Vaya Health
Non-Medicaid Authorization Guidelines for Child Mental Health/Substance Use Services Non-Medicaid MH/SU Child Services Utilization Review Guidelines Service
Service Code
Authorization Submission Requirements
Clinical Assessment (E) Psychiatric Assessment In-home Psychiatric Diagnostic Evaluation
90791, T1023, YP830, YP836
No auth required up to max (F)(H)
90792
No auth required up to max (F)
90791SR
No auth required up to max
In-home Psychotherapy In-home Family Therapy Psychological Testing Individual Therapy (E) Individual Therapy Add-On to E/M (E) Family Therapy Group Therapy/ Counseling (E) Individual Therapy for Crisis
90832SR (30 minutes) 90834SR (45 minutes) 90837SR (60 minutes) 90846SR (without PT) 90847SR (with PT) 96110, 96111, 96116, 96121, 96130, 96131, 96136, 96137 90832, 90834, 90837, YP831
SAR and treatment plan (A)(F)(H)
90833, 90836, 90838
No authorization required (A)(F)
90846, 90847, YP833, YP834 90849, 90853, YP832, YP835
SAR and treatment plan (A)(F)(H)
90839, 90840
Service Definition Authorization Parameters
Authorization Guidelines
No auth required No auth required SAR, Vaya psych testing request form, (C)
Up to the following per year: 96101, 96118 = 12; 96110 = 6; 96111 = 8; 96116 = 4
No authorization required (A)(F)(H) No authorization required up to max (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
(A) Services provided by a physician do not require a referral/service order.
(C) Comprehensive Clinical Assessment is required. Also, an individualized treatment plan (or PCP if noted) is required to be maintained in beneficiary’s service record. (E) Interactive Therapy (90785) may be used in conjunction with the following codes: 90791, 90792, 90832 – 90838, 90853. (F) Provider must be enrolled to bill this service. To be enrolled, the provider must contact MCO Access to Care Line with the member and provide information to complete enrollment. Vaya Health | Non-Medicaid Authorization Guidelines for Child MH/SU Services Copyright © 2021 Vaya Health. All rights reserved.
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(H) Important note about YP830 to YP836 : These codes are for designated non-licensed substance use counseling professionals (specified in DMH/DD/SAS Communication Bulletin #091) and require a Substance Abuse Specific Target Pop.
Local management entity (LME) funds are the payment of last resort. All other payer sources, including Medicaid, Medicare, and insurance benefits must be used prior to requesting authorization of services from the LME/MCO. Providers may be reimbursed only for those specific services included in their contracts with Vaya Health (Vaya). All individuals receiving services under this plan must be registered and active with the Vaya and CDW systems (see the Vaya Health Provider Operations Manual for specific registration and enrollment requirements). These guidelines represent the array of services determined to best meet the needs of most recipients within available funding. Maximum numbers of units are shown for services with limits on the service intensity that may be authorized. The authorization time periods pertain to recipients’ episodes of care, not calendar year or contract year. Continued services across contract years are authorized according to a recipient’s episode of care and do not start over with a new year. Likewise, transition of a recipient to a new provider does not necessarily begin a new episode of care; providers are encouraged to consult with Vaya UM staff regarding services that may be authorized upon transition to a new provider. Services at a higher level of intensity than that listed in the guidelines may be requested and will be reviewed for approval by Vaya 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 recipient 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.** Some services (e.g., assessment) do not require preauthorization by Vaya. However, all services provided under these guidelines are subject to post-payment review that may result in required corrective actions and/or recoupment of payments if found to have not been medically necessary when provided or to have not been provided according to the N.C. Department of Health and Human Services (DHHS) and Non-Medicaid Service Definitions and other requirements in the provider’s contract with Vaya. Any and all services provided under these authorization guidelines are subject to the availability of funds as determined by Vaya. These guidelines should not be interpreted as an entitlement. Services provided must be in provider contract. **Per diem services are not available for funding at higher intensity levels. Previous effective date: New effective date:
08.23.2021 01.01.2022
REVISION INFORMATION: Date 04/15/2014 08/04/2014
Section revised Psychological Testing - Auth Submission Requirements "Source" column
08/04/2014
Footnote “F”
08/04/2014 08/04/2014
Footnote “G”
Vaya Health | Non-Medicaid Authorization Guidelines for Child MH/SU Services Copyright © 2021 Vaya Health. All rights reserved.
Change Added (C) – CCA is required Column deleted Reference changed to inform about enrollment; had previously given information about January 2013 CPT bulletin Row deleted. State funds no longer available for this service. Deleted Clinical Strategies | Effective 01.01.2022 Version 4.0
Date
Section revised
08/04/2014
SAIOP Service Definition Authorization Parameters
06/15/2015
Psychological Testing – h Authorization Guidelines
06/15/2015 06/15/2015 10/01/2015
Intensive In-Home Multisystemic Therapy Individual Therapy, Individual Therapy Add-On to E/M, Family Therapy, Group Therapy/Counseling: Auth Submission Section Psych Testing – Service Definition Authorization Parameters
03/03/2019
Full document
04/01/2019
Psychological Testing; SAIOP
10/01/2015
9/20/19 9/20/19
Clinical Assessment Individual, Family and Group Therapy
9/20/19
Individual Therapy for Crisis
9/20/19 9/20/19 9/20/19 9/20/19
Family Therapy Group Therapy Authorization guidelines Psychiatric Assessment
11/13/19
Authorization caveat note
02/03/20 8/23/21 8/23/21 01/01/22 01/01/22 01/01/22 01/01/22 01/01/22
Entire document Individual Therapy Add-On to E/M (E) Group Therapy/Counseling (E) Psychological Testing In-home psychiatric diagnostic evaluation In-home psychotherapy In=home family therapy Whole document
01/01/22
Note
Vaya Health | Non-Medicaid Authorization Guidelines for Child MH/SU Services Copyright © 2021 Vaya Health. All rights reserved.
Change Clarified that additional two weeks authorization is available for Matrix Management programs Removed counting against unmanaged. Auth is required, as unmanaged is not available. Row deleted. State funds no longer available for this service. Row deleted. State funds are no longer available for this service. Removed counting against unmanaged. Auth is required, as unmanaged is not available. Removed limit of five hours/day Document reformatted, language updated, no change to individual guidelines Removed code 96101, added codes 96130, 96131, 96136, 96137; removed SAIOP Removed authorization parameters and added code YP856 Removed authorization parameters Removed authorization parameter and added: “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” Added YP834 Added YP832 and YP835. Removed authorization guideline parameter Removed ASAM levels Removed service definition and authorization guideline parameters Removed: “In order to be authorized, services in the non-Medicaid authorization guidelines must be determined to be medically necessary at a specific intensity level for each individual member. There is no entitlement for authorization of these services at any intensity level. The maximum number of units listed is not necessary for all members requiring the service—the necessary amount of service must be determined individually for each member. Individuals receiving multiple services generally require lower amounts of services than individuals receiving a single service. The service intensities listed in the guidelines are the maximum amounts that will be necessary and approved for most members.” Added: Services provided must be in provider contract. Formatting changes; creation of single Authorization guidelines column Amended to no authorization required Amended to no authorization required Removed code 96118 and added 96121 Added service Added service Added service Changed “member” to “recipient’ Removed “(J) DMH/DD/SAS Non-Medicaid-funded enhanced service definitions dated August 1, 2014.”
Clinical Strategies | Effective 01.01.2022 Version 4.0