2021-2022 medicaid adult mh/su benefit plan · 2021. 7. 2. · 2021-2022 medicaid adult mh/su...
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2021-2022 Medicaid Adult MH/SU Benefit Plan
Service Code(s): Services Included:
90791, 90792, 90785 Clinical Assessment
T1023 Diagnostic Assessment
96132, 96133, 96137 Neuropsychological Testing
96110, 96112, 96113 Developmental testing
96130, 96131, 96116, 96132, 96133, 96136, 96137, 96138, 96139
Psychological Testing (Hourly)
90832, 90833, 90834, 90836, 90837, 90838, 90785 Individual Therapy
90846, 90847 Family Therapy
90849, 90853, 90785 Group Therapy
90839, 90840 Psychotherapy for Crisis
99201 – 99255, 99304 – 99337, 99341 – 99350 Evaluation & Management
H0038, H0038HQ Peer Support Services
All Services Code Community Support Team
H2017U5 Individual Rehabilitation, Coordination, and Support Services
H0032 Mental Health/Substance Abuse Targeted Case Management
H2017 Psychosocial Rehabilitation
H0040, H0040:22 Assertive Community Treatment Program
H0035 Partial Hospitalization
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 2
Service & Code Brief Service Description Auth Submission
Requirements Authorization Parameters
Source Age Group Level of Care
Clinical
Assessment
Code(s): 90791 - Psychiatric Diagnostic Evaluation (No Medical Services) 90792 - Psychiatric Diagnostic Evaluation with Medical Services 90785 - Interactive Complexity (add on)
Clinical Assessment services are intended to determine a member’s treatment needs. In general, outpatient
behavioral health services focus on reducing
psychiatric and behavioral symptoms in order to
improve the member’s functioning in familial, social, educational, or
occupational life domains
No authorization required. Up to 2 per year, to include a maximum of 1 Diagnostic Assessment (T1023).
Units: Up to 2 per year [to include a maximum of 1 Diagnostic Assessment (T1023)] Other: 1. A CCA that demonstrates medical necessity must be completed by a licensed professional prior to provision of outpatient therapy services. 2. The provider will communicate and coordinate care with other professionals providing care to the member. 3. For services that require a PCP, a CCA must be completed prior to service delivery.
Clinical Coverage
Policy No. 8C: Outpatient Behavioral
Health Services
APSM 45-2
Records Management
and Documentation
Manuals
PCP Instruction
Manual
September 2011 Medicaid
Bulletin
Adults (age 21 and
older)
LOC: Not applicable.
Note: For members having both Medicaid and Medicare, the provider shall bill Medicare as primary before submitting a claim to Medicaid. For beneficiaries having both Medicaid and any other insurance coverage, the other insurance shall be billed prior to billing Medicaid, as Medicaid is considered the payor of last resort.
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 3
Service & Code Brief Service Description Auth Submission
Requirements Authorization Parameters
Source Age Group Level of Care
Diagnostic
Assessment (DA)
Code(s): T1023
A DA is an intensive clinical and functional
evaluation of a member’s mental health, intellectual
and developmental disability, or substance use
condition. A diagnostic assessment determines
whether the member meets medical necessity
and can benefit from: mental health, intellectual disability, developmental
disability, or substance use disorder services based on the member’s diagnosis, presenting problems, and treatment and recovery
goals.
No authorization required (no more than 1 per year) Note: This assessment must be signed and dated by the MD, DO, PA, NP, or licensed psychologist and can serve as the initial order for services included in the PCP. Note: For members having both Medicaid and Medicare, the provider shall bill Medicare as primary before submitting a claim to Medicaid. For beneficiaries having both Medicaid and any other insurance coverage, the other insurance shall be billed prior to billing Medicaid, as Medicaid is considered the payor of last resort.
Units: 1 unit =1 event (an assessment equals 1 event). No more than 1 event per year. Other: 1. The DA must include all 10 elements detailed in the CCP. 2. For SU-focused DA, the DA must recommend an ASAM LOC determination. 3. The DA team must include at least 2 QPs: A) An LP that can dx MH or SU disorders, and; B) An MD, DO, NP, PA, or licensed psychologist.
Clinical Coverage
Policy No. 8A-5: Diagnostic Assessment
APSM 45-2
Records Management
and Documentation
Manuals
PCP Instruction
Manual
Adults (age 21 and
older)
LOC: Not applicable.
