medicaid-1915b-authorization-guidelines-for-child-mh_su by Vaya Health

Medicaid 1915(b) Authorization Guidelines for Child MH/SU Services Medicaid 1915(b) Child MH/SU Services Utilization Review Guidelines Service Code(s)

Authorization Submission Requirements

Clinical Assessment (E)

90791, T1023

No auth required

8A - T1023; 8C for the others

Psychiatric Assessment (E)

90792

No auth required

8C (F)

Psychological Testing

96112,96113, 96116, 96121, 96130, 96131, 96132, 96133.96136, 96137

No auth required

Individual Therapy (E)

90832, 90834, 90837

Service

Individual Therapy 90833, 90836, 90838 Add-On to E/M (E) Family Therapy 90846, 90847

Service Definition Authorization Parameters

Source

Authorization Guidelines

There is a limit of 8 hours of service per date of service

8C (F) No auth required

8C (F)

Individual and Family Therapy may be provided on the same date at different times

90839, 90840

No auth required

8C (F)

90839: Up to 2 sessions/fiscal year/provider; 90840: Up to 2 add-ons per episode No other outpatient services may be billed on the same day

90849, 90853

No auth required

90849 may not be used with 90785

90837SR

No auth required

Intensive In-Home

H2022

SAR, CCA, PCP including Service Order (C) (include CALOCUS/ASAM worksheet). Comprehensive Crisis Plan, CANS (for children 3-5)*

Max 60 days per auth

MST (Multisystemic Therapy)

H2033

No auth required

Ages 7 - 17

H2022U5

Initial: CCA and Ansell Casey Life Skills assessment; PCP recommended but not required

Ages 16 to 21

Individual Therapy for Crisis Group Therapy/ Counseling (E) Home-Based Therapy

Transitional Youth Services

Initial authorization up to 3 months. Three additional concurrent authorizations up to 3 months Utilization Management | Rev. 01.04.2021 Version 3.1

Medicaid 1915(b) Child MH/SU Services Utilization Review Guidelines Service Code(s)

Authorization Submission Requirements

Service Definition Authorization Parameters

Source

Day Treatment

H2012HA

SAR, PCP including Service Order (C) (include CALOCUS/ASAM worksheet), Comprehensive Crisis Plan, CANS (for children 3-5)*

Max 60-day auth periods. ASAM II.1

MH Partial Hospitalization

H0035

SAR, PCP including Service Order (C) (include CALOCUS/ASAM worksheet), Comprehensive Crisis Plan, CANS (for children 3-5)*

Max 7-day on prospective and concurrent authorizations

H0046

SAR, PCP including Service Order (C) (include CALOCUS/ASAM worksheet), Comprehensive Crisis Plan, CANS (for children 3-5)

Service

Residential Treatment – Level 1/Family Type

8D-2

Authorization Guidelines

Up to 90-day auth period

S5145 CTSP Residential(family) H2020 Residential S5145HA CTSP FAM TYPE RES II IAFT

Residential Treatment – Level II

S5145HK Enhanced Rate Therapeutic Foster Care S5145U5 Enhanced Therapeutic Foster Care (in lieu of service)

Prospective: SAR, PCP including Service Order (C) (include CALOCUS/ASAM worksheet), Comprehensive Crisis Plan Concurrent: SAR, updated PCP including signature page (include CALOCUS/ASAM worksheet), Comprehensive Crisis Plan, CANS (for children 3-5)

(30-day pass thru notification only SAR is allowed for the first 30 days) 8D-2 Initial authorization is to 60 days; concurrent up to 90 days

S5156Z3 Rapid Response Therapeutic Foster Care Residential Treatment – Level III (<= 4 beds)

H0019HQ

Prospective: SAR, PCP including Service Order (C) (include CALOCUS/ASAM worksheet), Comprehensive Crisis Plan

8D-2

Initial up to 120 days; concurrent up to 60 days

Utilization Management | Rev. 01.04.2021 Version 3.1

Medicaid 1915(b) Child MH/SU Services Utilization Review Guidelines Service Residential Treatment – Level III (5+ beds)

Residential Treatment – Level IV/ Secure

Authorization Submission Requirements

Service Code(s)

H0019TJ

8D-2

H0019HK

For auths beyond 180 days: CCA or Psychiatric Evaluation recommending continued need for this level of residential care needs to be completed by psychiatrist (MD/DO) or psychologist (PhD/PsyD). CCA must be completed by an independent practitioner not affiliated with the provider

8D-2

0911 Concurrent: SAR, updated PCP including signature page (C) (include CALOCUS/ ASAM worksheet), Comprehensive Crisis Plan, CANS (for children 0-5)

Therapeutic Leave: Residential Level II, III or IV and PRTF

0183

No auth required

Tobacco Cessation

99406, 99407

No auth required

(A) (C) (E) (F)

Source

Concurrent: SAR, updated PCP including signature page (include CALOCUS/ASAM worksheet), Comprehensive Crisis Plan, CANS (for children ages 0-5); see next page

Prospective: SAR, Certificate of Need, PCP including Service Order (C) (include CALOCUS/ASAM worksheet), Comprehensive Crisis Plan PRTF

Service Definition Authorization Parameters

Authorization Guidelines

Initial up to 120 days; concurrent up to 60 days

Initial auth: 45 days; Concurrent auth: 30 days

8D-1

Up to 30 days

Max 15 days within calendar quarter; unused days do not carry over to next quarter; max 45 days per year

8D-1

Up to 15 days within calendar quarter; up to 45 days per year

99406 – Intermediate visit (3-10 minutes) ($11.93) 99407 – Intensive visit (> 10 minutes

Referral required for those under age 21. Services provided by a physician do not require a referral/service order. Comprehensive Clinical Assessment (CCA) is required. Also an individualized treatment plan (or PCP if noted) is required to be maintained in recipient's service record. Interactive Therapy (90785) may be used in conjunction with the following codes: 90791, 90792, 90832 – 90838, 90853. For information on new CPT codes, refer to the January 2013 DMA Medicaid Bulletin.

