Authorize Treatment Plan

The Authorize Treatment Plan business process encompasses both a prior authorization and post-approved treatment plan. The State Medicaid Agency (SMA) uses the Authorize Treatment Plans primarily in the care coordination setting where the care management team assesses the member’s needs, decides on a course of treatment, and completes the treatment plan. NOTE: MITA contains three (3) different authorization business processes: 1. Authorize Service - the standard process of prior authorization of services. 2. Authorize Treatment Plan - the approval of a treatment plan prepared by a care management team in a care management setting. 3. Authorize Referral - specifically the approval of a referral to another provider, requested by a primary care physician. A treatment plan prior-authorizes the named providers or provider types and services or category of services. The SMA prior authorizes individual providers for the service or category of services, and they do not have to submit their own prior authorizations or service requests. A treatment plan typically is a schedule of medical, therapeutic, and /or psychological procedures and appointments that spans a length of time designed to restore a patient's specific health condition. In contrast, the SMA limits an individual service request, primarily associated with fee-for-services payment, to focus on a specific visit, services, or products (e.g., a single specialist office visit, approval for a specific test or particular piece of Durable Medical Equipment (DME)). The prior authorized treatment plan generally begins with the receipt of an authorize treatment plan request from the care management team. The SMA staff then evaluates it based on urgency, state priority requirements, and type of service/taxonomy (speech, physical therapy, home health, behavioral, social), a validates key information, and ensures that requested plan of treatment is appropriate and medically or behaviorally necessary. After reviewing, staff approves, modifies, suspends for additional information or denies the request. Business process sends an alert to Manage Case Information business process. A post-approved treatment plan is an audit function that reviews suspended or paid claims to ensure the services were appropriate and in accordance with the treatment plan.