Note: Service Exclusions – A DA cannot be billed on the same day as ACT, IIH, MST or CST services. This service cannot be provided in an institution for mental disease (IMD) (for adults) or in a public institution.
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 4
Service & Code Brief Service Description Auth Submission
Requirements Authorization Parameters
Source Age Group Level of Care
Neuropsychological
Testing
Code(s): 96132: First hour of assessment 96133: For each additional full hour of assessment 96137: For each additional 30 minutes
Neuropsychological Testing is intended to assess cognition and
behavior, examining the effects of any brain injury
or neuropathological process that a person may
have experienced.
All Requests: SAR: required if the unmanaged units have been exhausted. Providers may seek prior approval if they are unsure the member has reached their unmanaged visit limit. To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.
Units: For Medicaid members age 21 and over, outpatient services coverage is limited to 16 unmanaged outpatient visits per state fiscal year (for any combination of Clinical Assessment, Neuropsych Testing, Developmental Testing, Individual, Family or Group Therapy). Other: The provider will communicate and coordinate care with other professionals providing care to the member.
Clinical Coverage
Policy No. 8C: Outpatient Behavioral
Health Services
APSM 45-2
Records Management
and Documentation
Manuals
PCP Instruction
Manual
September 2011 Medicaid
Bulletin
Adults (age 21 and
older)
LOC: Not applicable.
Note: For members having both Medicaid and Medicare, the provider shall bill Medicare as primary before submitting a claim to Medicaid. For beneficiaries having both Medicaid and any other insurance coverage, the other insurance shall be billed prior to billing Medicaid, as Medicaid is considered the payor of last resort.
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 5
Service & Code Brief Service Description Auth Submission
Requirements Authorization Parameters
Source Age Group Level of Care
Developmental
testing
Code(s): 96110: Developmental Testing - Limited 96112: Developmental Testing administrative - first hour 96113: Developmental Testing - each additional 30 minutes
An in-depth look at a member’s development, usually done by a trained
specialist, such as a developmental
pediatrician, psychologist, speech-language
pathologist, occupational therapist, or other
specialist. The specialist may observe the member,
give the member a structured test, ask the
guardian questions, or ask them to fill out questionnaires.
All Requests: SAR: required if the unmanaged units have been exhausted. Providers may seek prior approval if they are unsure the member has reached their unmanaged visit limit. To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.
Units: Up to 6 unmanaged units of Developmental Testing – Limited (96110). For Medicaid members over the age of 21, outpatient behavioral health services coverage is limited to 16 unmanaged outpatient visits per state fiscal year (for any combination of Clinical Assessment, Developmental Testing, Individual, Family or Group Therapy). Other: The provider will communicate and coordinate care with other professionals providing care to the member.
Clinical Coverage
Policy No. 8C: Outpatient Behavioral
Health Services
APSM 45-2
Records Management
and Documentation
Manuals
PCP Instruction
Manual
September 2011 Medicaid
Bulletin
Adults (age 21 and
older)
LOC: Not applicable.
Note: For members having both Medicaid and Medicare, the provider shall bill Medicare as primary before submitting a claim to Medicaid. For beneficiaries having both Medicaid and any other insurance coverage, the other insurance shall be billed prior to billing Medicaid, as Medicaid is considered the payor of last resort.
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 6
Service & Code Brief Service Description
Auth Submission Requirements
Authorization Parameters
Source Age Group Level of Care
Psychological Testing (Hourly)
Code(s): 96130: 1st hour 96131: Additional 30 minutes, used with 96130 96116 or 96132: 1st hour 96133: Additional hour, used with 96132 96136: First 30 minutes, used with 96130 or 96132 96137: Additional 30 minutes, used with 96136 96138: First 30 minutes 96139: Additional 30 minutes, used with 96138
Psychological testing involves the culturally
and linguistically appropriate
administration of standardized tests to assess a member’s
psychological or cognitive functioning. Testing results must
inform treatment selection and
treatment planning.
All Requests: 1. SAR: required if the unmanaged units have been exhausted. Providers may seek prior approval if they are unsure the member has reached their unmanaged visit limit. To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit. 2. Submission of all records that support the member has met the medical necessity criteria. Note: For members having both Medicaid and Medicare, the provider shall bill Medicare as primary before submitting a claim to Medicaid. For beneficiaries having both Medicaid and any other insurance coverage, the other insurance shall be billed prior to billing Medicaid, as Medicaid is considered the payor of last resort.
