Mental Health/Substance Abuse Assessment Requirements (BadgerCare Plus and Medicaid SSI) Sample Clauses

Mental Health/Substance Abuse Assessment Requirements (BadgerCare Plus and Medicaid SSI). The HMO must assure that authorization for mental health/substance abuse treatment for its members is governed by the findings of an assessment performed promptly by the HMO upon request of a client or referral from a primary care provider or physician in the HMO’s network. Such assessments must be conducted by qualified staff in a certified program who are experienced in mental health/substance abuse treatment. All denials of service and the selection of particular modalities of service shall be governed by the findings of this assessment, the effectiveness of the therapy for the condition (including best practice, evidence based practice), and the medical necessity of treatment. The lack of motivation of a member to participate in treatment shall not be considered a factor in determining medical necessity and may not be used as a rationale for withholding or limiting treatment of a client/member. The HMO will use the Wisconsin Uniform Placement Criteria (WI-UPC), or the placement criteria developed by the American Society of Addiction Medicine (ASAM) as mandated for substance abuse care providers in DHS 75. The requirement in no way obligates the HMO to provide care options included in the placement criteria that are not covered services under FFS. The HMO must involve and engage the member in the process used to select a provider and treatment option. The purpose of the participation is to ensure participants have culturally competent providers and culturally appropriate treatment and that their medical needs are met. This section does not require the HMO to use providers who are not qualified to treat the individual member or who are not contracted providers.