Vaya Health
Non-Medicaid Authorization Guidelines for Adult MH/SU Services Non-Medicaid Adult MH/SU Services Utilization Review Guidelines Service
Service Code
Clinical Assessment (E) Psychiatric Assessment
90791, YP830, YP836, T1023 90792
Authorization Submission Requirements No authorization required up to max (F)(H) No authorization required up to max (F)
96130, 96131, 96136, 96137, 96110, 96112, 96113, 96116, 96121, 96132, 96133
SAR, Vaya psych. testing request form, (C)
Individual Therapy (E)
90832, 90834, 90837, YP831
SAR and treatment plan (A)(F)(H)
Individual Therapy Add-On to E/M (E)
90833, 90836, 90838
SAR and treatment plan (A)(F)
Psychological Testing
Family Therapy Group Therapy/ Counseling (E) Individual Therapy for Crisis
Community Support Team (J)
90846, 90847, YP833, YP834 90849, 90853, YP832, YP835
Authorization Guidelines:
Service Definition Authorization Parameters None None Up to the following per year: 96130, 96131, 96136, 96137, 96132, 96133 = 12; 96110 = 6; 96112, 96113 = 8; 96116, 96121 = 4
SAR and treatment plan (A)(F)(H) No authorization required up to max (F)
90839, 90840
No authorization required up to max (F)
All Services
SAR, service order, PCP and LOCUS worksheet (C)(F). 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 service authorization request
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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. 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 Re-authorization without actively pursuing housing = max of 90 days/192 units. Re-authorization and actively pursuing housing = max of 90 days/630 units.
Utilization Management | Rev. 03.11.2020 Version 2.1
Service Code
Authorization Submission Requirements
PSR (J)
H2017
No authorization required
SAIOP (J)
H0015
No authorization required
Service
Peer Support
Assertive Community Treatment (ACT)
H0038, H0038 HQ
H0040
No authorization required
Initial: SAR, (C), service order, LOCUS and ATR worksheet; Re-authorization: SAR, PCP, LOCUS worksheet, ATR worksheet, Contacts Worksheet and transition plan (F) 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
Service Definition Authorization Parameters Up to 1,560 units per 90 days Up to two rounds of treatment/year Up to 270 units per 90 days for initial and concurrent stays.
LOCUS level 1 members 18-21 residing in Medicaid-funded group facility are not eligible Four units max per month
Prospective and concurrent authorization: 180 days maximum
H2023 Z2 Milestone 2 – no prior authorization required. Required documentation: Intake and Career profile to be uploaded to Alpha.
IPS Supported Employment
H2023 Z1, H2023 Z2, H2023 Z3, H2023 Z6 H2023 Z7, H2023 Z8
H2023 Z3 Milestone 3 – authorization to be requested only requested if member has refused to utilize NCDVRS services. Documentation required: Monthly summary reports during job development including employer contact log, job placement summary, individual job support plan, PCP.
.
H2023 Z6 Milestone 6 – no prior authorization required. Documentation required: Service notes and updated Career Profile should be uploaded to Alpha H2023 Z7 or H2023 Z8 Milestone 7– SAR shall indicate the reasoning for Milestone 7 payment. Documents required: for promotion, a copy of a Vaya Health | Non-Medicaid Authorization Guidelines for Adult MH/SU Services Copyright © 2019 Vaya Health. All rights reserved.
Utilization Management | Rev. 03.11.2020 Version 2.1
Service
Family Living – Low, Moderate, High Apartment Living/Supervised Living - Low, Moderate Group Living - Low, Moderate, High
Service Code
YP740, YP750, YM755 YP710, YP720
YP760, YP770, YP780
Authorization Submission Requirements recent pay stub indicating promotion/raise. For completion of educational program, an official certificate of completion. (2 units per year may be requested for H2023 Z7 and 3 units per year for H2023 Z8)
Service Definition Authorization Parameters
SAR, PCP, LOCUS worksheet (F)
Authorization can be up to 365 days
Initial: PCP and most recent CCA; concurrent: PCP; CCA within one year from request, evidence of service engagement Initial: PCP and most recent CCA; concurrent: PCP; CCA within one year from request, evidence of service engagement
Authorization can be up to 365 days
Authorization can be up to 365 days
One unit per day up to 365 days One unit per day
One unit per day
(A) (C) (E) (F)
Services provided by a physician do not require a referral/service order. Comprehensive Clinical Assessment is required. Also, an individualized treatment plan (or PCP, if noted) is required to be maintained in beneficiary’s service record. Interactive Therapy (90785) may be used in conjunction with the following codes: 90791, 90792, 90832 – 90838, 90853. Provider must be enrolled to bill this service. To be enrolled, the provider must contact the MCO Access to Care Line with the member and provide information to complete enrollment. (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 Use Specific Target Pop. (J) DMH/DD/SAS non-Medicaid-funded enhanced service definitions dated August 1, 2014
Previous Effective Date: 12.30.2019 New Effective Date: 03.11.2020 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 these guidelines must be registered and active with the Vaya and CDW systems (see the Vaya Provider Operations Manual) for specific registration and enrollment requirements. These guidelines represent the array of services determined to best meet the needs of most members within the 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 members’ episodes of care, not calendar year or contract year. Continued services across contract years are authorized according to a member’s episode of care and do not start over with a new year. Likewise, transition of a member 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 those 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: Vaya Health | Non-Medicaid Authorization Guidelines for Adult MH/SU Services Copyright © 2019 Vaya Health. All rights reserved.