Units: Unmanaged coverage is limited to eight hours of service per state fiscal year. Other: 1. May only be performed by licensed psychologists, licensed psychological associates, and qualified physicians. 2. Testing must include all 9 elements detailed in the CCP. 3. The provider will communicate and coordinate care with other professionals providing care to the member.
Clinical Coverage
Policy No. 8C: Outpatient Behavioral
Health Services
APSM 45-2
Records Management
and Documentation
Manuals
PCP Instruction
Manual
September 2011 Medicaid
Bulletin
Adults (age 21 and
older)
LOC: Not applicable.
Note: Service Exclusions – Testing for the following is not covered: a) for the purpose of educational testing; b) if requested by the school or legal system, unless MN exists for the psych testing; c) if the proposed psych testing measures have no standardized norms or documented validity, OR; d) if the focus is not the symptoms of the DSM-5 diagnosis.
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 7
Service & Code Brief Service Description
Auth Submission Requirements
Authorization Parameters
Source Age Group Level of Care
Individual Therapy
Code(s): 90832: 30 Minutes 90833: 30 Minute add on to E&M. 90834: 45 Minutes 90836: 45 Minute add on to E&M. 90837: 60 Minutes 90838: 60 Minute add on to E&M. 90785: Interactive Complexity (Add on to codes 90832 thru 90838
Service is focus on reducing
psychiatric and behavioral
symptoms to improve the member’s
functioning in familial, social, educational, or
occupational life domains. The
member’s needs and preferences determine the
treatment goals, frequency, and
duration of services, as well as
measurable and desirable outcomes.
Initial Requests: SAR: required if the unmanaged units have been exhausted. Providers may seek prior approval if they are unsure the member has reached their unmanaged visit limit. To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit. Reauthorization Requests: 1. SAR: required after unmanaged visits. Requests should be submitted prior to the last unauthorized visit. 2. Submission of all records that support the member has met the medical necessity criteria. Note: Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
Units: 1. For Medicaid members age 21 and over, outpatient services coverage is limited to 16 unmanaged outpatient visits per state fiscal year (for any combination of Clinical Assessment, Neuropsych Testing, Developmental Testing, Individual, Family or Group Therapy). 2. LOCUS or ASAM Level 1 - 6: See LOC section Other: 1. When receiving multiple BH services in addition to outpatient, a PCP must be developed. 2. The provider will communicate and coordinate care with other professionals providing care to the member.
Clinical Coverage
Policy No. 8C: Outpatient Behavioral
Health Services
APSM 45-2
Records Management
and Documentation
Manuals
PCP Instruction
Manual
September 2011 Medicaid
Bulletin
Adults (age 21 and
older) Note: Service Exclusions – Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
1. ASAM or LOCUS Level 1: Up to an additional 8 sessions per state fiscal year after the unmanaged units have been exhausted (for any combination of Individual, Family or Group Therapy) 2. ASAM Level 1 or LOCUS Level 2 thru 6: Up to an additional 13 sessions per state fiscal year after the unmanaged units have been exhausted (for any combination of Individual, Family or Group Therapy).
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 8
Service & Code Brief Service Description
Auth Submission Requirements
Authorization Parameters
Source Age Group Level of Care
Family Therapy
Code(s): 90846: Family Therapy w/o member. May not be used with 90785. 90847: Family Therapy with member. May not be used with 90785.
Service is focus on reducing
psychiatric and behavioral
symptoms to improve the member’s
functioning in familial, social, educational, or
occupational life domains. The
member’s needs and preferences
determine the treatment goals, frequency, and
duration of services, as well as
measurable and desirable
outcomes.
Initial Requests: SAR: required if the unmanaged units have been exhausted. Providers may seek prior approval if they are unsure the member has reached their unmanaged visit limit. To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit. Reauthorization Requests: 1. SAR: required after unmanaged visits. Requests should be submitted prior to the last unauthorized visit. 2. Submission of all records that support the member has met the medical necessity criteria. Note: Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
Units: 1. For Medicaid members age 21 and over, outpatient services coverage is limited to 16 unmanaged outpatient visits per state fiscal year (for any combination of Clinical Assessment, Neuropsych Testing, Developmental Testing, Individual, Family or Group Therapy). 2. LOCUS or ASAM Level 1 - 6: See LOC section Other: 1. When receiving multiple BH services in addition to outpatient, a PCP must be developed. 2. The provider will communicate and coordinate care with other professionals providing care to the member.
