There are two ways the Service Authorization process can be used. The first is by the Local Mental Health Authority (LMHA) Utilization Management (UM) staff to authorize and determine level of care (LOC) for mental health client services. The second is by the Local Behavioral Health Authority (LBHA) Utilization Management (UM) staff to authorize and determine level of care (LOC) for mental health and substance use disorder (SUD) client services. Targeted Case Management providers using CMBHS through privileges granted by Senate Bill 58, use the same process as the LMHAs. The instructions provided are intended to explain the online process for service authorization. Mental Health Providers can batch their documents from their local system, if they choose. Please see the Data Exchange section for more information.
The service authorization process begins when the mental health staff at the LMHA creates a uniform assessment. All the tabs of the assessment are completed, except the Authorization tab, and the document is saved in Ready for Review. When the assessment is saved in Ready for Review, it is placed on the Service Authorization List located under the Provider Tools menu on the Administrative Toolbar. The Service Authorization list is used by the Utilization Management (UM) staff to review and authorize the assessment and determine level of care (LOC).
The client must have a client profile and a diagnosis in closed complete status and dated prior to the creation of the uniform assessment.
The staff creating the assessment must have the correct roles and credentials. To view a list of Page Rights by Role in CMBHS, click here.
A non-credentialed staff can enter the document, however, the staff listed in the Performed By field must have the appropriate credentials.
Requesting Authorization for Mental Health Services
A Mental Health organization, whether it is an LMHA or LBHA, uses the Authorization Tab on the Mental Health Assessment to authorize client services.
The authorization is performed at the Utilization Management (UM) location and the Assessment can be accessed by going to the client’s workspace or by using the Service Authorization List.
Calculated Level of Care Recommended (View only) – This field displays the LOC calculated by CMBHS based on the information entered into the Assessment by the clinician.
Level of Care Authorized (LOC-A) – dropdown list of available Level of Care. Required field.
Authorization Date – date the Mental Health Assessment was authorized. Required field.
End Date – system calculates expiration date of the Assessment. Adult Assessments are valid for six months and youth assessments are valid for 90 days. Not editable.
Justification for Late Authorization of Uniform Assessment – dropdown list. Required field. Options are as follows:
Authorized By – dropdown list of staff with MH Approver role. Required field.
Statement displayed – For persons with Medicaid, Fair Hearing Rules apply.
Notes – textbox. Optional field. Maximum length: not specified.
Prior Notes – system will display previous notes entered on the Assessment.
How to use the Service Authorization List – LMHA
From UM-MH location, select Provider Tools > Service Authorization List from the Administrative Toolbar.
The list page is displayed. The Select Filter fields are:
Authorization Status – All, Submitted, Assigned
Age Type – Youth or Adult
Authorizer – staff list populates names of staff with the MH Approver role.
MH Assessment Type – Initial, Update, Crisis
MH Document Status – All, Ready for Review
Provider – All and the provider location
Provider Location – All and any location that would have assessment that needs to be authorized
Document Status
MH Calculated Level of Care (LOC) Recommended – The following is a list of the Levels of Care (LOCs):
MH Provider Requested Deviation – Same as the list of LOCs above.
Checkboxes:
Buttons in the Select Filter section
The list section has the following columns:
The MH staff with the appropriate roles to authorize assessments will use the filter fields to query for any assessment submitted by their MH location(s).
Once the assessment has been displayed, the user can select the View button and the system will display the assessment in Edit mode on the Authorization tab. The user will take the appropriate action. If they choose not to authorize, they can close out of the document and leave it in Ready for Review. If they choose to authorize, they would complete the authorization tab and close the assessment in Closed Complete status.
The location where the Assessment was created will also list the Assessment pending authorization by the UM location so the staff can monitor the progress of the authorization.
The functions of the Select Filter, Customize, and Service Authorization List behavior are the same as described for the LMHA Location, although some fields are removed.
The Local Behavioral Health Authority approves services for Mental Health and Substance Use Disorder Services. The process for authorizing Mental Health Services are as described for the LMHA, where the Utilization Management (UM) staff complete the Authorization Tab of the Assessment. See the Service Authorization Request – Local Mental Health Authority (LMHA) section for more information.
The service authorization process begins when a service provider, having completed an assessment on a client, submits a request for service authorization to the approvers designated for that client’s funding source. After the request has been saved, it can be viewed on the provider’s Service Authorization List page available from the Administrative Toolbar at the top of each page of CMBHS, and from the Client Document List i n the Client Workspace.
