KMAP BULLETIN: PRTF Clinical Requirements

Date: 03/07/24

KMAP GENERAL BULLETIN 24026 (PDF)

Effective with dates of service retroactive to June 15, 2017, Medicaid covered members (children/youth) presenting for Psychiatric Residential Treatment Facility (PRTF) admission consideration must be assessed for medical necessity as this is a higher level of care. The Managed Care Organizations (MCOs) may request both a Community Based Services Team (CBST) meeting and a Psychiatric Diagnostic Evaluation for a recommendation for admission or diversion.

The following codes are defined as "per evaluation." Codes 90791 and 90792 can only be billed once per day, and both codes cannot be billed on the same day. Codes 90791 or 90792 may be billed on the same day as codes H0032-HA*, H0031, and H0032.

*Code H0032-HA is only billable by a Community Mental Health Center (CMHC)/Certified Community Behavioral Health Clinic (CCBHC).

The Psychiatric Diagnostic Evaluation must be conducted face-to-face with the child/youth using the approved methods. Additionally, a CBST meeting may be requested and completed. If requested by the MCO, both the Psychiatric Diagnostic Evaluation and a CBST meeting will be held each time a prior authorization for a PRTF level of care is requested or is set to expire.

The CMHC/CCBHC or private clinician shall submit the Psychiatric Diagnostic Evaluation and/or the CBST meeting results to the MCO. The MCO shall utilize assessments to determine medical necessity for admission to a PRTF. The MCO will begin their utilization management process by applying their criteria for medical necessity. If the MCO determines the child meets medical necessity for the higher level of care in a PRTF, the child will be placed on the waitlist. The MCO may determine the need for and authorize community-based services to be provided in the community.

Note: The effective date of the policy is June 15, 2017. The implementation of State policy by the KanCare MCOs may vary from the date noted in the Kansas Medical Assistance Program (KMAP) bulletins. The KanCare Open Claims Resolution Log on the KMAP Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates once the policy is implemented.

For changes resulting from this provider bulletin, see the updated CCBHC Fee-for-Service Provider manual.