Clinical Coverage
Policy No. 8C: Outpatient Behavioral
Health Services
APSM 45-2
Records Management
and Documentation
Manuals
PCP Instruction
Manual
September 2011 Medicaid
Bulletin
Adults (age 21 and
older) Note: Service Exclusions –Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
1. ASAM or LOCUS Level 1: Up to an additional 8 sessions per state fiscal year after the unmanaged units have been exhausted (for any combination of Individual, Family or Group Therapy) 2. ASAM Level 1 or LOCUS Level 2 thru 6: Up to an additional 13 sessions per state fiscal year after the unmanaged units have been exhausted (for any combination of Individual, Family or Group Therapy).
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 9
Service & Code Brief Service Description
Auth Submission Requirements
Authorization Parameters
Source Age Group Level of Care
Group Therapy
Code(s): 90849: Group Therapy (multi-family). May not be used with 90785. 90853: Group Therapy 90785: Interactive Complexity
Service is focus on reducing
psychiatric and behavioral
symptoms to improve the member’s
functioning in familial, social, educational, or
occupational life domains. The
member’s needs and preferences determine the
treatment goals, frequency, and
duration of services, as well as
measurable and desirable outcomes.
Initial Requests: SAR: required if the unmanaged units have been exhausted. Providers may seek prior approval if they are unsure the member has reached their unmanaged visit limit. To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit. Reauthorization Requests: 1. SAR: required after unmanaged visits. Requests should be submitted prior to the last unauthorized visit. 2. Submission of all records that support the member has met the medical necessity criteria. Note: Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
Units: 1. For Medicaid members age 21 and over, outpatient services coverage is limited to 16 unmanaged outpatient visits per state fiscal year (for any combination of Clinical Assessment, Neuropsych Testing, Developmental Testing, Individual, Family or Group Therapy). 2. LOCUS or ASAM Level 1 - 6: See LOC section Other: 1. When receiving multiple BH services in addition to outpatient, a PCP must be developed. 2. The provider will communicate and coordinate care with other professionals providing care to the member.
Clinical Coverage
Policy No. 8C: Outpatient Behavioral
Health Services
APSM 45-2
Records Management
and Documentation
Manuals
PCP Instruction
Manual
September 2011 Medicaid
Bulletin
Adults (age 21 and
older) Note: Service Exclusions –Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
1. ASAM or LOCUS Level 1: Up to an additional 16 sessions per state fiscal year after the unmanaged units have been exhausted (of Group Therapy) 2. ASAM Level 1 or LOCUS Level 2 thru 6: Up to an additional 26 sessions per state fiscal year after the unmanaged units have been exhausted (of Group Therapy).
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 10
Service & Code Brief Service Description Auth Submission
Requirements Authorization Parameters
Source Age Group Level of Care
Psychotherapy for
Crisis
Code(s): 90839: First 60 Minutes 90840: For each additional 30 minutes. Must be used with 90839. Up to two addons per 90839 event.
On rare occasions, licensed outpatient service
providers are presented with individuals in crisis situations which may
require unplanned extended services to
manage the crisis in the office with the goal of
averting more restrictive levels of care. This service
is used only in those extreme situations in which
an unforeseen crisis situation arises, and
additional time is required to manage the crisis event. Services are restricted to
outpatient crisis assessment, stabilization, and disposition for acute, life-threatening situations.
Prior approval is not required for Psychotherapy for Crisis. A provider shall provide no more than two Psychotherapy for Crisis services per member, per state fiscal year. Note: For members having both Medicaid and Medicare, the provider shall bill Medicare as primary before submitting a claim to Medicaid. For beneficiaries having both Medicaid and any other insurance coverage, the other insurance shall be billed prior to billing Medicaid, as Medicaid is considered the payor of last resort.
Units: Up to two events per calendar year per attending provider Other: 1. The provider will complete an assessment prior to the delivery of any subsequent services following the provision of this service. 2. When receiving multiple BH services in addition to outpatient, a PCP must be developed. 3. The provider will communicate and coordinate care with other professionals providing care to the member.
