Newsletter Vol. 9, No. 74

Immediately: Billing and clinical teams must implement the following controls for PC/PH mental health claims: (1) Require providers to document in the treatment plan that all off-site activities are physician-prescribed, individualized, therapeutic in nature, and integrated into specific treatment goals with measurable objectives. (2) Update billing system rules to track off-site activity time and flag claims when off-site services exceed 10% of a client's 12-month programming time—require prior authorization from the Division before submitting these claims. (3) Establish that prior authorization is NOT required for clients receiving fewer than 90 days of PH services or less than $6,000 of PC services annually; PA IS required for continued services beyond these thresholds. (4) Ensure encounter documentation captures sign-in/sign-out times at the clinic for both on-site and off-site activities separately. (5) Reject or return claims for off-site services that are solely recreational in nature or lack clear therapeutic linkage to treatment plan goals. (6) For transportation claims: only count time when a counselor (not a driver) is actively conducting billable PC/PH activities in the vehicle; flag transportation-only time as non-billable. Failure to comply will result in claim denials and potential overpayment recapture.