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["Service Authorization Requirements by Benefit Type Report"]
["This template is required under Section 8 of the Medicaid Managed Care Contract. Each MCO must complete this tab in full to support the Department’s oversight of service authorization practices and compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA)."]
[]
[]
[]
["Instructions:"]
["The Template (Tab B) is the only tab you need to complete.\n\nOther tabs in this workbook are included for reference and should not be edited.\n\nThe Template tab includes embedded instructions to guide you through each required field.\n\nYou will be asked to list all services offered, indicate whether they require service authorization, and provide relevant details such as associated codes, benefit category, and authorization criteria/processes.\n\nPlease follow all formatting and data validation rules as built into the template.\n\nIf you have questions or encounter issues, please contact the Department for assistance."]

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["B. Service Authorization Requirements by Benefit Type"]
[]
[null,"Service Name","Code(s)","Associated Benefit","Benefit Type","Benefit Classification","If \"Other,\" Specify Benefit","Service Authorization Required?","Authorization Description"]
[null,"List **all services covered** by your plan, including but not limited to those requiring service authorization. Use the official name from your benefit package. Each row should represent a distinct service.","Enter all billing codes used to identify this service for claims processing (e.g., CPT or HCPCS). Use commas to separate multiple codes.","Select all applicable benefit categories under which this service falls, based on your internal classification. Use commas to separate multiple benefit categories (e.g., \"Behavioral Health – Outpatient, Pharmacy\"). If none of the available options apply, select “Other” and complete Column G.","Auto-populated based on the benefit(s) selected in Column C using the Department's MH/SUD vs. M/S crosswalk. Do not edit.","Auto-populated based on the benefit(s) selected in Column C using the Department’s classification crosswalk. Classifications include: Inpatient, Outpatient, Emergency Care, and Prescription Drugs. Do not edit.","Complete this column **only if you selected “Other”** in Column D. Enter the benefit name, and specify both the benefit type (M/S or MH/SUD) and benefit classification (Inpatient, Outpatient, Emergency Care, or Prescription Drugs). If Column C does not include \"Other,\" leave this cell blank.","Select “Yes” if **any form of service authorization or utilization management** is required before or during delivery of this service. This includes, but is not limited to: prior authorization, concurrent review, step therapy, fail-first protocols, medical necessity review, benefit limit overrides, or referral requirements. Select “No” if the service is not subject to authorization.","If you selected “Yes” in Column G, describe both the authorization requirement and the process for how it is applied. Include the type of authorization (e.g., prior auth, step therapy, concurrent review), when it is triggered, and any guidelines, criteria, or protocols used to determine when authorization is required. Also include any key details such as forms, timelines, or vendor involvement. If “No” was selected in Column H, leave this cell blank."]
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{"sheet":"C_MS Benefit Mapping","index":2,"n_rows":68,"n_cols":5,"rows_kept":68,"cut":false,"hidden":false,"merged":[]}
["C. Mapping of Medical/Surgical Benefits"]
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[null,"Inpatient Rehabilitation","Ambulatory Care"]
[null,"Intermediate Care Facility for Individuals with Intellectual Disabilities","Radiology and Nuclear Medicine"]
[null,"Hospice","EPSDT Services (Ages 21 and Under)"]
[null,"Emergency Hospital Services","Family Planning"]
[null,"Hospital Inpatient Maternity","Tobacco Cessation"]
[null,"Organ and Tissue Transplantation","Physician Services"]
[null,"Anesthesia Services (Inpatient)","Dermatology Services"]
[null,"Hospital  Inpatient Days","Oncology and Hematology Services"]
[null,"Pediatric Inpatient Rehabilitation","Medcial and Surgical Services Furnished by a Dentist"]
[null,"Nursing Facility Resident Care","Podiatrist Services"]
[null,"Skilled/Intermediate Nursing Services","Ophthalmology and Optometry Services"]
[null,"Subacute Care","Anesthesia (Outpatient)"]
[null,null,"Chiropractic Services"]
[null,null,"Home Health Care"]
[null,null,"Physical Therapy"]
[null,null,"Occupational Therapy"]
[null,null,"Speech Pathology"]
[null,null,"Audiology Services"]
[null,null,"Private Duty Nursing"]