Clinical Coverage
Policy No. 8C: Outpatient Behavioral
Health Services
APSM 45-2
Records Management
and Documentation
Manuals
PCP Instruction
Manual
September 2011 Medicaid
Bulletin
Adults (age 21 and
older)
LOC: Not applicable.
Note: Service Exclusions – Psychotherapy for Crisis is not covered: a) if the focus of tx does not address the symptoms of the DSM-5 dx or related symptoms; b) in emergency departments, inpatient settings, or facility-based crisis settings, OR; c) if the member presents with a medical, cognitive, intellectual or development issue that would not benefit from outpatient tx services.
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 11
Service & Code Brief Service Description Auth Submission
Requirements Authorization Parameters
Source Age Group Level of Care
Evaluation & Management
Code(s): 99201 – 99255 99304 – 99337 99341 – 99350
Evaluation and Management provided by a Psychiatrist / MD or a
Psych NP/PA.
No SAR required. E/M codes are not specific to mental health and are not subject to prior approval. Note: For members having both Medicaid and Medicare, the provider shall bill Medicare as primary before submitting a claim to Medicaid. For beneficiaries having both Medicaid and any other insurance coverage, the other insurance shall be billed prior to billing Medicaid, as Medicaid is considered the payor of last resort.
Units: A member 21 years of age and over is allowed 22 unmanaged visits counted separately from outpatient behavioral health services visit limits Other: 1. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service. 2. The provider will communicate and coordinate care with other professionals providing care to the member.
Clinical Coverage
Policy No. 8C: Outpatient Behavioral
Health Services
APSM 45-2
Records Management
and Documentation
Manuals
PCP Instruction
Manual
September 2011 Medicaid
Bulletin
Adults (age 21 and
older)
LOC: Not applicable.
Note: Service Exclusions – Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 12
Service & Code Brief Service Description
Auth Submission Requirements
Authorization Parameters Source Age Group Level of Care
Peer Support
Services
Code(s):
H0038: Peer Support, Individual H0038HQ: Peer Support, Group
An evidenced-based mental health model of care that provides
community-based recovery services
directly to a Medicaid-eligible
adult member diagnosed with an MH or SU disorder.
PSS provides structured, scheduled services that promote
recovery, self-determination, self-
advocacy, engagement in self-care and wellness
and enhancement of community living
skills of beneficiaries
Initial Requests: 1. SAR: Prior approval is required beyond the unmanaged limit. 2. CCA: Required 3. Complete PCP: Required 4. Service Order: Required, signed by physician or other licensed clinician, per their scope of practice. 5. Submission of all records that support the member has met the medical necessity criteria. Reauthorization Requests: 1. SAR: prior approval required 2. Complete PCP: recently reviewed detailing the member’s progress with the service 3. Submission of all records that support the member has met the medical necessity criteria.
Length of Stay: Providers will seek prior approval if member is engaged in other MH or SU services. Providers shall seek prior approval if they are uncertain that the member has reached the unmanaged unit limit. Units: 1. Units are billed in 15-increments. 2. For unmanaged visit Eastpointe will continue to authorize 270 units for 90 days for initial requests. This will include services with the SE modifier for services engagement. 3. Up to 270 units for 90 days for the initial auth period. Up to 270 units for 90 days for reauth periods, if medically necessary. Additional units may be auth’d as clinically appropriate.
Clinical Coverage
Policy No 8G: Peer Support
Services
LME-MCO Joint
Communication Bulletin # J344
APSM 45-2
Records Management
and Documentation
Manuals
PCP Instruction Manual
Adults (age 18 and
older)
ASAM or LOCUS Level of 1 or higher
Note: Service Exclusions - May not be provided during the same auth period as ACTT or CST. Member with a sole diagnosis of IDD is not eligible this service.
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 13
Service & Code Brief Service Description
Auth Submission Requirements
Authorization Parameters Source Age
Group Level of
Care
Community
Support Team (CST)
Code(s): All Services (used in place of the following individual codes) H2015 HT: CST H2015HTHO: Licensed Team Lead H2015HTHF: LCAS, LCAS-A, CCS, CSAC H2015 HTHNSE: QP, AP H2015HTU1: NC Peer Support Specialist H2015HTHM: Paraprofessional
Provides direct support to adults with
a MH, SU, or co-morbid disorder and who have complex
and extensive treatment needs.
