medicaid-1915b-authorization-guidelines-for-adult-mh_su-20220101 by Vaya Health

Vaya Health

Medicaid 1915(b) Authorization Guidelines for Adult Mental Health/Substance Use Services Medicaid 1915(b) Adult MH/SU Services Utilization Review Guidelines Service Clinical Assessment (E) In-Home Psychiatric Diagnostic Evaluation Psychiatric Assessment

Service Code(s) Authorization Submission Requirements

Service Definition Authorization Parameters

Source

Authorization Guidelines

90791, T1023

No auth required

90791SR

No auth required

90792

No auth required

Psychological Testing

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

No auth required

Individual Therapy (E)

90832, 90834, 90837

Individual Therapy Add-On to E/M (E)

90833, 90836, 90838

Family Therapy

90846, 90847

Group Therapy/ Counseling (E)

90849, 90853

90849 may not be used with 90785

No auth required

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.

No auth required

Individual Therapy for Crisis

Home-Based Therapy

90839, 90840 90837SR (60 minutes), 90832SR (30 minutes), 90834SR (45 minutes)

No auth required

8A - T1023; 8C - 90791

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

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

Clinical Strategies | Effective 01.01.2022 Version 5.0

Medicaid 1915(b) Adult MH/SU Services Utilization Review Guidelines Service Outpatient Plus

Assertive Community Treatment Team

Service Code(s) Authorization Submission Requirements

Service Definition Authorization Parameters 1 unit = 15 minutes; up to 16 units per week; 180 days maximum

H2021

SAR, CCA PCP including Service Order (C) (include LOCUS/ASAM worksheet); Comprehensive Crisis Plan

H0040

Initial Authorization 1 year or end of PCP year); If clear indication that needs to remain in ACTT can request 1 year, if indication that Initial: SAR, (C), service order, LOCUS and clinically can be transitioned ATR worksheet. Re-authorization: SAR, authorization can be PCP, LOCUS worksheet, ATR worksheet, requested for time period Contacts Worksheet and Transition Plan needed average 90-120 for transition, with clear transition plan or detailed information why longer than this period would be required.

SAR, PCP including Service Order (C) (include LOCUS worksheet). When it is medically necessary for services to be authorized for more than six months, a new comprehensive clinical assessment (CCA) or an addendum to the original CCA must be completed and submitted with a new SAR.

Source In-lieu-of service

8A-1

All services

MH Partial Hospitalization

H0035

SAR, PCP including Service Order (C) (include LOCUS worksheet).

H2017

No auth required

H0020

No auth required

SAIOP

H0015

No auth required

SACOT SU Non-Medical Community Residential Treatment

H2035

No auth required

H0012HB

SAR, PCP with Service Order

Up to 412 units for 180 days (initial and concurrent requests)

4 units may be billed per month

30-day pass thru SAR for 36 units Initial SAR without actively pursuing housing = max of 60 days/128 units. Initial SAR and actively pursuing housing = max of 60 days/420 units

Community Support Team

Psychosocial Rehabilitation Outpatient Opioid Treatment

Authorization Guidelines

Re-authorization without actively pursuing housing = max of 90 days/192 units; Re-authorization and actively pursuing housing = max of 90 days/630 units Prospective and concurrent auth: 14-day maximum

Up to 7 days on initial and reauth

1 unit per day

8A Max. 10 days on initial auth; max. 10 days on reauth; max. of 30 days in a 12-month period

ASAM3.5 Clinical Strategies | Effective 01.01.2022 Version 5.0

Medicaid 1915(b) Adult MH/SU Services Utilization Review Guidelines Service

Service Code(s) Authorization Submission Requirements

SA Med Mon Community Residential Treatment

H0013

SAR, PCP with Service Order

Ambulatory Detox

H0014

No auth required

H0032U5 H0032U5U1 (pre-CTI)

10 hours pre-CTI service are unmanaged Initial: PCP or phase plane; CCA or abbreviated assessment; Service Order

99406, 99407

No auth required

H0038 (individual), H0038 HQ (group)

No auth required

Critical Time Intervention (CTI)

Tobacco Cessation

Peer Support

Service Definition Authorization Parameters Max. 10 days on initial auth; max. 10 days on reauth; max. of 30 days in a 12-month period 10-day maximum per episode Initial request: 3-month period for up to 144 units or 36 hours: 1 unit = 15 minutes Concurrent: 6-month period for up to 168 units or 42 hours: 1 unit = 15 minutes

Source

Authorization Guidelines

ASAM 3.7

ASAM 1-D Up to 10 hours (40 units) of Pre-CTI are unmanaged; 312 units during the 9-month service delivery model; CTI may be provided for someone transitioning from or to ACTT or CST for a period of up to 90 days 99406 – Intermediate visit (3-10 minutes) 99407 – Intensive visit ( > 10 minutes)

270 units per 90 days for initial and concurrent stays

(C) Comprehensive Clinical Assessment is required. Also, an individualized treatment plan (or PCP, if noted) is required to be maintained in member's service record. (E) Interactive Therapy (90785) may be used in conjunction with the following codes: 90791, 90792, 90832 - 90838, 90853. Services provided must be in provider contract.

