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

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

Authorization Submission Requirements

90791, T1023

No auth required

8A - T1023; 8C - 90791

90791SR

No auth required

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 Clinical Assessment (E) In-home Psychiatric Diagnostic Evaluation Psychiatric Assessment (E)

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

Individual Therapy for Crisis

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

Group Therapy/ Counseling (E)

90849, 90853

No auth required

90849 may not be used with 90785

Home-Based Therapy

90832SR (30 minutes); 90834SR (45 minutes); 90837SR 60 minutes)

No auth required

H2022

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

Intensive In-Home

Max 60 days per auth

Utilization Management | Effective 01.01.2022 Version 4.0

Medicaid 1915(b) Child MH/SU Services Utilization Review Guidelines Service MST (Multisystemic Therapy) Transitional Youth Services

Day Treatment

MH Partial Hospitalization

Residential Treatment – Level 1/Family Type

Service Code(s)

Authorization Submission Requirements

Service Definition Authorization Parameters

Source

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

H2012HA

SAR, PCP including Service Order (C) Authorization 90 days (include CALOCUS/ASAM worksheet), (Initial + Re-Auth) max. 30 Comprehensive Crisis Plan, CANS (for units per week children 3-5)*

H0035

SAR, PCP including Service Order (C) Max 14-day on (include CALOCUS/ASAM worksheet), prospective and Comprehensive Crisis Plan, CANS (for concurrent authorizations children 3-5)*

H0046

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

Authorization Guidelines

Initial authorization up to 3 months. Three additional concurrent authorizations up to 3 months

8D-2

Up to 180-day authorization 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 can be up to 180 days; re-auth can be for 60 days

Utilization Management | Effective 01.01.2022 Version 4.0

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

Specialized Level II (TFC) – MH/IDD

Service Code(s)

S5145 HI

Source

Authorization Guidelines

SAR, Psychological Evaluation for I/DD dx, PCP

8D-2 Initial auth can be up to 180 days; re- auth can be for 60 days

H0019HQ

Residential Treatment – Level III (5+ beds)

H0019TJ

Residential Treatment – Level IV/ Secure

H0019HK

PRTF Assessment Center

Service Definition Authorization Parameters

(30-day pass thru notification; only SAR is allowed for the first 30 days)

Residential Treatment – Level III (<= 4 beds)

PRTF

Authorization Submission Requirements

0911; H0019UR Residential Level IV (5+ Beds)

0919

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

8D-2

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

8D-2

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 Prospective: SAR, Certificate of Need, CCA/Addendum (include CALOCUS/ASAM worksheet), Comprehensive Crisis Plan (A PCP should be completed within 14 days Initial auth: 45 days; of admission) Concurrent auth: 30 days Concurrent: SAR, PCP including signature page (C) (include CALOCUS/ ASAM worksheet), Comprehensive Crisis Plan, CANS (for children 0-5) SAR, Certificate of Need, CCA/Addendum (include CALOCUS/ASAM worksheet), Comprehensive Crisis Plan

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

0183

No auth required

Tobacco Cessation

99406, 99407

No auth required

8D-2

Initial up to 120 days; concurrent up to 60 days

8D-1

Up to 30 days

30 day initial and concurrent authorization

8D-1

1 unit per day

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

8D-1

99406 – Intermediate visit (3-10 minutes) ($11.93) 99407 – Intensive visit (> 10 minutes) Utilization Management | Effective 01.01.2022 Version 4.0

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

High Fidelity Wraparound Outpatient Plus Equine Therapy

Contact UM H2021 individual; H2021HQ group 90834Z4, 90837Z4, 90853Z4

In-Home Therapy Services (IHTS) Trauma Informed CCA (TICCA), (Partnering for Excellence)

Notification SAR only if not stacked with other services. If stacked: CCA, PCP, Crisis Plan, signature page CALOCUS/ASAM CCA, PCP, signature page CALOCUS/ASAM, CCP

Service Definition Authorization Parameters

Source

In-lieu-of service In-lieu-of service

Authorization Guidelines Pass-through allowed unless stacked. Pass-through would require notification SAR and documentation. If stacked, 1 unit per 30 days for 6 months (Initial and concurrent) 412 max units for 180 days for individual or group request (or up to 824 for Asheville City Schools)