The provider view of the Service Authorization List allows providers to see all the requests submitted for approval from their CMBHS location and the status of each request as it moves through the approval process.
The authorization approvers receive the request for service authorization in real time and views it on his/her view of the Service Authorization List. The authorization approver view of the list is populated with requests submitted by the service providers and locations assigned to them.
The authorization approver can select a request for service authorization and view it with the client’s clinical documentation to make a decision to approve or deny the request. After review of the clinical documentation, the authorization approver documents a decision and saves.
For Multi-level Approver Process – Service Authorization will be available for next level Approver to make a decision to approve or deny the request. After review of the clinical documentation, the authorization approver documents a decision and saves. This process will repeat based on the number of approvers associated with the client’s funding source.
The authorization requester receives the approver’s decision, which can be viewed from the Service Authorization List or the Client Workspace. The authorization requester may respond with an appeal if the approver’s decision is averse to the client’s clinical need.
After the Authorization Requester has created a Request for Service Authorization and placed it in any status, it can be viewed on the Client Workspace Document List. The Request for Service Authorization only displays on the provider’s Service Authorization Request List when it has been Saved in Closed Complete status. CMBHS then submits the Request to the approver and it displays on the Approver’s Service Authorization List.
As soon as a Request for Service Authorization displays on the Approver’s Service Authorization List, the Approver can review the client’s clinical documentation by CLICKING on the blue Client Workspace link in the last column to the right.
After reviewing the clinical documentation, the approver enters a decision of Approved, Pending, or Denied and CMBHS displays the decision on the Service Authorization List.
When the Requester receives a denial decision, he/she may ask for an appeal by CLICKING the Appeal button on the Request for Service Authorization page. This is documented in the Service Authorization List, the Request reappears in the Authorizer’s History, and the status of Appealed displays on both the Requester’s and the Authorizer’s Service Authorization Lists.
All Authorization transactions between the Requester and the Approvers are automatically documented in the Authorization History on the Service Authorization page.
Requests on the Service Authorization List remain on the Provider’s Service Authorization List for 90 days. After that, they are removed from the list and must then be accessed from the Client Workspace.
Requests on the Service Authorization List remain on the Authorizer’s Service Authorization List until a disposition is made. After the Request is removed from the list, it can still be accessed from the Client Workspace in the Client Document List.
If the requesting provider appeals the Approver’s decision, the status for that Service Authorization Request changes on the Service Authorization List to Appealed.
Your business unit and service location must have a contract with HHSC that allows you to document and submit requests for authorization of services.
A user must be assigned the role of Authorization Requestor to allow him/her to document a request for authorization of services in CMBHS. To view a list of Page Rights by Role in CMBHS, click here.
Check the client’s name and a second identifier at the top of CMBHS page to ensure you are requesting authorization of services for the correct client.
Service Authorization will display Approver and Approver Level Dynamically – This will allow requester to see list of approvers.
You must be in the Client Workspace to document and submit a request for authorization of services.
A complete and unexpired Financial Eligibility Assessment must be in the client record before the Authorization Requester can request authority for services.
Also, the eligibility status must be Eligible for HHSC Funded Services, or Eligible for partial HHSC Funded services.
An Authorization for Release of Health Information must be in the client record releasing information to the Authorization Approver, and consent for the Authorization Approver to release client identifying information back to the Authorization Requester.
Authorization Rules
If the Authorization Requester submits a request for authorization for a client and there is already an open authorization for that client, then the system displays the message “There is already an open authorization for this client, are you sure you want to continue?”
If the user chooses Yes, the system closes the previously existing Authorization for Services by setting the Authorization End Date to one day before the new Authorization Begin Date.
An open authorization is determined by the authorization begin and authorization end dates. The authorization is open on the begin date and closed on the end date.
There cannot be more than one authorization open, per client, per admission to a provider.
If a client has a substance use admission and a mental health admission to the same provider at the same time and both services require authorization, then the client would have two admissions and one authorization for each admission.
Accessing the Request for Authorization Page
First select a client and go to the Client Workspace.
On the Client Services Toolbar on the left, select Service Management > Service Authorization.
The Request Service Authorization page will display.
Level of Care Calculated
This field displays the LOC calculated by CMBHS based on the information entered into the Assessment by the clinician.
If the Assessment has not been completed at the time that the authorization is requested, the Level of Care Calculated will default to blank.
One of these service packages will display:
If the client has not been admitted to the business entity, the Level of Care Requested will default to None Selected because there are no services types associated with pre-admission (the default) that require authorization.
Pre-admission will not be a selectable service package in Level of Care Requested or Level of Care Approved.