Previous effective date: New effective date:

03.18.2021 01.01.2022

REVISION INFORMATION: Date

Section revised

Change

4/15/2014 4/15/2014 6/1/2014 6/1/2014 6/1/2014

Psychological Testing – Auth Submission Requirements Outpatient Opioid Treatment – Auth Submission Requirements Clinical Assessment – Auth submission requirements Individual Therapy – Auth submission requirements Individual Therapy add-on to E/M – Auth submission requirements

Added (C) – CCA is required Deleted (C) – CCA is not required. No auth required No auth required No auth required

6/1/2014

Family Therapy – Auth submission requirements

No auth required

6/1/2014 6/1/2014

Group Therapy – Auth submission requirements SACOT - Auth. Guidelines

No auth required Changed "events" to "units" for congruent wording with CCP 8A

7/1/2014

All

Added (b)(3): Supported Employment/LTVS Service

Clinical Strategies | Effective 01.01.2022 Version 5.0

Date 9/1/2014 9/15/2014 9/15/2014 9/15/2014 1/1/2015 1/1/2015 5/1/2015 7/9/2015 8/14/2015 8/14/2015 9/15/2015 9/15/2015 9/15/2015 9/15/2015 9/15/2015 12/9/2015 2/15/2016 2/15/2016 2/15/2016 3/2/2016

Section revised Psychological Testing – Auth Submission Requirements and Guidelines CST Service Definitions Authorization Parameters All ADATC (18-20) service code Header and individual score references throughout grid. 90837SR Psychological Testing – Auth Submission Requirements and Guidelines Psychological Testing – Service Definition Authorization Parameters ACT – Source ACT – Auth Submission Requirements (b)(3) Services (b)(3) Peer Support – Auth Submission Requirements Footnote (G) (b)(3) Physician Consult ADATC (18-20) – Auth Submission Requirements (b)(3) Supported Employment – Auth Submission Requirements Supported Employment – Auth Submission Requirements Outpatient Opioid Treatment – Auth Submission Requirements Non-Hospital Med. Detox – Auth Submission Requirements (b)(3)3 Supported Employment – Service Definition Authorization Parameters Non-Hospital Med. Detox. and Medically Monitored Intensive Inpatient Detox (ADATC) Source (b)(3) Supported Employment – Authorization Guidelines SAIOP and SACOT – Auth Submission Requirements All Individual Support (T1019U4) Outpatient Opioid Treatment - Authorization Parameters Outpatient Opioid Treatment and Psychosocial Rehabilitation Services – Auth Submission Requirements

Change No auth required for up to nine units in a 12-month period Removed max of six months per year Removed H2036 Replaced H2036 with 0101 Updated ASAM score to reflect Arabic numbers instead of Roman numerals Added service to benefit No auth required for up to eight units in a 12 month period Removed limit of five units (hours) allowed per date of service. Changed to 8A-1 PCP no longer required at initial SAR Added "*" to authorization guidelines section to reference new note No Auth Required Deleted (G) Added service to benefit Changed to SAR only Guidelines – updated max units to match current definition Added IPS-SE FCH In/At-Risk Checklist Added requirement of PCP, Comprehensive Crisis Plan and Service Order Added RARF and removed PCP Clarification in wording to separate H2023 and H2026.

10/30/2017

Outpatient Plus

Service added

01/10/2018 4/23/2018 4/23/2018 5/29/2018

Critical Time Intervention H0014 Ambulatory detox (b)(3): Supported Employment/Long-Term Vocational Support Individual Support Services Medicaid (b)(3) services: Peer Support, Supported Employment/Long-Term Vocational Support, Physician Consultation Service, Individual Support and Critical Time Intervention (CTI) Psychological Testing

Service added Changed to “no auth required” Updated Added CCA required

5/9/2016 5/9/2016 7/12/2016 7/12/2016 11/9/2016 2/10/2017 3/15/2017 7/1/2017

03/15/2019 04/01/2019 9/20/19

Service codes, Critical time Intervention (CTI) Clinical Assessment

Moved to Acute Care Guidelines Removed footnote F Revised first 90 days units and hours to match waiver language No Auth Required Formatting changes; name change to “Vaya” conversion to PDF Added service to benefit Revised initial authorization period from 60 days to 180 days. No auth required

Medicaid 1915 (b)(3) services auth information re-organized into new document; no change to individual Vaya authorization guidelines except Psychological Testing updated Removed H001, H0031, H004/modifiers, H005; moved Critical Time Intervention (CTI) from Medicaid 1915(b)(3) guidelines to Medicaid 1915(b) guidelines Removed service definition and authorization guideline parameters Clinical Strategies | Effective 01.01.2022 Version 5.0

Date 9/20/19

Section revised 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 9/20/19 9/20/19 9/20/19 9/20/19 9/20/19

Home Based Therapy Psycho-social Rehabilitation SAIOP SACOT Service definition guideline Tobacco Cessation

9/20/19

Authorization caveat note

12/30/19

Peer Support Service

3/18/21

Outpatient Plus

01/01/22

ACTT

01/01/22 01/01/22

MH Partial Hospitalization In-Home Psychiatric Evaluation

Change Removed authorization guideline parameter Removed code 96110; Added codes 96130, 96131, 96136, 96137. Added “There is a limit of 8 hours of service per date of service” 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 day.” No authorization required Removed authorization guideline parameter Removed authorization guideline parameter Removed authorization guideline parameter Removed ASAM levels Service Added 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. Added Peer Support per service definition change effective 11/1/19. Added new CST authorization parameters and code changes; formatting Removed HO and HN modifiers. Amended allowable units and time frame for service. Amended authorization parameter to: Initial Authorization 1 yr. (or end of PCP yr.); If clear indication that needs to remain in ACTT can request 1 yr., if indication that clinically can be transitioned authorization can be requested for time period needed avg. 90-120 for transition, with clear transition plan or detailed information why longer than this period would be required. Changed to 14 day authorization for initial and concurrent requests Added this service

Clinical Strategies | Effective 01.01.2022 Version 5.0