Provider Alert! Peer Specialist Services Became a Benefit of Texas Medicaid January 1, 2019

Attention: Behavioral Health Providers

Effective Date: October 28, 2020

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that Code H0038 is a benefit of Texas Medicaid for members 21 years of age and older effective, January 1, 2019. Reimbursement for procedure code H0038 is limited to substance use disorders and mental health conditions, including, but not limited to, schizophrenia spectrum and other psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, trauma and stressor related disorders, and feeding and eating disorders.

Procedure code H0038 will be limited to 104 units in a rolling six-month period. This limit may be exceeded with demonstrated medical necessity for the additional services. Peer specialist services will also be limited as follows:

• May not be delivered simultaneous to other behavioral health services being delivered to an individual or group of individuals
• Must be delivered in person and not via advanced telecommunications technology
• When delivered in a group setting, limited to 12 total individuals per group session

How this impacts providers: Provider Certification: A peer specialist must complete all required training and certification before providing services. To be certified as a peer specialist as specified in 1 TAC §354.3155, a candidate must complete the following training:

• Required orientation
• Self-assessment activities
• Core training delivered by a certified training entity
• Supplemental training in one of two specialty areas:
• Mental health peer specialist
• Recovery support peer specialist

The candidate can apply for initial certification after successful completion of core and one supplemental training and a knowledge assessment.

Source: Section 6.2 Peer Specialist Requirements and 6.2.1 Certification, BEHAVIORAL HEALTH AND CASE MANAGEMENT SERVICES HANDBOOK

Next steps for providers: Providers should follow the following Prior Authorization Requirements:

Prior authorization is not required for the first 104 units of peer specialist services in a rolling 6-month period. Prior authorization is required once a client exceeds 104 units of individual or group peer specialist services in a rolling 6-month period.

Prior authorization requests for procedure code H0038 must be submitted to TMHP using the Special Medical Prior Authorization (SMPA) Request Form. Requests for continued services must demonstrate all of the following:

• The client continues to meet eligibility criteria as outlined in the statement of benefits above, including current DSM diagnoses
• The current person-centered recovery plan and goals
• The progress made relative to the goals outlined in the person-centered recovery plan
• The need for continued services

Requests must indicate how many additional units of service are being requested (up to 30 units are allowed per request) and the type (individual or group), as well as the expected time frame when services will be delivered.

Note: The requesting provider may be asked for additional information to clarify or complete a request.

Retrospective review may be performed to ensure that the documentation supports the medical necessity of the requested service.

Refer to:  Refer to: “Section 5: Fee-for-Service Prior Authorizations” (Vol. 1, General Information) for more information on submitting prior authorization methods.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.