medicaid-1915b-and-non-medicaid-authorization-guidelines-for-mh_su_idd-acute-services-20220101 by Vaya Health

Vaya Health

Medicaid 1915(b) and Non-Medicaid Authorization Guidelines for Mental Health, Substance Use, and Intellectual/Developmental Disability (I/DD) Acute Services Medicaid 1915(b) and Non-Medicaid Acute Services Utilization Review Guidelines Service

Service Code

Authorization Submission Requirements

Service Definition Authorization Parameters

Source

Age group

Non-State Hospital: MH/SU Inpatient

Revenue center codes (0101, 0160)

Clinical Assessment for all ages; Certificate of Need (CON) if under age 21; for concurrent requests: Vaya Inpatient Concurrent Review Form (or provider may upload stand-alone clinical progress notes)

Initial auth: 7 days Concurrent: 3 days

Children and adults

State Hospital: MH/SU Inpatient

Regional Referral Form (RRF)or Clinical Assessment for all ages; Certificate of Revenue Need (CON) if under center age 21; I/DD exception form per codes diversion law; for concurrent requests: (0101, Vaya Inpatient Concurrent Review 0160) Form (or provider may upload stand-alone clinical progress notes)

Initial auth: 3 days Concurrent: 7 days

Children and adults (under 21; 65 and older)

Criterion V

Mobile Crisis Management

Facility-Based Crisis

0902

SAR and Vaya Criterion V Form

Medical necessity

Age 17 and under

H2011

SAR required when beyond initial pass-thru

32-unit initial pass thru; 24-hour max per episode; member not enrolled with a provider who should and can provide/be involved with the response

Children and adults

Admissions assessment for initial Up to 7 days for initial and concurrent “pass-thru” authorization. For requests. concurrent requests: Vaya Inpatient Max of 16 units in 24-hour period for Concurrent Review Form (or provider adults and 24 units for children. may upload stand-alone clinical Max of 30 days in 12-month period progress notes)

Children and adults

S9484, S9484HA

Authorization Guidelines

Clinical Strategies | Effective 01.01.2022 Version 3.0

Medicaid 1915(b) and Non-Medicaid Acute Services Utilization Review Guidelines Service

Service Code

Authorization Submission Requirements

Service Definition Authorization Parameters

Source

Age group

Authorization Guidelines

SAR or similar admissions assessment

Initial 4-day pass through; Concurrent: Up to three days, with a max total of 20 days per episode of care with appropriate ASAM justification; one unit = one day not to exceed more than 30 days in a rolling 12-month period per member

Adults

ASAM 3.7-D

Auth required after initial 7 days of service

Adults

ASAM 3.9-WM

YP790

SAR required on or before the date of admission

Initial: 3 days if voluntary; 10 days if involuntary. Concurrent: (voluntary) 1 unit daily up to 10 days; (Involuntary) Daily

3-way

Children and adults

YP821

Admissions assessment for initial “pass-thru” authorization. For concurrent requests: Vaya Inpatient Concurrent Review Form and/or MD/nursing progress notes

Initial: 7 days Concurrent: 3 days

3-way

Children and adults

SU Non-Hospital Medical Detox

H0010

SU Medically Supervised Detoxification Crisis Stabilization (ADATC)

0160, H2036

SA Detox Social Setting

Regular Three-Way Inpatient (MH or SA) Initial

Previous effective date: New effective date:

SAR, RRF, or similar admissions assessment

06.17.2021 01.01.2022

Services provided must be in provider contract.

REVISION INFORMATION: Date

Change

3/03/19

Guidelines reformatted; Medicaid 1915(b) specified; noted added; no change to individual guidelines

4/01/19

Facility-Based Crisis: Removed age range “18-20” from service code category

9/20/19

Removed ASAM level authorization guideline grid

9/20/19

Facility Based Crisis: Amended units to 24 for children

9/20/19

Mobile Crisis: Removed authorization guideline parameter

9/20/19

Detoxification Crisis: Removed maximum of 30 days in short term and added 30 days maximum for 12 months

9/20/19

ADATC: added code 0160, added ASAM 3.9-WM

Clinical Strategies | Effective 01.01.2022 Version 3.0

Date

Change

9/20/19

Authorization note caveat: Removed “In order to be authorized, services in the authorization guidelines must be determined to be medically necessary at a specific intensity level for each individual member. The maximum number of units listed in the authorization guidelines is not necessary for all members requiring the service—the necessary amount of service must be determined individually for each member. The service intensities listed in the guidelines are the maximum amounts that will be necessary and approved for most members at a given Level of Care. Services at a higher level of intensity than that listed in the guidelines may be requested and will be reviewed for approval by Vaya’s UM staff. Three criteria must be met in order to authorize services at an intensity that is higher than that listed in the guidelines: (1) the higher level of intensity is determined to be medically necessary; (2) it is established that the member will be at serious risk of deterioration or other harm if the higher intensity level is not provided; and (3) Vaya has funding available for the higher intensity level.” Added: Services provided must be in provider contract.

2/03/20

Formatting changes; creation of single Authorization Guidelines column

6/17/21

Added concurrent request information for state Hospital, non-state Hospital and Facility Based Crisis: “For concurrent requests: Vaya Inpatient Concurrent Review Form (or provider may upload stand-alone clinical progress notes)”. Clarified authorization parameter for Facility Based Crisis: “Up to 7 days for initial and concurrent requests.”

01/01/22

Amended title to include Non-Medicaid funding; added revenue codes for non-state and state hospitals; amended H0010 detox authorization parameters; added H2036 to Medically monitored detox; added SA Detox Social; added Regular 3-way inpatient

Clinical Strategies | Effective 01.01.2022 Version 3.0