Vaya Health
Medicaid 1915(b) Authorization Guidelines for Non-Innovations Intellectual/Developmental Disability (I/DD) Services Medicaid 1915(b) Child/Adult Non‐Innovations I/DD Services Authorization Guidelines Service ICF
Long Term Community Support (LTCS)
Billing Code
Auth Required?
Utilization Parameters
0100
Yes
Max. 180 days
T 2016 U5 U1, T2016 U5 U2, T2016 U5 U3, T2016 U5 U4, T2016 U5 U5
Yes
Max of 180 units/6 months authorization, T2016 U5 U1 (level 1) max. of 5 units/week 180-day authorization
Applied Behavioral Analysis (ABA)
97151, 97152,97153,97154, 97155,97156
Yes
97151 – to occur no more than once every six months (180 days), all codes at 180-day authorization and 15-minute units Reauthorization must be submitted prior to initial or concurrent authorization expiring.
Documentation Submission Requirements Initial request: LOC signed by MD, current psychological evaluation, admissions application, any other supporting documentation; Concurrent request: LOC signed by MD, PCP Annual PCP with LTCS goals, psychological evaluation to determine eligibility, guardianship papers if applicable justification for ongoing services in SAR For members under age 21 diagnosed with ASD utilizing a scientifically validated diagnostic tool or tools such as psychological evaluation with ASD diagnosis; service order required to begin initial services and then annually thereafter; continuing services require behavioral assessment, medical necessity in Treatment Plan, and supporting documentation
These are the authorization guidelines for Medicaid 1915(b) Non‐Innovations Intellectual/Developmental Disabilities (I/DD) Services for child and adult residents of the Vaya Health (Vaya) catchment area. Providers may be reimbursed only for those specific services included in their contracts with Vaya. Some services for particular age or disability groups in selected counties may only be provided by designated providers. 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 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. Previous effective date: New effective date:
03.03.2019 01.01.2022
Vaya Health | Medicaid 1915(b) Authorization Guidelines for Non-Innovations I/DD Services Copyright © 2021 Vaya Health. All rights reserved.
Clinical Strategies | Effective 01.01.2022 Version 5.0
REVISION INFORMATION: Date 03/18/2014 07/01/2014 09/01/2014 08/01/2015 09/15/2015 03/01/2017 03/03/2019 01/01/2022
Change Added documentation requirements Added service of Supported Employment, removed Therapeutic Leave as no auth required Increased respite from 30 hours/month to 32 hours/month Documentation requirements modified to exclude service order requirement; annual authorization for LTVS; annual authorization for Respite Additional information re: annual auths for respite and LTVS for clarity; removed NC-SNAP requirement Updated Respite to reflect authorization requirements and fiscal year calendar; changed Community Guide to Community Navigator Moved all (b)(3) services (Community Navigator, Respite and Supported Employment) to a separate document, “Medicaid 1915(b)(3) Authorization Guidelines for IDD Non-Innovations”; reworded and reformatted; no change to individual auth guidelines Added Applied Behavioral Analysis Guidelines
Vaya Health | Medicaid 1915(b) Authorization Guidelines for Non-Innovations I/DD Services Copyright © 2021 Vaya Health. All rights reserved.
Clinical Strategies | Effective 01.01.2022 Version 5.0