Possible Choices:
This field reflects the length of time the service authorization will last.
Reason for Deviation (Required for substance use disorder services)
If the LOC-R is different from the LOC-C, then a reason for the deviation must be documented.
One of the answer choices must be selected.
Possible Choices:
If there is a reason other than the answer choices above for the deviation between the calculated and clinician recommended service package, it is documented here. (Required for substance use disorder services)
The end date cannot be edited to be past the maximum time allowed for that service package. A service will be “unauthorized” if the date the service was delivered is past the new authorization end date.
You must enter eight numbers that represent the date and CMBHS will put them into the correct date format (mm/dd/yyyy). Or you can type the forward slashes yourself.
Authorization Narrative
Authorization Status
This column displays the current status of the Request for Service Authorization.
The possible statuses for the Authorizer view of the List are:
Approver Level:
This column will display level of approval for Service Authorization. In the below examples, “N” is the total number of levels of approval needed based on the client’s funding source.
How to Respond to a Request for Service Authorization
Pick a client from the Service Authorization Request List by CLICKING ON the client’s name.
The Clinical Management for Behavioral Health Services (CMBHS) Service Authorization List displays information used to manage service authorization processes. There is a provider/requester view of the page and an approver/authorizer view of the page. These views are essentially the same, with a few differences in the fields and functions.
The Service Authorization List is also used for substance use disorder services and mental health services where service authorization is required.
The Service Authorization Requester version of the list provides a centralized display of information needed to monitor the status of requests as they move through the approval process. The items that populate the provider view of Service Authorization List include only the Service Authorization Requests submitted at that location.
The Service Authorization Approver/Authorizer version of the list contains an assortment of functions and display options that allows the user to manage the large number of Service Authorization Requests they receive from providers daily. The items that display on the Authorization Approver view of the List include requests submitted by the providers with whom they have an approver relationship set up in CMBHS.
Service Authorization Approvers/Authorizers are currently either staff of a Behavioral Health Organization (BHO) that contracts with HHSC for the management of substance use disorder and/or mental health services, or staff of a mental health–utilization management (MH-UM) department of a Local Mental Health Authority (LMHA).
The service authorization function in CMBHS provides the method by which the provider, through his/her Authorization Requester, documents a request for approval of payment for a client’s services using an automated process.
You can access the Service Authorization List from the Provider Tools menu in the Administrative Toolbar at the top of your screen.
The designated Authorization Approver receives the request through CMBHS and views it on the Service Authorization List. After receipt of the Request, the Approver can access the clinical documentation needed to make a decision to approve or deny the request.
For Substance Use Disorder Services, the client must have signed an Authorization for Disclosure of Information before the Approver may view the records.
The Authorization Approver documents their decision in the client record. The Authorization Requester receives the decision and may respond with an appeal, if appropriate. The Service Authorization List on the Administrative Toolbar displays for the Provider and for the Service Authorization Approver (an OSAR, BHO, or LMHA-UM Department).
The Authorization Requester may be the clinician that evaluated the client and made the recommendation for services, or another person designated by the provider. The person fulfilling this role documents a request for authorization for services in the client’s health record and electronically submits the request to the Authorization Approver.
The Authorization Approver is a qualified and credentialed staff person employed by an OSAR, BHO, or LMHA-UM Department (or other business entity contracting with an OSAR, BHO or LMHA) who receives the request for service authorization for a client and makes a determination to approve, pend, or deny the request. The person fulfilling this role views supporting documentation in the client’s health record and then electronically submits a determination to the Authorization Requestor.
If the Authorization Approver denies a Request for Authorization of Services but is willing to approve other services that are available and appropriate for the client, the Authorization Approver must document an Approver Initiated Authorization for Services for the alternate services.
The provider location in CMBHS that submits the Service Authorization Request must have a relationship set up in CMBHS with the approver business entity. HHSC does this during the initial organizational setup process for both business entities and will update as needed. If the approving entity for your provider organization changes, notify HHSC so that we can make the change in CMBHS.
A CMBHS Security Administrator must set up user roles correctly in CMBHS so users can access the Service Authorization List:
The substance use disorder services client must have at minimum, a Client Profile, Financial Eligibility, and Admission before a Service Authorization Request can be created and submitted for the client.
A Financial Eligibility, valid as of the begin date of the Service Authorization Request, is required with one of the following eligibility status:
A Consent for Release of Information signed by the client is not required in CMBHS.
The Service Authorization List is located on the Administrative Toolbar (at the top of every CMBHS page) under Provider Tools. The Service Authorization List page will only display if the location is designated for the UM function.
