non-medicaid-authorization-guidelines-for-adult-mh_su-20220101 by Vaya Health

Vaya Health

Non-Medicaid Authorization Guidelines for Adult Mental Health/Substance Use Services Non-Medicaid Adult MH/SU Services Utilization Review Guidelines Service Clinical Assessment (E) Psychiatric Assessment Psychological Testing Individual Therapy (E) Individual Therapy Add-On to E/M (E) In-Home Psychiatric Diagnostic Evaluation In-Home Psychotherapy In-Home Family Therapy Family Therapy Group Therapy/ Counseling (E) Individual Therapy for Crisis

Service Code 90791, YP830, YP836, T1023 90792 96130, 96131, 96136, 96137, 96110, 96112, 96113, 96116, 96121, 96132, 96133 90832, 90834, 90837, YP831

Authorization Submission Requirements No authorization required up to max (F)(H) No authorization required up to max (F) SAR, Vaya psych. testing request form, (C)

No authorization required up to max (A)(F)

90791SR

No authorization required up to max (F)

90839, 90840

Authorization Guidelines

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)

90833, 90836, 90838

90832SR (30 minutes) 90834SR (45 minutes) 90837SR (60 minutes) 90846SR (without recipient) 90847SR (with recipient) 90846, 90847, YP833, YP834 90849, 90853, YP832, YP835

Service Definition Authorization Parameters

SAR and treatment plan (A)(F)(H)

SAR and treatment plan (A)(F)(H) No authorization required up to max (F) 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 same day. Clinical Strategies | Effective 01.01.2022 Version 3.0

Non-Medicaid Adult MH/SU Services Utilization Review Guidelines Service

Community Support Team (J)

PSR (J) SAIOP (J) Peer Support Assertive Community Treatment (ACT)

IPS Supported Employment

Service Code

Authorization Submission Requirements

Service Definition Authorization Parameters 30-day pass thru SAR for 36 units

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

Initial SAR without actively pursuing housing = max of 60 days/128 units. Initial SAR and actively pursuing housing = max of 60 days/420 units

H2017 H0015

No authorization required No authorization required

H0038, H0038 HQ

No authorization required

H0040

H2023 Z1, H2023 Z2, H2023 Z3, H2023 Z6 H2023 Z7, H2023 Z8

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 recipient in services H2023 Z2 Milestone 2 – no prior authorization required. Required documentation: Intake and Career profile to be uploaded to Alpha.

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.

Up to 270 units per 90 days for initial and concurrent stays. Prospective and concurrent authorization: 180 days maximum

Up to 1,560 units per 90 days Up to two rounds of treatment/year LOCUS Level 1 recipients 18-21 residing in a Medicaidfunded group facility are not eligible

Four units max per month

H2023 Z3 Milestone 3 – authorization to be requested only requested if recipient has refused to utilize NCDVRS services. Documentation required: Monthly summary reports during job development including employer Vaya Health | Non-Medicaid Authorization Guidelines for Adult MH/SU Services Copyright © 2021 Vaya Health. All rights reserved.

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Non-Medicaid Adult MH/SU Services Utilization Review Guidelines Service

Service Code

Authorization Submission Requirements contact log, job placement summary, individual job support plan, PCP.

Service Definition Authorization Parameters

Authorization Guidelines

Authorization can be up to 365 days

One unit per day up to 365 days

Authorization can be up to 365 days

One unit per day

Authorization can be up to 365 days

One unit per day

Allows for 1:1 for a period of time in conjunction with group home codes

1 unit up to 8 units per day for 30 days if no behavior plan in place, 90 days if there is a plan at initial

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. (2 units per year may be requested for H2023 Z7 and 3 units per year for H2023 Z8) Family Living – Low, Moderate, High Apartment Living/Supervised Living - Low, Moderate Group Living Low, Moderate, High

YP740, YP750, YM755

YP710, YP720

YP760, YP770, YP780

SAR, PCP, LOCUS worksheet (F) 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

Assertive Engagement

YA341 YA323, YA368

No authorization required

Case Support

YA402

No authorization required

YA385

Documents for initial PCP, Fading Plan, Service Order. Concurrent 90 days behavior plan is required with PCP, Service Order, Fading Plan

Safety Supervision

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Non-Medicaid Adult MH/SU Services Utilization Review Guidelines Service Code

Authorization Submission Requirements

YA346

No authorization required

YA349

No authorization required

SA Halfway House

H2034

CCA (at least annually) Plan + SAR

Outpatient Opioid Treatment

H0020

No authorization required

Service Hospital Discharge Transition service Jail Support

Service Definition Authorization Parameters

Authorization Guidelines

Authorization every 180 days (1 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 recipient 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: 08.23.2021 New Effective Date: 01.01.2021 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 recipients 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 recipients’ episodes of care, not calendar year or contract year. Continued services across contract years are authorized according to a recipients’ 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 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: 1. 2. 3.

The higher level of intensity is determined to be medically necessary; 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 Vaya has funding available for the higher intensity level.

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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 recipient. 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 9/20/19

Clinical Assessment Psychiatric Assessment Family Therapy Group Therapy Peer Support Individual and Group Therapy Individual Crisis Therapy Family Living and Group Living

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 Combined low, moderate and high grids

Clinical Strategies | Effective 01.01.2022 Version 3.0

9/20/19

Authorization notes caveat

9/20/19

Authorization guideline

12/30/19

Authorization parameter

12/30/19 3/11/20 8/23/21 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

IPS Supported Employment IPS/Supported Employment Individual Therapy Add-On to E/M (E) Assertive Engagement Case Support Safety Supervision Hospital Discharge Transition service Jail Support SA Halfway House In-Home Psychiatric Diagnostic Evaluation In-Home Psychotherapy Whole document

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 recipient. 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 Amended to no authorization required Added service Added service Added service Added service Added service Added service Added service Added service Changed “member” to “recipient”

Clinical Strategies | Effective 01.01.2022 Version 3.0