Vaya Health
Medicaid 1915(b)(3) Authorization Guidelines for Child and Adult Mental Health/Substance Use Services Medicaid 1915(b)(3) Child and Adult MH/SU Utilization Review Guidelines Service
Service Code(s)
Service Definition Authorization Parameters
Authorization Submission Requirements
Source
Authorization Guidelines
Vaya (b)(3) service definition
No more than 64 units per day
CHILD Respite
H0045 U4 HA (child SAR individual)
No authorization required up to 1,536 units per fiscal year (July-June). If requesting past limit, No auth required up to note: (1) PCP not required for members receiving 1,536 units per fiscal respite services ONLY – in these cases, an year H0045 HQ U4 HA individualized treatment plan may be utilized in lieu of the PCP; (2) no service order is required (child group)
ADULT H2023 Z1 Milestone 1– provider must submit SAR for up to 3 units for six months. Required documentation: service notes demonstrating effort to engage member in services H2023 Z2 Milestone 2 – no prior authorization required. Required documentation: Intake and Career profile to be uploaded to AlphaMCS
IPS Supported Employment
H2023 Z3 Milestone 3 – authorization to be requested only requested if member has refused to utilize NCDVRS services. Documentation required: Monthly summary H2023 Z1, H2023 Z2, reports during job development including H2023 Z3, H2023 Z6 employer contact log, job placement summary, H2023 Z7, H2023 Z8 individual job support plan, PCP.
Vaya (b)(3) service definition
H2023 Z6 Milestone 6 – no prior authorization required. Documentation required: Service notes and updated Career Profile should be uploaded to AlphaMCS H2023 Z7 or H2023 Z8 Milestone 7– SAR shall indicate the reasoning for Milestone 7 payment. Documents required: for promotion, a copy of a recent pay stub indicating promotion/raise. For completion of educational program, an official certificate of completion. Vaya Health | Medicaid 1915(b)(3) Authorization Guidelines for Child and Adult MH/SU Services Copyright © 2021 Vaya Health. All rights reserved.
Clinical Strategies | Effective 01.01.2022 Version 3.0
Physician Consultation
Individual Support
99214U4 (brief), 99242U4 (intermediate), 99244U4 (extensive) T1019U4
No auth required
Vaya (b)(3) service definition
Justification (including amount, duration and frequency of service) must be included in the Individual Support Plan (for Innovations Waiver participants) or PCP/Tx Plan (for individuals with SMI/SPMI)
SAR, PCP including service order, CCP, CCA including CCA addendum if not completed within 30 days
Vaya (b)(3) service definition
No more than 240 units per month for 90 days are allowed
Medicaid (b)(3) services have limited funding and are not an entitlement. These are the authorization guidelines for Medicaid 1915(b)(3) Child and Adult MH/SU Services for 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. Medicaid (b)(3) services are not an entitlement and are therefore dependent upon availability of funds. Services provided must be in provider contract. Previous effective date: New effective date:
09.01.2021 01.01.2021
REVISION INFORMATION: MEDICAID 1915(b)(3) AUTHORIZATION GUIDELINES FOR CHILD AND ADULT MH/SU Date
Section revised
03/03/19
Document created
04/01/19 9/20/19 9/20/19
Transitional Youth Services, Critical Time Intervention (CTI) Authorization guideline Respite
9/20/19
Authorization note caveat
12/30/19
Peer Support Services
12/30/19
IPS Supported Employment
09/01/2021
Individual Support Services
01/01/2022
Entire document
Vaya Health | Medicaid 1915(b)(3) Authorization Guidelines for Child and Adult MH/SU Services Copyright © 2021 Vaya Health. All rights reserved.
Change
Medicaid 1915 (b)(3) services auth information re-organized into new document; previously found in Medicaid Authorization Guidelines for Child MH/SU and Medicaid Authorization Guidelines for Adult MH/SU; no change to individual Vaya authorization guidelines Moved from Medicaid 1915(b)(3) guidelines to Medicaid 1915(b) guidelines Removed ASAM levels Amended codes to H0045 U4 HA and H0045 HQ U4 HA Added “B3 services have limited funding and not an entitlement”. 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 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.” Added: Services provided must be in provider contract. Removed Peer Support per service definition change Changed codes and amended authorization guidelines for service definition change; formatting Authorization now required, 90 day auth period specified. CCP required and CCA addendum noted to be required. Updated formatting for consolidation effective date; no changes to guidelines Clinical Strategies | Effective 01.01.2022 Version 3.0
RELATED REVISION INFORMATION: MEDICAID 1915(b) AUTHORIZATION GUIDELINES FOR CHILD MH/SU: 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
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
5/3/2015
Psych testing
7/9/2015
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
ABA (b)(3) ABA MST & Intercept Outpatient Plus Respite (b)(3) Applied Behavioral Analysis (ABA)
11/28/2017 01/10/2018
Outpatient Plus Transitional Youth Services
02/27/2019
Medicaid (b)(3) services: Respite, Transitional Youth Services Document name
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 (b)(3) services re-organized into separate document, Medicaid (b)(3) Authorization Guidelines for Child and Adult MH/SU Document name changed to specify Medicaid (b)
RELATED REVISION INFORMATION: MEDICAID 1915(b) AUTHORIZATION GUIDELINES FOR ADULT MH/SU: Date 4/15/2014 4/15/2014 6/1/2014 6/1/2014 6/1/2014
Section revised 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
Vaya Health | Medicaid 1915(b)(3) Authorization Guidelines for Child and Adult MH/SU Services Copyright © 2021 Vaya Health. All rights reserved.
Change Added (C) – CCA is required Deleted (C) – CCA is not required. No auth required No auth required No auth required Clinical Strategies | Effective 01.01.2022 Version 3.0
Date 6/1/2014 6/1/2014 6/1/2014 7/1/2014 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 5/9/2016 5/9/2016 7/12/2016 7/12/2016 11/9/2016 2/10/2017 3/15/2017 7/1/2017 10/30/2017 1/10/2018 4/23/2018 4/23/2018 5/29/2018 03/03/2019
Section revised Family Therapy – Auth submission requirements Group Therapy – Auth submission requirements SACOT - Auth. Guidelines All 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 Outpatient Plus Critical Time Intervention H0014 Ambulatory detox (b)(3): Supported Employment/Long-Term Vocational Support
Service added Service added Changed to “no auth required” Updated
Individual Support Services Medicaid 1915(b)(3) services: Peer Support, Supported Employment/Long-Term Vocational Support, Physician Consultation Service, Individual Support and Critical Time Intervention (CTI); document name
Added CCA required Medicaid 1915(b)(3) services re-organized into new document, Medicaid 1915(b)(3) Authorization Guidelines for Child and Adult MH/SU Services; original document name changed to specify Medicaid 1915(b)
Vaya Health | Medicaid 1915(b)(3) Authorization Guidelines for Child and Adult MH/SU Services Copyright © 2021 Vaya Health. All rights reserved.
Change No auth required No auth required Changed "events" to "units" for congruent wording with CCP 8A Added (b)(3): Supported Employment/LTVS Service 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. 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
Clinical Strategies | Effective 01.01.2022 Version 3.0