[null,null,"Clinic Services"]
[null,null,"Preventive Dental Services"]
[null,null,"Orthotics and Prosthetics"]
[null,null,"Diagnostic Services"]
[null,null,"Screening Services"]
[null,null,"Preventive Services"]
[null,null,"Rehabilitation Services"]
[null,null,"Nurse Midwife"]
[null,null,"Hospice"]
[null,null,"Case Management Services"]
[null,null,"Tuberculosis Directly Observed Therapy"]
[null,null,"Pregnancy-Related Postpartum Services"]
[null,null,"Services for Conditions that may Complicate Pregnancy"]
[null,null,"Ambulatory Prenatal Care"]
[null,null,"Respiratory Care Services"]
[null,null,"Pediatric and Nurse Practitioner Services"]
[null,null,"Non-emergency Medical Transportation"]
[null,null,"Personal Care Services"]
[null,null,"Targeted Case Management"]
[null,null,"Durable Medical Equipment"]
[null,null,"Renal Dialysis Clinic Services"]
[null,null,"Ambulatory Surgery Center Services"]
[null,null,"Professional Dietician Services"]
[null,null,"Developmental Evaluation Services"]
[null,null,"Injectable and Self-Administered Injectable Drugs"]
[null,null,"Outpatient Hospital Dialysis"]
[null,null,"Outpatient Pediatric AIDS Clinic Services"]
[null,null,"Diabetes Management"]
[null,null,"Sickle Cell Disease Management"]
[null,null,"Preventive and Rehabilitative Services for Primary Care Enhancement"]
[null,null,"Home Visiting"]
[null,null,"Medicaid Adolescent Pregnancy Prevention Services"]
[null,null,"School Based Services"]
[null,null,"PACE Services"]
[null,null,"Primary Care Services"]
[null,null,"Office/Outpatient Exams"]
[null,null,"Evaluation and Management"]
[null,null,"Cancer Screening"]
[null,null,"Telehealth"]
[null,null,"Pharmacist Services"]
[null,null,"Pain Management"]
[null,null,"Pathology and Laboratory Services"]
[null,null,"PACE Services"]

{"sheet":"D_MHSUD Benefit Mapping","index":3,"n_rows":53,"n_cols":5,"rows_kept":53,"cut":false,"hidden":false,"merged":[]}
["D. Mapping of Mental Health/Substance Use Disorder Benefits"]
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[null,"Psychiatric Residential Treatment Facility Services","Behavioral Health Screening","Perinatal Emergency Room Visit","Pharmacy Supplies and Supplements"]
[null,"Clinically Managed Residential Detoxification","Diagnostic Assessment","Crisis Intervention Service"]
[null,"Medical Monitored Residential Detoxification","Individual Psychotherapy"]
[null,"Long-Term Residential Treatment","Group Psychotherapy"]
[null,"Short-Term Residential Treatment","Family Psychotherapy"]
[null,"Hospital-Based Crisis Stabilization","Multiple Family Group Psychotherapy"]
[null,"Psychiatric Physician Inpatient","Crisis Intervention Service"]
[null,"Residential Substance Abuse Treatment","Peer Support Therapy"]
[null,null,"Applied Behavioral Analysis Assessment Services"]
[null,null,"Applied Behavioral Analysis Treatment Services"]
[null,null,"Adaptive Behavior Treatment"]
[null,null,"Group Adaptive Behavior Treatment"]
[null,null,"Psychiatric Diagnostic Evaluation"]
[null,null,"Developmental Evaluation Center Services"]
[null,null,"Psychological Testing and Evaluation"]
[null,null,"Alcohol and Drug Abuse Rehabilitation Services"]
[null,null,"Alcohol and Drug  Assessment"]
[null,null,"Structured Screening and Brief Intervention"]
[null,null,"Service Plan Development"]
[null,null,"Individual Alcohol and Drug / Substance Abuse Counseling"]
[null,null,"Group Alcohol and Drug Substance Abuse Counseling"]
[null,null,"Medication Management"]
[null,null,"Medication Administration"]
[null,null,"Psychosocial Rehabilitation Individual"]
[null,null,"Psychosocial Rehabilitation Group"]
[null,null,"Family Support"]
[null,null,"Intensive Outpatient"]
[null,null,"Day Treatment / Partial Hospitalization"]
[null,null,"Opioid Treatment Program Services"]
[null,null,"Mental Health Comprehensive Assessment"]
[null,null,"Assertive Community Treatment"]
[null,null,"Multisystemic Therapy"]
[null,null,"Intensive In-Home Services"]
[null,null,"Community Integration Services"]
[null,null,"Behavioral Modification"]
[null,null,"Therapeutic Childcare Individual"]
[null,null,"Therapeutic Childcare Group"]
[null,null,"Therapeutic Foster Care"]
[null,null,"Injectable Medication Administration"]
[null,null,"Nursing"]
[null,null,"Medical Evaluation and Management"]
[null,null,"Nutrition Counseling"]
[null,null,"Telehealth"]
[null,null,"Environmental Intervention for Medical Management"]
[null,null,"Neuropharmagen-genomic Testing"]
[null,null,"Skills Training and Development Services for Children"]
[null,null,"Evaluation and Management of Medical Services"]
[null,null,"Psychiatric Collaborative Care Model Services"]

{"sheet":"E_Benefits List","index":4,"n_rows":140,"n_cols":1,"rows_kept":140,"cut":false,"hidden":false,"merged":[]}
["Adaptive Behavior Treatment"]