The service authorization location at a BHO, LMHA, or other entity must develop its own procedures for how the Authorization Approvers will use the Service Authorization List to ensure that Requests for Authorization are addressed in a timely manner.
Service Authorization List Functions
The Service Authorization List is located on the Administrative Toolbar (at the top of every CMBHS page) under Provider Tools.
CMBHS submits the Service Authorization Request to the approver and it displays on the Approver’s Service Authorization List.
As soon as a Request for Service Authorization displays on the Approver’s Service Authorization List, the Approver can review the client’s clinical documentation by CLICKING on the blue Client Workspace link in the last column to the right.
After reviewing the clinical documentation, the approver documents his/her decision of Approved, Pended, or Denied in the Authorization, and then CMBHS displays the decision on the Service Authorization List.
When the Requester receives a denial decision, he/she may ask for an appeal by CLICKING the Appeal button on the Request for Service Authorization page. This is documented in the Service Authorization List and the Request reappears in the Authorizer’s History. The status of Appealed displays on both the Requester and the Authorizer’s Service Authorization List.
All Authorization transactions between the Requester and the Approvers are automatically documented in the Authorization History on the Service Authorization page.
Requests on the Service Authorization List remain on the Authorizer’s List until a decision is documented in CMBHS, when the system automatically removes them. If you need to see a Request after it has been removed, go to the Client Workspace Client Document List. Use the Document Type filter to locate the Request for Service Authorization.
If the requesting provider appeals the Approver’s decision, the status of that Service Authorization Request changes on the Service Authorization List to Appealed.
After the Authorization Requester has created a Request for Service Authorization and placed it in any status, it can be viewed on the Client Workspace Document List. The Request for Service Authorization only displays on the provider’s Service Authorization Request List when it has been Saved in Closed Complete status. CMBHS then submits the Request to the approver and it displays on the Approver’s Service Authorization List.
As soon as a Request for Service Authorization displays on the Approver’s Service Authorization List, the Approver can review the client’s clinical documentation by CLICKING on the blue Client Workspace link in the last column to the right.
After reviewing the clinical documentation, the approver enters a decision of Approved, Pending, or Denied in the Authorization and CMBHS displays the decision on the Service Authorization List.
When the Requester receives a denial decision, they may ask for an appeal by CLICKING the Appeal button on the Request for Service Authorization page. This is documented in the Service Authorization List and the Request reappears in the Authorizer’s History; the status of Appealed displays on both the Requester's and the Authorizer’s Service Authorization List.
All Authorization transactions between the Requester and the Approver are automatically documented in the Authorization History on the Service Authorization page.
Requests on the Service Authorization List remain on the Provider’s Service Authorization List for 90 days. After that they are removed from the list and must then be accessed from the Client Workspace.
Requests on the Service Authorization List remain on the Authorizer’s Service Authorization List until a disposition is made. After the Request is removed from the list, it can still be accessed from the Client Workspace in the Client Document List.
If the requesting provider appeals the Approver’s decision, the status for that Service Authorization Request changes on the Service Authorization List to Appealed.
Requester Parent Provider – The field displays the name of the parent organization from which the Request for Authorization was submitted.
Requester Business Location – The field displays the name of the requester’s location. This is the CMBHS location from which the Request for Authorization was generated. The Requester location may be a clinic or service site or a “virtual” location in CMBHS, dependent on how the organization was created in CMBHS.
Document Status Date – This is the date the Request for Authorization was placed in Closed Complete by the Requester.
Client number – The CMBHS Client number.
Client Name – This field displays the Name of the client for whom a Request for Authorization for services has been submitted. Only the client First and Last name display.
Birth Date – The Date of Birth for the client.
Age Type – Adult or Youth
HHSC/DSHS Calculated Recommended Course of Treatment – populated from client’s most recent assessment.
Provider Requested Level of Care – This data field displays the Level of Care being requested by the provider for the client. The information comes directly from the Request for Authorization completed by the provider.
Authorization Status – This column displays the status of the Request for Authorization. As the Request for Authorization moves through the review process, the status that displays will change.
The possible statuses for the Provider/Requester view of the list are:
Note: If the user navigates away from the Service Authorization List, it will refresh automatically.
Approver Level – This column will display the level of submitted, approved, modified approved, pended, denied request in numeric value like 0/2, 1/2, 2/2, n/n (Note: “N” is the total number of levels of approval needed based on the client’s funding source.
Authorization Approver Name – this is the name of the agency staff who approved the authorization.
Requester – Staff name of individual who created the document.