Utilization Management | Rev. 03.11.2020 Version 2.1
1. 2. 3.
The higher level of intensity is determined to be medically necessary; 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 Vaya has funding available for the higher intensity level.
Some services (e.g., assessments) do not require preauthorization by Vaya. However, all services provided under this plan 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 N.C. DHHS and non-Medicaid Service Definitions and other requirements in the provider’s contract with the Vaya member. Any and all services provided under this benefit plan are subject to the availability of funds as determined by Vaya. This plan should not be interpreted as an entitlement. Services provided must be in provider contract.
REVISION INFORMATION: Date 4/15/2014 8/4/2014
Section revised Psychological Testing – Auth Submission Requirements "Source" column
8/4/2014
Footnote "F"
8/4/2014
Footnote "G"
8/4/2014
SAIOP Service Definition Authorization Parameters
9/15/2014
CST Service Definition Authorization Parameters
6/15/2015
Psychological Testing – Auth Guidelines
8/14/2015 10/1/2015 7/15/2016 8/1/2016 9/1/2016 11/9/2016
ACT – Auth Submission Requirements Individual Therapy, Individual Therapy Add-on to E/M, Family Therapy: Auth Submission Section Psych Testing – Service Definition Authorization Parameters Revised residential service lines (YP740, YP750, YM755) SAIOP Auth Submission Requirements YP630, YM645 All
10/24/2017
Peer Support, PSR, CST
1/10/2018
Apartment Living Group Living – Low Group Living – High
03/15/2019
Full document, ACT, Psychological Testing
10/1/2015
9/20/19 9/20/19 9/20/19 9/20/19 9/20/19 9/20/19 9/20/19
Clinical Assessment Psychiatric Assessment Family Therapy Group Therapy Peer Support Individual and Group Therapy Individual Crisis Therapy
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Change Added (C) – CCA is required Column deleted Reference changed to inform about enrollment; had previously given information about January 2013 CPT bulletin Deleted Clarified that additional two weeks authorization is available for Matrix Management programs Removed max of 6 months per calendar year Removed counting against unmanaged. Auth is required, as unmanaged is not available. PCP no longer required at initial SAR Removed counting against unmanaged. Auth is required, as unmanaged is not available. Removed limit of 5 hours/day Removed codes that do not require authorization and updated those that do. No auth required No auth required, but part of Benefit Plan Formatting changes, name change to “Vaya’ Peer support service added; auth need deleted from PSR, CST auth period deleted Services added Renamed document to “Non-Medicaid” v. “State,” updated formatting and language; updated ACT, Psychological Testing guidelines Removed authorization parameter and added YP836 Removed authorization parameter Removed authorization parameter. Added YP834 Removed authorization parameter. Added YP832 Removed service code modifier U4 Removed authorization parameters Removed authorization parameters Utilization Management | Rev. 03.11.2020 Version 2.1
9/20/19
Family Living and Group Living
9/20/19
Authorization notes caveat
9/20/19
Authorization guideline
12/30/19
Authorization parameter
12/30/19 3/11/20
IPS Supported Employment IPS/Supported Employment
Vaya Health | Non-Medicaid Authorization Guidelines for Adult MH/SU Services Copyright © 2019 Vaya Health. All rights reserved.
Combined low, moderate and high grids 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. Removed ASAM levels Amended Peer Support guidelines for service definition change effective 11/1/19. Amended CST code change and authorization parameters. Amended codes and authorization parameters for service definition change. Added units allowed for milestone 7
Utilization Management | Rev. 03.11.2020 Version 2.1