired judgment;(d) poor impulse control; or(e) lack of family or other community or social supports.(3) Due to the SDMI, the member exhibits an impaired ability toperform daily living activities in an appropriate manner;(4) The member exhibits symptoms related to the SDMI severeenough that a less intensive level of service would be insufficientto support the member in an independent living setting or themember is currently being treated or maintained in a morerestrictive environment and requires a structured treatmentenvironment to be successfully treated in a less restrictivesettingBiopsychosocial assessment; psychiatric intake assessment;and/or psychiatric provider discharge summary from psychiatricfacility/providerExamples of clinical documentationto support PA criteriaPA RequiredTimeframe for PA requestInitial Authorization PeriodOutcome of missing PA timeframeTAT for UM review of PACSR RequiredMCG Guideline Name – CSRspecificCSR CriteriaAny additional clinical documentation provider sees fit to provideto demonstrate PA criteria including justification for service atrequested LOCYes – Electronic fields in provider portal (QT)*Faxed requests possible until 2/28/20; form available onMountain-Pacific provider portal for faxes onlyNo earlier than 5 business days prior to admit dateMNC up to 120 daysTechnical denial for requests earlier than 5 business days;Requests received after admission will be reviewed for MNCfrom date of submission moving forward3 business days (additional 3 business days for PR)Yes – Electronic fields in provider portal (QT)*Faxed requests possible until 2/28/20; form available onMountain-Pacific provider portal for faxes onlyMT Adult Group Home CSR(1) The member continues to exhibit symptoms related to theSDMI severe enough that a less intensive level of service wouldbe insufficient to support the member in an independent livingsetting and requires a structured treatment environment to besuccessfully treated. The member must continue to meet themedical necessity criteria AND the following:11

Examples of clinical documentationto support CSR criteriaTimeframe for CSRCSR coverage periodOutcome of missing CSR timeframeTAT for CSRTimeframe for RFI for PA or CSRTAT of UM review after RFIsubmittedOutcome of missing RFI for PA orCSROutcome of UM for PA or CSRDischarge Notification Required(a) active treatment is occurring, which is focused onstabilizing or alleviating the psychiatric symptoms andprecipitating psychosocial stressors that are interfering withthe ability of the member to receive services in a lessintensive outpatient setting;(b) demonstrated and documented progress is being madetoward the treatment goals and there is a reasonablelikelihood of continued progress; and(c) AGH is the least restrictive service to meet the clinicalneeds of the memberMost recent treatment plan demonstrating progress towardsgoals; discharge plan including projected discharge date andprogress towards completion of the plan; medication listincluding rationale for med changes, if applicable; progressnotes or assessments detailing the following: changes toDSM/ICD diagnosis, description of Interventions and criticalincidents;Any additional clinical documentation provider sees fit to provideto demonstrate CSR criteria including justification for continuedservice at current LOCNo earlier than 5 business days prior to last covered dayMNC up to 90 daysTechnical denial if received earlier than 5 business days;Requests received after the authorized period has expired willbe reviewed for MNC from the date of submission movingforward3 business days (additional 4 business days for PR)Must be submitted to UM team within 5 business days ofrequest3 business days (additional 4 business days for PR)Technical denialApproval, Partial or DenialYes – Completed via Discharge Status Task in QT12

SUD Medically Monitored Intensive Inpatient (ASAM 3.7), Adult (21 andover)SUD Medically Monitored Intensive Inpatient (ASAM 3.7), Adolescent(under 21)Review Type in QTPlace of ServiceType of ServiceTimingProcedure CodeBehavioral Health Residential99 – Other Place of ServiceAMDD ASAM 3.7 Adult -or- AMDD ASAM 3.7 AdolRetrospective, Concurrent, Continued StayH0010MCG Guideline Name – PA specificDiagnostic/MNC CriteriaMT ASAM 3.7 Initial(1) Meets SUD criteria as described in AMDD Provider Manual;(2) Meets ASAM 3.7 criteriaBiopsychosocial assessment; intake assessment; history andphysical exam from current treatment episode; urine drugscreen results OR serum drug screen (for providers that do notutilize UDS)Examples of clinical documentationto support PA criteriaPA RequiredTimeframe for PA requestInitial Authorization PeriodOutcome of missing PA timeframeTAT for UM review of PACSR RequiredMCG Guideline Name – CSRspecificCSR CriteriaExamples of clinical documentationto support CSR criteriaTimeframe for CSRAny additional clinical documentation provider sees fit to provideto demonstrate PA criteria including justification for service atrequested LOCYes – Electronic fields in provider portal (QT)*Faxed requests possible until 2/28/20; form available onMountain-Pacific provider portal for faxes onlyWithin 3 business days of admission3 daysTechnical denial if received earlier than 3 business days ofadmission; Requests received after the authorized period hasexpired will be reviewed for MNC from the date of submissionmoving forward2 business days (additional 3 business days for PR)Yes – Electronic fields in provider portal (QT)*Faxed requests possible until 2/28/20; form available onMountain-Pacific provider portal for faxes onlyMT ASAM 3.7 CSR(1) Continue to meet the SUD criteria as described in AMDDProvider Manual;(2) Continue to meet the ASAM 3.7 criteria;(3) Initial lab results at admissionMost recent treatment plan demonstrating progress towardsgoals; discharge plan including projected discharge date andprogress towards completion of the plan; urine drug screenresults OR serum drug screen (for providers that do not utilizeUDS); current labs (complete metabolic panel and completeblood count)Any additional clinical documentation provider sees fit to provideto demonstrate CSR criteria including justification for continuedservice at current LOCNo earlier than 3 business days and prior to last covered day13

CSR coverage periodOutcome of missing CSR timeframeTAT for CSRTimeframe for RFI for PA or CSRTAT of UM review after RFIsubmittedOutcome of missing RFI for PA orCSROutcome of UM for PA or CSRDischarge Notification RequiredMNC up to 5 business daysTechnical denial if received earlier than 3 business days;Requests received after the authorized period has expired willbe reviewed for MNC from the date of submission movingforward3 business days (additional 4 business days for PR)Must be submitted to UM team within 5 business days ofrequest3 business days (additional 4 business days for PR)Technical denialApproval, Partial or DenialYes – Completed via Discharge Status Task in QT14

SUD Clinically Managed High-Intensity Residential (ASAM 3.5), Adult (21and over)SUD Clinically Managed Medium-Intensity Residential (ASAM 3.5),Adolescent (under 21)Review Type in QTPlace of ServiceType of ServiceTimingProcedure CodeBehavioral Health Residential99 – Other Place of ServiceAMDD ASAM 3.5 Adult -or- AMDD ASAM 3.5 AdolProspective, Retrospective, Concurrent, Continued StayH0018MCG Guideline Name – PA specificDiagnostic/MNC CriteriaMT ASAM 3.5(1) Meets SUD criteria as described in AMDD Provider Manual;(2) Meets ASAM 3.5 criteriaBiopsychosocial assessment; intake assessment; urine drugscreen results OR serum

BEHAVIORAL HEALTH PROVIDER USER GUIDE for Montana Medicaid Behavioral Health Services Transitioning to Qualitrac Effective January 1, 2020 This project is funded in whole or in part under a Contract with the Montana Department of Public Health