BHO Provider ID – this is populated from the organization provider location detail identifiers.
NPI – National Provider ID from the Provider location detail identifiers.
Vendor Number – Vendor Number (when applicable) from the Provider location detail identifiers.
Received Date & Time – this is the time the document was placed on the Service Authorization List. (HHSC/DSHS)
Select All – Check box (HHSC/DSHS)
Assigned Authorizer – If the Assigned Authorizer is selected, the list will display the name and the list will be filtered for this name.
View – Hyperlink to view the source document (Service Authorization Request).
Substance Use Disorder Services Requests – a Service Authorization must be saved by the user in Closed Complete status in order for the Service Authorization Request to be submitted and appear on the Service Authorization List. All Requests on the list will be in Closed Complete status.
Mental Health Service Authorizations in the MH Uniform Assessment – MH service authorization requests will be saved by the provider in Ready for Review status. Placing the Service Authorization in Ready for Review status triggers the MH Service Authorization to be submitted and display on the Service Authorization List page at the correct Approver location.
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NOTE: If you have questions about how locations are set up at your organization, consult your CMBHS Security Administrator. |
Program Type (Optional): The user may choose to filter the list by Program Type if the user is an approver for mental health and/or substance use services. To filter the list, select SUD, MH, or Both from the dropdown list.
Columns: The user can choose to filter the list by as few or as many columns as they would like. Do this by using the Customize button at the top right of the page.
Customized Display: A Customize button has been added to the top of the list to add, hide, and change the order of the columns. Your customization to the list is maintained from session to session. To return to the original display, select the Default button.
Select Filter: The Service Authorization List can be filtered by selecting a value from the dropdown lists in this section. Only list entries that include that value will display on the list. Multiple filters can be applied at the same time. The filters are:
In addition, you can use the calendar icons in Document Status to select dates a week at a time.
Sort: Using this function changes the order of the entries in the list. All entries remain on the list; only their order is changed. The Service Authorization List can only sort by one column at a time. To sort, CLICK on the header at the top of the column.
Drag and Drop: The user can drag a column and drop it at a new location. If you use the drag and drop and refresh your page, leave the page or log out, the columns will return to their usual location.
Assign Approver: A single service authorization or a group of service authorizations can now be assigned to a specific approver and reassigned if needed.
Length of Display: For providers, authorizations in any status remain on their list for 90 days or until deleted. The approver can view an authorization until it is approved, or for 90 days if in pending or appealed status.
Pagination: Page buttons display at the bottom of the list if you have more than one page of service authorization requests. One page at a time or Beginning or End of the list.
Current Page Number: The current page number is displayed and highlighted.
When the request for an appeal is made by a requester/provider, it re-appears on the Approver/Authorizer’s Service Authorization List, assigned to the original approver. The Approver/Authorizer may be reassigned.
The request for an appeal remains on all views of the Service Authorization List until the approver makes a determination and saves it in CMBHS.
The Customize button will allow the user to add, hide, and change the order of the columns. Your customization to the list is maintained from session to session.
Selecting the Customize button, will display a window with a list of the Service Authorization List columns. The list can be customized by selecting a column name from the left box and using an arrow to move it to the right box. The double arrows will move the entire list from one box to the other.
The Service Authorization column headers can be arranged by using the Drag and Drop feature. Hover over the column header and a directional icon will appear. Hold the left button on the mouse and move the column to the right or left. Release the left mouse button and the column will remain in that position. Drag and drop changes are not maintained from session to session.
The information displayed in a column can be listed in ascending order by clicking on the column header. Click on the column header again to list the information in descending order.
Providers who use CMBHS can exchange data with CMBHS in batch mode, in addition to entering information online into the CMBHS application. Data Exchange refers to this batch process.
CMBHS Data Exchange consists of three main parts. These are the Batch Parser, Data Feeds, and the Report Generator.
Using the Batch Parser, providers drop whole data files that are picked up and processed by CMBHS. There are two main kinds of files that providers send to the parser. They are Claims, and Assessments (or TRRs). The provider-dropped files are formatted either in XML or in "fixed width" format.
In addition to receiving and processing the batched information, CMBHS also validates it. Several different Data Feeds are sent back to providers so they can determine the validity of the data they are batching. This leads to better batch processing.
A third feature of Data Exchange is the Report Generator. Two main types of reports are sent from CMBHS back to providers. The first is the Batch Report, which identifies problems such as invalid values in the files the provider dropped. The second type of report is the Data Dump, which is sent back to providers so they can evaluate the success of their batching transactions.