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NOTICE: Clinical Documentation to Support Medical Necessity for Behavioral Health and Substance Use Disorder Services that Require Prior Authorization

Date: 04/02/21

Superior HealthPlan is responsible for ensuring that members have timely access to all medically necessary and appropriate covered health-care services. For services that require authorization of the medical necessity of the service, it is imperative that all required clinical documentation is included with the prior authorization request. Timely provision of the required clinical documentation facilitates completion of the utilization review process to render a timely and appropriate authorization decision.

Beginning on June 1, 2021, Superior will no longer accept clinical information telephonically for Superior Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, STAR+PLUS Medicare-Medicaid Plan (MMP), Allwell from Superior HealthPlan (HMO and HMO SNP) and Ambetter from Superior HealthPlan. Superior reminds providers that clinical documentation can be sent through fax or electronically submitted through Superior’s Secure Provider Portal with the authorization request. Please note that telephonic communication of clinical information is not an appropriate method of delivering clinical information for use for utilization review. Effective immediately, all providers should submit clinical documentation by fax or portal. Superior appreciates provider adherence to its requirements for receipt of clinical information related to all behavioral health and substance use disorder treatment in lower levels of care, as well as concurrent and retrospective utilization review.

This policy is applicable for all inpatient level-of-care behavioral health admissions, including mental health and inpatient alcohol and substance use disorders detoxification, as well as lower level of care to include Behavioral Health Partial Hospitalization (BH PHP) and Intensive Outpatient Programs (BH IOP), Substance Use Disorder Partial Hospitalization (SUD PHP) and Intensive Outpatient Programs (SUD IOP), Residential Detoxification, Substance Use Disorder Residential Treatment (SUD RTC), and Outpatient Electroconvulsive Therapy (ECT).

How to submit clinical information:

Medical record documentation for inpatient behavioral health and lower levels of care, concurrent and retrospective review can be submitted through any of the following methods:

What clinical information to submit:

Facilities must submit:

  • All relevant and updated information and medical records related to the inpatient admission and lower level of care, necessary to complete the review [28 TAC §19.1707(b)], including:
    • An enrollee/member's mental health medical record summary; or
    • Medical records or process or progress notes that relate to treatment of conditions or disorders other than a mental or emotional condition or disorder [28 TAC §19.1707(d)(1-2)].

As specified in the Texas Utilization Review Rule, 28 TAC §19.1707(b)(1), the medical record documentation may include clinical and diagnostic testing information regarding the diagnoses of the enrollee and the medical history of the enrollee relevant to the diagnoses; the enrollee's prognosis; and the plan of treatment prescribed by the provider of record, along with the provider of record's justification for the plan of treatment. The required information should be obtained from the appropriate source. The documentation should also include identifying information about the enrollee; the benefit plan or claim, the treating physician, doctor, or other health-care provider; and the facility rendering care.

As is currently the case, providers are afforded peer-to-peer discussion prior to denial of a concurrent or retrospective review for an inpatient stay or lower level of care service, if the medical necessity of one or more inpatient or lower level of care days cannot be substantiated based on the clinical documentation received.

Superior appreciates the provider participation in our facility network, and values the continued collaboration with your facility. If you have any questions, or would like to obtain further information, please contact your assigned Superior Account Manager.