MHRS

Initial program eligibility is determined following an initial screening and assessment conducted by an enrolled provider. If an individual seems to meet medical necessity criteria based on the initial screening, the provider continues the eligibility process. Medical necessity for services is based on the three D’s which includes:

Diagnosis
Disability
Duration

For a complete description of the medical necessity criteria, or the three D’s, refer to the Program Eligibility Criteria documents below and the MHR manual.

The initial assessment must be completed within 30 calendar days following the eligibility screen. Extensions beyond the 30-day assessment period may be granted, on a case-by-case basis, under exceptional circumstances at the discretion of the Medicaid Behavioral Health Section.

All of the following must be met to establish eligibility for services and receive an authorization:

	Member/family agrees to receive services from the provider as indicated by a signature on the Freedom of Choice form;
	Member meets the medical necessity criteria;
	Member has a LOCUS or CALOCUS level of 4 or above (level 3 or above if returning to community living from structured residential settings under OCS or OYD authority);
	Documentation indicates a thorough and accurate assessment which supports the diagnosis and LOCUS or CALOCUS level;
	Member has agreed to participate in the development of the interim ISRP as indicated by a signature on the ISRP (all children 6 and older must also sign plan);
	The interim ISRP reflects the most urgent needs of the recipient;
	The crisis plan addresses problem areas—especially those in which the recipient is at risk of harm to self or others;
	The request packet includes all required documentation and signatures;
	All identifying information such as Social Security number, address, Medicaid number is present;
	A record in MHRSIS must be opened and a data file submitted before an authorization request is submitted to SAA.

Note: This list is not all-inclusive.

Program Eligibility Criteria (06/17/2009)
	General (07/24/2010)
		Eligibility, Discharge, and Exclusionary Criteria (06/17/2009) Download file \| View Details