["Alcohol and Drug Abuse Rehabilitation Services"]
["Alcohol and Drug Assessment"]
["Ambulatory Care"]
["Ambulatory Prenatal Care"]
["Ambulatory Surgery Center Services"]
["Anesthesia (Outpatient)"]
["Anesthesia Services (Inpatient)"]
["Applied Behavioral Analysis Assessment Services"]
["Applied Behavioral Analysis Treatment Services"]
["Assertive Community Treatment"]
["Audiology Services"]
["Behavioral Health Screening"]
["Behavioral Modification"]
["Brand Medications"]
["Cancer Screening"]
["Case Management Services"]
["Chiropractic Services"]
["Clinic Services"]
["Clinically Managed Residential Detoxification"]
["Community Integration Services"]
["Crisis Intervention Service"]
["Day Treatment/Partial Hospitalization"]
["Dermatology Services"]
["Developmental Evaluation Center Services"]
["Developmental Evaluation Services"]
["Diabetes Management"]
["Diagnostic Assessment"]
["Diagnostic Services"]
["Durable Medical Equipment"]
["Emergency Department Services"]
["Emergency Hospital Services"]
["Emergency Transportation/Ambulance"]
["Environmental Intervention for Medical Management"]
["EPSDT Services (Ages 21 and Under)"]
["Evaluation and Management"]
["Evaluation and Management of Medical Services"]
["Family  Support"]
["Family Planning"]
["Family Psychotherapy"]
["Federally Qualified Health Center Services Furnished by an FQHC"]
["Generic Medications"]
["Group Adaptive Behavior Treatment"]
["Group Alcohol and Drug Substance Abuse Counseling"]
["Group Psychotherapy"]
["Home Health Care"]
["Home Visiting"]
["Hospice"]
["Hospital  Inpatient Days"]
["Hospital Inpatient Maternity"]
["Hospital-Based Crisis Stabilization"]
["Individual Alcohol and Drug/Substance Abuse Counseling"]
["Individual Psychotherapy"]
["Injectable and Self-Administered Injectable Drugs"]
["Injectable Medication Administration"]
["Inpatient Hospital"]
["Inpatient Psychiatric Services"]
["Inpatient Rehabilitation"]
["Intensive In-Home Services"]
["Intensive Outpatient"]
["Intermediate Care Facility for Individuals with Intellectual Disabilities"]
["Long-Term Residential Treatment"]
["Medicaid Adolescent Pregnancy Prevention Services"]
["Medical and Surgical Services Furnished by a Dentist"]
["Medical Evaluation and Management"]
["Medical Monitored Residential Detoxification"]
["Medication Administration"]
["Medication Assisted Therapy"]
["Medication Management"]
["Mental Health Comprehensive Assessment"]
["Multiple Family Group Psychotherapy"]
["Multisystemic Therapy"]
["Neuropharmagen-genomic Testing"]
["Non-emergency Medical Transportation"]
["Nurse Midwife"]
["Nursing"]
["Nursing Facility Resident Care"]
["Nutrition Counseling"]
["Occupational Therapy"]
["Office/Outpatient Exams"]
["Oncology and Hematology Services"]
["Ophthalmology and Optometry Services"]
["Opioid Treatment Program Services"]
["Organ and Tissue Transplantation"]
["Orthotics and Prosthetics"]
["Other"]
["Outpatient Hospital"]
["Outpatient Hospital Dialysis"]
["Outpatient Pediatric AIDS Clinic Services"]
["PACE Services"]
["Pain Management"]
["Pathology and Laboratory Services"]
["Pediatric and Nurse Practitioner Services"]
["Pediatric Inpatient Rehabilitation"]
["Peer Support Therapy"]
["Perinatal Emergency Room Visit"]
["Personal Care Services"]
["Pharmacist Services"]
["Pharmacy Supplies and Supplements"]
["Physical Therapy"]
["Physician Services"]
["Podiatrist Services"]
["Pregnancy-Related Postpartum Services"]
["Preventive and Rehabilitative Services for Primary Care Enhancement"]
["Preventive Dental Services"]
["Preventive Services"]
["Primary Care Services"]
["Private Duty Nursing"]
["Professional Dietician Services"]
["Psychiatric Collaborative Care Model Services"]
["Psychiatric Diagnostic Evaluation"]
["Psychiatric Physician Inpatient"]
["Psychiatric Residential Treatment Facility Services"]
["Psychological Testing and Evaluation "]
["Psychosocial Rehabilitation Group"]
["Psychosocial Rehabilitation Individual"]
["Radiology and Nuclear Medicine"]
["Rehabilitation Services"]
["Renal Dialysis Clinic Services"]
["Residential Substance Abuse Treatment"]
["Respiratory Care Services"]
["Rural Health Clinic Services and Other Ambulatory Services Furnished by a Rural Health Clinic"]
["School Based Services"]
["Screening Services"]
["Service Plan Development"]
["Services for Conditions that may Complicate Pregnancy"]
["Short-Term Residential Treatment"]
["Sickle Cell Disease Management"]
["Skilled/Intermediate Nursing Services"]
["Skills Training and Development Services for Children"]
["Speech Pathology"]
["Structured Screening and Brief Intervention"]
["Subacute Care"]
["Targeted Case Management"]
["Telehealth"]
["Therapeutic Childcare Group"]
["Therapeutic Childcare Individual"]
["Therapeutic Foster Care"]
["Tobacco Cessation"]
["Tuberculosis Directly Observed Therapy"]