Consists of community-based MH and SU services, and
structured rehab interventions intended
to increase and restore a member’s
ability to live successfully in the
community. The team approach involves structured, face-to-
face therapeutic interventions that
assist in reestablishing the members
community roles related to life domains.
Initial Requests: 1. SAR: Prior approval is required beyond the unmanaged limit 2. CCA: Required 3. Complete PCP: Required 4. Service Order: Required, signed by a physician, licensed psychologist, PA, or NP. 5. Submission of all records that support the member has met the medical necessity criteria. Reauthorization Requests: 1. SAR: prior approval required 2. Complete PCP: recently reviewed detailing the member’s progress with the service 3. CCA: For services lasting more than six months, a new CCA or an addendum must be submitted. 4. Service Order: Service must be ordered at least annually. 5. Submission of all records that support the member has met the medical necessity criteria.
Units and Length of Stay: 1. One unit = 15 minutes 2. Up to 36 unmanaged units for an initial 30 calendar days. Exception: SE codes providers are allowed 128 unmanaged units for 90 days. 3. Initial Request: 128 units for 60-calendar days. Members searching for stable housing requiring permanent supportive housing interventions, 420 units for 60 days. 4. Reauth Request: up to 192 units for 90-days. Members searching for stable housing requiring permanent supportive housing interventions, up to 630 units for 90-days. Exception: When helping a member transition to and from a service, CST services may be provided for a max of eight units for the first and last 30-day period for members auth’d for: ACTT, SAIOP, SACOT. 5. It is expected that service intensity titrates down as the member demonstrates improvement.
Clinical Coverage
Policy No 8A-6: Community
Support Team
APSM 45-2 Records
Management and
Documentation Manuals
PCP Instruction
Manual
Adults (age 18
and older)
LOCUS Level of 3 or higher. For members
with an SU diagnosis, an ASAM score
of 2.1 is required.
Note: Service Exclusions - May not be provided in conjunction with ACTT or during the same auth period as any other State Plan service that contains duplicative service components.
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 14
Service & Code Brief Service Description Auth Submission
Requirements Authorization Parameters
Source Age Group Level of Care
Individual
Rehabilitation, Coordination, and
Support (IRCS) Services
Code(s): H2017U5
The purpose of this service is to enhance, restore
and/or strengthen the skills needed to promote and
sustain independence and stability within the
individual’s living, learning, social, and work
environments. IRCS assist individuals in achieving rehabilitative, resiliency and recovery goals. The
service consists of therapeutic interventions that facilitate illness self-
management, skill building, identification and
use of adaptive and compensatory strategies, identification and use of
natural supports, and use of community resources.
IRCS services help clients develop and practice skills
in their home and community. IRCS is a skill building service, not a form
of psychotherapy or counseling.
Initial Requests: 1. SAR: Prior approval is required. 2. CCA: Required, to include the info required in Admission Criteria E1-4. 3. Complete PCP: Required. The number of hours that participant receives IRCS services are to be specified in the PCP. 4. Service Order: Required. Reauthorization Requests: 1. SAR: Prior approval required. 2. Complete PCP: Required. Active treatment and discharge planning must be present. IRCS must be listed on the PCP, to include a description of the intervention, member's response to the intervention, and progress toward goals/objectives in the PCP. PCP must clearly reflect the specific need of the member and the interventions/ support rendered to address the need(s) of the individual.
Length of Stay: 1. Initial: Up to 90 days. 2. Reauth: Up to 180 days. 3. Services are generally more intensive and frequent at the beginning of tx and are expected to decrease as the member’s skills develop. 4. This service is to be available for at least 15 minutes per day, five days per week. 5. Service can be provided for no more five hours in a single day and may be provided on weekends or in the evening. Units: 1. Units are billed in 15-increments. 2. Maximum of 10 hours week, 5 days per week with no more than 5 hours in a single day. 3. Maximum 2,080 units per individual per 12 months
Individual Rehabilitation, Coordination, and Support
(IRCS) Services
Alternative Service
Definition
APSM 45-2 Records
Management and
Documentation Manuals
PCP Instruction
Manual
LME-MCO
Communication Bulletin #J334
(JCB 334)
Adults (Age 18
and older)
LOCUS Level of 3 or higher
Note: Service Exclusions - IRCS cannot be provided during the same authorization period as PSR-Group, ACTT, CST, Partial Hospitalization, Day Tx, Residential Tx, Supervised Living, IIH, FCT, MST, HFW, and Young Adults in Transition.