Services provided must be in provider contract. Previous effective date: New effective date:

11.13.2019 02.03.2020

Utilization Management | Rev. 01.04.2021 Version 3.1

REVISION INFORMATION: Date

Section revised

4/15/2014 4/17/2014 7/7/2014 7/7/2014 7/21/2014 9/1/2014 9/1/2014 1/1/2015 1/1/2015 3/13/2015 5/3/2015 5/3/2015 7/9/2015

Psychological Testing - Auth Submission Requirements N/S Group Therapy-Auth Guidelines SAIS-Service b(3) initial PRTF Psych testing 90837SR Header and individual score references throughout grid. Residential Level II Residential Level III Psych testing Psychological Testing - Service Definition Authorization Parameters

8/26/2015

b(3) Respite

2/3/2016

b(3) Respite

5/12/2016

IIH, Day Treatment, Level II-IV, PRTF

10/7/2016 3/6/2017 7/1/2017 7/1/2017 10/24/2017 11/15/2017 11/17/2017 11/28/2017 01/10/2018

ABA B-3 ABA MST & Intercept Outpatient Plus Respite (b)(3) Applied Behavioral Analysis (ABA) Outpatient Plus Transitional Youth Services

03/03/2019

Medicaid (b)(3) services: Respite, Transitional Youth Services Document name, notes

04/01/2019

Clinical Assessment, Individual Therapy, Family Therapy, Group Therapy/ Counseling, Psychological Testing; Transitional Youth Services

9/20/19

Clinical Assessment

Change Added (C) - CCA is required Added Section for new SAIS service on row 14 Enlarged cell to allow full reading content changed name to TASK updated guidelines on row 18, effective 7/1/14 row 28 "up to 30 days" rather than 60 Up to 9 units total per 12 month period without authorization. Added service to benefit Updated ASAM score to reflect Arabic numbers instead of Roman numerals Row 23,24 added IAFT Rows 25-30, added new modifiers Changed 9 units to 16 units total per 12 month period without authorization. Removed limit of five units (hours) allowed per date of service. (1) Changed auth submission requirements, (2) no signed service order required, (3) PCP not required for members receiving respite services ONLY, (4) for members who only receive Respite, an individualized treatment plan may be utilized in lieu of the PCP. Added no auth required up to limit without prior authorization for a maximum of 1,536 units (384 hours or 24 days) per calendar year. Prior auth is required for utilization above the annual amount. Added auth requirements for Level II-IV, PRTF; added ESS on row 16, 17; added CANS for children 0-5 yrs. Old; CANS to be submitted at the first concurrent request Add ABA to line 22 Clarified service based on fiscal year rather than calendar year Changed auth submission requirements No auth required Service added Changed auth required/units based on fiscal year, rather than calendar year Removed Changed auth guidelines to up to 412 units for 180 days Service added Medicaid 1915(b)(3) services re-organized into separate document, Medicaid 1915(b)(3) Authorization Guidelines for Child and Adult MH/SU Services; document name changed to specify Medicaid 1915(b); added notes Removed codes H001, H0031, H004/modifiers, H005, 96101; added 96130, 96131, 96136, 96137 to Psychological Testing; moved Transitional Youth Services from Medicaid 1915(b)(3) guidelines to Medicaid 1915(b) guidelines Removed service definition and authorization guideline parameters Utilization Management | Rev. 01.04.2021 Version 3.1

9/20/19

Psychiatric Assessment

9/20/19

Psychological Testing

9/20/19

Individual and Family Therapy

9/20/19

Group Therapy

9/20/19

Individual Therapy for Crisis

9/20/19

Home Based Therapy

No authorization required

9/20/19 9/20/19 9/20/19 9/20/19 9/20/19

Outpatient Plus Intercept TASK ESS Intensive In-Home

9/20/19

MST

9/20/19 9/20/19

Day Treatment Residential Treatment Level II

removed removed removed removed Removed authorization parameter Amended service definition authorization parameter to only state “Ages 717”. Removed authorization guideline note. Removed authorization parameter Combined initial and concurrent authorization information

9/20/19 9/20/19

IAFT Residential Level III (under and over 5 beds)

Combined initial and concurrent authorization information Combined initial and concurrent authorization information

9/20/19

PRTF

Combined initial and concurrent authorization information

9/20/19

Tobacco Cessation

11/13/19

Authorization caveat note

02/03/20

Entire document

01/04/21

Therapeutic Foster Care Level II residential services

Added service 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. Formatting changes; creation of single Authorization Guidelines column Added codes: S5145HA CTSP FAM TYPE RES II IAFT S5145HK Enhanced Rate Therapeutic Foster Care S5145U5 Enhanced Therapeutic Foster Care (in lieu of service) S5156Z3 Rapid Response Therapeutic Foster Care Added: 30-day pass thru notification only SAR is allowed for the first 30 days

Removed authorization guideline parameter Removed code 96110; Added codes 96130, 96131, 96136, 96137. Removed authorization guideline parameters Removed previous authorization guideline parameter and added “Individual and Family Therapy may be provided on the same date at different times” Removed previous authorization guideline and added “90849 may not be used with 90785” Removed service definition parameter. Amended authorization guideline to state: “90839: Up to 2 sessions/fiscal year/provider; 90840: Up to 2 add-ons per episode. No other outpatient services may be billed on the same”

Utilization Management | Rev. 01.04.2021 Version 3.1