No auth required

H2022 HE U5

Assessment, CANS, + PCP/PCP update

Full pass-through if in no other enhanced services; authorization can be for 120 days

90791-22

SAR to include information on referral source, trauma, and behaviors

Prior authorization required; authorization can be for up to 30 days

90899

SAR to include information on referral source, problem sexual behaviors, and behaviors

Prior authorization required; authorizations can be for up to 1 month (CHA – 3 months)

H0036 HA; (formerly billed by Cardinal providers as H0036 HK)

CCA, PCP, CCP, signature page, CALOCUS/ASAM.

Non-standard EPSDT service

1 unit per week (90 days)

H2029

PCP, CALOCUS, CESH

Specialty service

1 unit per week for up to 52 weeks

Contact UM

CCA, PCP, CCP, signature page, CALOCUS

In-lieu-of service

1 unit per 30 days for up to 6 months

Sexual Harm Evaluation

Intercept (EPSDT)

Authorization Submission Requirements

Service Code(s)

Treatment Alternatives for Sexualized Kids (TASK) (EPSDT) Family Centered Treatment

(C) 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. (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:

06.23.2021 01.01.2022

Utilization Management | Effective 01.01.2022 Version 4.0

REVISION INFORMATION: Date 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

Section revised 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 9/20/19

Clinical Assessment Psychiatric Assessment

9/20/19

Psychological Testing

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 Removed authorization guideline parameter Removed code 96110; Added codes 96130, 96131, 96136, 96137. Removed authorization guideline parameters Utilization Management | Effective 01.01.2022 Version 4.0

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 Outpatient Plus Intercept TASK ESS Intensive In-Home

9/20/19

MST

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

Day Treatment Residential Treatment Level II IAFT Residential Level III (under and over 5 beds) PRTF Tobacco Cessation

11/13/19

Authorization caveat note

2/03/20

Entire document

1/04/21

Therapeutic Foster Care Level II residential services

6/23/21

PRTF

01/01/22 01/01/22

Day Treatment MH Partial Hospitalization Residential Treatment – Level 1/Family Type

01/01/22

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” No authorization required 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 Combined initial and concurrent authorization information Combined initial and concurrent authorization information Combined initial and concurrent authorization information 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 Amended requirements for prospective authorization: Prospective: SAR, Certificate of Need, CCA/Addendum (include CALOCUS/ASAM worksheet), Comprehensive Crisis Plan (A PCP should be completed within 14 days of admission) Amended authorization period to 90 days for initial and concurrent requests Amended to allow for 14 day authorizations Amended to allow for 180 day authorizations Utilization Management | Effective 01.01.2022 Version 4.0

01/01/22 01/01/22 01/01/22 01/01/22 01/01/22 01/01/22 01/01/22 01/01/22 01/01/22 01/01/22 01/01/22 01/01/22 01/01/22 01/01/22 01/01/22

Residential Treatment – Level II High Fidelity Wraparound Outpatient Plus Equine Therapy In-Home Therapy Services (IHTS) Trauma Informed CCA Sexual Harm Evaluation Intercept Sexual Harm Assessment Treatment Alternatives for Sexualized Kids (TASK) TFC Rapid Response In-home Psychiatric Diagnostic Evaluation PRTF PRTF Assessment Center Hi-Fidelity Wraparound Family Centered Treatment

01/01/22

Notes

01/01/22

Specialized Level II (TFC) – MH/IDD

01/01/22

Amended auth parameter to 180-day initial and 60-day concurrent Added this service Added this service Added this service Added this service Added this service Added this service Added this service Added this service Added this service Corrected code to S5145Z3 Added this service Added H0019UR - Residential Level IV (5+ Beds) Added this service Removed codes and added “Contact UM” Added this service Removed: (A) Referral required for those under age 21. Services provided by a physician do not require a referral/service order. Removed: (F) For information on new CPT codes, refer to the January 2013 DMA Medicaid Bulletin. Added this service

Utilization Management | Effective 01.01.2022 Version 4.0