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 15
Service & Code Brief Service Description
Auth Submission Requirements
Authorization Parameters
Source Age Group Level of Care
Mental
Health/Substance Abuse Targeted
Case Management
Code(s): H0032
Case management (MH/SA TCM) is an activity that assists
members to gain access to necessary care:
medical, behavioral, social, and other services appropriate to their needs.
Case management is individualized, person-centered, empowering,
comprehensive, strengths-based, and outcome-
focused. This service is targeted at member’s who
have either a serious emotional disturbance,
mental illness or a substance related
disorder.
Initial Requests: 1. SAR: Prior approval is required 2. Complete PCP: Required 3. Service Order: Required, signed by a physician, licensed psychologist, or PA, or NP. 4. Submission of all records that support the member has met the medical necessity criteria. Reauthorization Requests: 1. SAR: prior approval required 2. Complete PCP: recently reviewed detailing the member’s progress with the service. 3. Submission of all records that support the member has met the medical necessity criteria.
Units and Length of Stay: 1. Weekly case rate of 1 unit per calendar week [Sunday-Saturday]. 2. Initial requests up to 13 units over 90 days. 3. Reauthorization up to 9 units over 60 days. 4. This is a short-term service. The functions of case management include: a) Case Management Assessment; b) Person-Centered Planning; c) Referral and linkage; and d) Monitoring and follow-up.
Clinical Coverage Policy 8-L:
Mental Health/Substance Abuse Targeted
Case Management
APSM 45-2
Records Management and Documentation
Manuals
PCP Instruction Manual
Adults LOCUS score of 3 or higher
Note: Service Exclusions - MH/SA TCM cannot be provided during the same auth period as: IIHS, CST, ACTT, MST, CADT, SAIOP, SACOT, or Substance Abuse Non-Medical Community Residential Treatment. Case Management is a component of these services.
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 16
Service & Code Brief Service Description Auth Submission
Requirements Authorization Parameters
Source Age Group Level of Care
Psychosocial Rehabilitation
Code(s): H2017
Service is designed to help adults with psychiatric
disabilities increase their functioning so that they can be successful and
satisfied in the environments of their choice with the least amount of ongoing
professional intervention. PSR focuses on skill and
resource development related to life in the community and to
increasing the participant’s ability to live as
independently as possible, to manage their illness and
their lives with as little professional intervention
as possible, and to participate in community opportunities related to
functional, social, educational, and vocational goals.
Initial Requests: 1. SAR: Prior approval is required. 2. CCA: Required 3. Complete PCP: Required. The amount, duration, and frequency of services must be included. If limited information is available at admission, staff shall document on the PCP whatever is known and update it when additional information becomes available. 4. Service Order: Required, signed by an MD, DO, NP, PA, or a Licensed Psychologist. 5. Submission of all records that support the member has met the medical necessity criteria. Reauthorization Requests: 1. SAR: prior approval required 2. Complete PCP: recently reviewed detailing the member’s progress with the service. For PSR, the PCP shall be reviewed at least every 6 months. The amount, duration, and frequency of services must be included in a member’s PCP. 3. Submission of all records that support the member has met the medical necessity criteria.
Length of Stay: Initial authorization for services must not exceed 90 days. Reauthorization must not exceed 180 days. This service is to be AVAILABLE for a period of five or more hours per day at least five days per week and it may be provided on weekends or in the evening. Units: 1. Units are billed in 15-increments. 2. Up to 2080 units per 90 days. 3. The number of hours that a member receives PSR services are to be specified in his or her PCP.
