Dear Behavioral Health Providers,
The Division of Behavioral Health (DBH) acknowledges that implementation of Service Authorizations (SA) for select 1115 Behavioral Health Reform Waiver (1115) services has been challenging. We recognize that differences between how service authorization reviews are conducted and how services are documented at provider agencies have resulted in many SAs being pended. We understand the difficulties and delays this has caused for providers.
In response, DBH is implementing temporary measures to help address these issues while we work to align processes and improve consistency in the application of SA decisioning criteria. These measures will remain in place through December 31, 2025. Over the coming weeks, we will be expanding provider training and implementing online access to the InterQual standards to support greater transparency, shared understanding, and improved workflow. Our goal is to ensure timely SA decisions and reduce administrative burden while maintaining program integrity and compliance with federal requirements.
In response to provider feedback and trends observed in the SA review process, DBH is supporting providers by:
- Temporarily creating administrative flexibility to review and approve submitted service authorization (SA) requests.
- Expanding the SA review process to include clinically tailored feedback from the review team to strengthen documentation in future submissions.
- Updating guidance and forms to make SA process expectations clearer.
- Developing training materials for improving documentation standards.
SA requests will continue to utilize the InterQual review process to determine if the documentation supports continuation of services at the current level of care. If submitted documentation is insufficient, the HMS clinical review team will work with the provider to obtain additional supporting documentation and provide clinically tailored feedback instead of pending or denying the request.
During this period, please continue to submit SAs when recipient fiscal year limits are reached and provide any follow-up information that HMS-Gainwell requests. These actions will support continued reimbursement for services provided in good faith while DBH resolves challenges with the InterQual system and finalizes provider education materials.
Why SAs Are Pending:
In reviewing pending service authorization submissions, DBH and HMS-Gainwell observed the following common issues that made it difficult for reviewers to determine whether the requested level of care meets medical necessity criteria:
- Documentation doesn’t clinically describe the recipient’s current symptoms, risk, or functioning
- Prognosis information is missing or vague
- Treatment plans, interventions, or goals aren’t clearly explained
- Progress notes or strategies to address lack of progress aren’t included
- Discharge planning or barriers to step-down care aren’t documented
- Required clinician or prescriber documentation is missing
About InterQual: DBH uses InterQual behavioral health criteria to guide medical necessity decisions. This is a nationally recognized, evidence-based, clinical tool that assesses recipient:
- Symptom severity and functional impairment
- Risk and safety concerns
- Comorbid conditions and past treatment response
- Discharge readiness
Soon, you’ll be able to access the InterQual Transparency Tool online, along with guidance and instructions for setting up your account.
A link, service crosswalk and user guidance for establishing a OneHealth ID account will be posted on the Department’s Service Authorization webpage.
SA Approval Tips:
- Include detailed, clinically focused, current information about the recipient symptoms, risk, and functioning
- Clearly explain why continued care is medically necessary
- Document specific, measurable goals, interventions, and progress
- Document discharge planning and barriers to step-down care
- Submit supporting documentation that is up to date (within 24–48 hours of the SA request)
- Follow revised SA forms and prompts carefully
- Make sure documentation aligns with InterQual/medical necessity criteria
As a reminder, all Medicaid-reimbursable behavioral health services must be medically necessary and properly documented in a clinical record that meets the requirements in 7 AAC 135.100 – 7 AAC 139.900. Regulations require that assessments, treatment plans, and progress notes be updated regularly. Medical necessity should be reflected in all assessments, treatment plans, and progress notes.
DBH is committed to making the SA process clearer, more consistent and aligned with market considerations. We greatly value your partnership and feedback, which are essential to ensuring Alaskans get the care they need.
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