Clinical Coverage Policy 8A: Enhanced
Mental Health and Substance
Abuse Services,
Psychosocial Rehabilitation
section
APSM 45-2 Records
Management and
Documentation Manuals
PCP Instruction
Manual
Adults (Age 21 and
older)
LOCUS Level of 3 or higher
Note: Service Exclusions - PSR cannot be provided during the same authorization period as Partial Hospitalization and ACTT
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 17
Service & Code Brief Service Description
Auth Submission Requirements
Authorization Parameters
Source Age Group Level of Care
Assertive
Community Treatment (ACT)
Program
Code(s): H0040 H0040:22 - for Encounter Claims
An ACT team assists a member in advancing toward personal goals
with a focus on enhancing community
integration and regaining valued roles
(example: worker, daughter, resident, spouse, tenant, or
friend). A fundamental charge of ACT is to be
the first-line (and generally sole provider) of all the services that
an ACT member needs. A member who is appropriate for ACT does not benefit from
receiving services across multiple, disconnected
providers, and may become at greater risk
of hospitalization, homelessness, substance use,
victimization, and incarceration.
Initial Requests: 1. SAR: Prior approval is required. 2. CCA: Required 3. Complete PCP: Required. If limited information is available at admission, staff shall document on the PCP whatever is known and update it when additional information becomes available. 4. Service Order: Required, signed by an NP, PA, physician, or a Licensed Psychologist. 5. An LME Consumer Admission and Discharge Form 6. Submission of all records that support the member has met the medical necessity criteria. Reauthorization Requests: 1. SAR: prior approval required 2. Complete PCP: recently reviewed detailing the member’s progress with the service. 3. An LME Consumer Admission and Discharge Form 4. Submission of all records that support the member has met the medical necessity criteria.
Length of Stay: Max of 30 days without a complete PCP. A PCP must be completed within 15 days of the initial auth date. Up to 180 days for the initial and reauthorization period when the supporting docs (specifically the PCP), are present. Units: 1. One unit = 1 event. 2. Four units are auth’d per month, although an encounter claim should be billed every time an encounter occurs. 3. The expectation is most ACT members will receive more than 4 contacts per month, with most seeing at least 3 team members in a given month.
Clinical Coverage
Policy 8A-1: Assertive
Community Treatment
(ACT) Program
APSM 45-2
Records Management
and Documentation
Manuals
PCP Instruction
Manual
LME Consumer
Admission and Discharge
Form
Adults (Age 18 and
older)
LOCUS Level of 3 or higher
Note: Service Exclusions – Members with a primary dx of a SU, IDD, TBI, borderline personality disorder, or an autism spectrum disorder are not the intended member group for ACT and should not be referred if they do not have a co-occurring psychiatric disorder. ACT cannot be provided concurrently w/: Outpatient therapy, Med Mngmnt, or Psych Services; Mobile Crisis; PSR (after a 30-day transition period); CST; Partial Hospitalization; Tenancy Support Services; Nursing home facility, or IPS-Supported Employment or LTVS.
2021-2022 Medicaid Adult MH/SU Benefit Plan
Revised: 6/30/21 Page 18
Service & Code Brief Service Description
Auth Submission Requirements
Authorization Parameters
Source Age Group Level of Care
Partial
Hospitalization
Code(s): H0035
A short-term service for acutely mentally ill children or adults,
which provides a broad range of intensive
therapeutic approaches which may include: group activities
or therapy, individual therapy, recreational therapy, community
living skills or training, increases the
individual’s ability to relate to others and to function appropriately, coping skills, medical services. This service is designed to prevent
hospitalization or to serve as an interim
step for those leaving an inpatient facility.
Initial Requests: 1. SAR: Prior approval is required. 2. CCA: Required 3. Complete PCP: Required. The amount, duration, and frequency of services must be included. If limited information is available at admission, staff shall document on the PCP whatever is known and update it when additional information becomes available. 4. Service Order: Required, signed by a physician, doctoral level licensed psychologist, psychiatric NP, psychiatric clinical nurse specialist. 5. Submission of all records that support the member has met the medical necessity criteria. Reauthorization Requests: 1. SAR: prior approval required. 2. Complete PCP: recently reviewed detailing the member’s progress with the service. 3. Submission of all records that support the member has met the medical necessity criteria.
Length of Stay: Initial and Reauthorization requests shall not exceed seven calendar days. Units: 1. One unit = 1 event. 2. This is day or night service provided a minimum of 4 hrs/day, 5 days/week, and 12 months/year (excluding transportation time). Excludes legal or governing body designated holidays.
Clinical Coverage Policy 8A: Enhanced
Mental Health and Substance
Abuse Services,
Partial Hospitalization
section
APSM 45-2 Records
Management and
Documentation Manuals
PCP
Instruction Manual
Adults LOCUS Level of 4 or higher