Vaya Health Authorization Guidelines
Medicaid 1915(b) Mental Health/Substance Use Services – Adult
Services must be in the provider’s contract with Vaya Health (Vaya). Acronyms are defined below. For services that do not require authorization, a concurrent request must be submitted if the maximum (if it exists) is exhausted. Benefit limits may be exceeded for Early and
and
(EPSDT) requests.
Medicaid 1915(b) MH/SU Services – Adult
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Vaya Health | Authorization Guidelines: Medicaid 1915(b) MH/SU Services – Adult Clinical Strategies| Rev. 04-18-2023 Copyright © 2023 Vaya Health. All rights reserved. Version 6.0
Diagnostic,
Periodic Screening,
Treatment
Service Service Code Age(s) Documentation Requirements Guidelines Clinical Assessment 90791 (CCP 8C) T1023 (CCP 8A) 90791 T1023 18+ N/A • Prior authorization not required • Four units per fiscal year In-Home Psychiatric Diagnostic Evaluation (CCP 8C) 90791 SR 18+ N/A • Prior authorization not required • Four units per fiscal year Psychiatric Assessment (CCP 8C) 90792 18+ N/A • Prior authorization not required • Four units per fiscal year Psychological Testing (CCP 8C) 96112 96113 96116 96121 96130 96131 96132 96133 96136 96137 18+ N/A • Prior authorization not required
Effective date: 04-18-2023
Eight hours per day (and
of
combination
codes)
96130,
per fiscal year
96131, 96136, 96137, 96132, and 96133: one hour
six hours per fiscal year
• 96110:
96112 and 96113: eight hours per fiscal year
hours
fiscal year
• 96116 and 96121: four
per
Medicaid 1915(b) MH/SU Services – Adult
Vaya Health | Authorization Guidelines: Medicaid 1915(b) MH/SU Services – Adult Clinical Strategies| Rev. 04-18-2023 Copyright © 2023 Vaya Health. All rights reserved. Version 6.0
Effective date: 04-18-2023 Service Service Code Age(s) Documentation Requirements Guidelines Individual Therapy (CCP 8C) 90832 90834 90837 18+ N/A Prior authorization not required Individual Therapy Add-On to E/M (CCP 8C) 90833 90836 90838 18+ N/A Prior authorization not required Family Therapy (CCP 8C) 90846 90847 18+ N/A Prior authorization not required Group Therapy/ Counseling (CCP 8C) 90849 90853 18+ N/A • Prior authorization not required • 90849 may not be billed at the same time as 90785 Individual Therapy for Crisis (CCP 8C) 90839 90840 18+ N/A • Prior authorization not required • Two visits per fiscal year, up to two add-ons per episode Concurrent:
90839: up to two additional visits per fiscal year per provider
90840: up to two additional add-ons per episode Home-Based Therapy (CCP 8C) 90832 SR 90834 SR 90837 SR 18+ N/A Prior authorization not required
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Medicaid 1915(b) MH/SU Services – Adult
Effective date: 04-18-2023
H0040 18+
(CCP 8A-1)
• Initial: SAR; person-centered plan (including Comprehensive Crisis Plan)*; SO; ASAM Criteria LOC (if applicable); ATR
• Concurrent: SAR; person-centered plan (including Comprehensive Crisis Plan) updated within past 30 days; SO; ASAM Criteria LOC (if applicable); ATR; Transition Plan
* Providers have up to 14 calendar days to submit the person-centered plan (including Comprehensive Crisis Plan); initial requests may be submitted with SO only
Initial and concurrent: four units per month for one year
Community Support Team (CST)
(CCP 8A-6)
“All Services” code 18+
• Initial: SAR; person-centered plan (including Comprehensive Crisis Plan); SO; CCA; ASAM Criteria LOC (if applicable)
• Concurrent: SAR*; person-centered plan (including Comprehensive Crisis Plan) updated within past 30 days; ASAM Criteria LOC (if applicable)
*When medically necessary for services to be authorized for more than six months, new CCA or addendum to original CCA must be completed and submitted with new SAR
Prior authorization not required for first 36 units within 30 days
For members pursuing housing:
• Initial: up to 420 units for 60 days
• Concurrent: up to 630 units for 90 days
For members not pursuing housing:
• Initial: up to 128 units for 60 days
• Concurrent: up to 192 units for 90 days
Vaya Health | Authorization Guidelines: Medicaid 1915(b) MH/SU Services – Adult Clinical Strategies| Rev. 04-18-2023 Copyright © 2023 Vaya Health. All rights reserved. Version 6.0
Service Service Code Age(s) Documentation Requirements Guidelines
Assertive Community Treatment (ACT)
Medicaid 1915(b) MH/SU Services – Adult
Effective date: 04-18-2023
• Initial: SAR; person-centered plan (including Comprehensive Crisis Plan); SO; CCA; ASAM Criteria LOC (if applicable)
• Concurrent: SAR; person-centered plan (including Comprehensive Crisis Plan) updated within past 30 days; ASAM Criteria LOC (if applicable); weekly service notes
Initial and concurrent: one unit per day for 14 days Psychosocial
Vaya Health | Authorization Guidelines: Medicaid 1915(b) MH/SU Services – Adult Clinical Strategies| Rev. 04-18-2023 Copyright © 2023 Vaya Health. All rights reserved. Version 6.0
Service Service Code Age(s) Documentation Requirements Guidelines
MH Partial Hospitalization (CCP 8A) H0035 (Day program) H0035 HK (Residential) 18+
Rehabilitation (PSR) (CCP 8A) H2017 18+ N/A Prior authorization not required Outpatient Opioid Treatment (CCP 8A) H0020 18+ N/A Prior authorization not required Substance Abuse Intensive Outpatient Program (SAIOP) (CCP 8A) H0015 18+ N/A Prior authorization not required Substance Abuse Comprehensive Outpatient Treatment (SACOT) (CCP 8A) H2035 18+ N/A Prior authorization not required
Medicaid 1915(b) MH/SU Services – Adult
Effective date: 04-18-2023
18+
• Initial: SAR; person-centered plan (including Comprehensive Crisis Plan); SO; ASAM Criteria LOC
• Concurrent: SAR; person-centered plan (including Comprehensive Crisis Plan) updated within past 30 days; ASAM Criteria LOC
Initial and concurrent: one unit per day for 10 days; no more than 30 days within a 12-month period
Substance Abuse Medically Monitored Community Residential Treatment (CCP 8A)
H0013 18+
• Initial: SAR; person-centered plan (including Comprehensive Crisis Plan); SO; ASAM Criteria LOC
• Concurrent: SAR; person-centered plan (including Comprehensive Crisis Plan) updated within past 30 days; ASAM Criteria LOC
Initial and concurrent: one unit per day for 10 days; no more than 30 days within a 12-month period.
• Prior authorization not required
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Vaya Health | Authorization Guidelines: Medicaid 1915(b) MH/SU Services – Adult Clinical Strategies| Rev. 04-18-2023 Copyright © 2023 Vaya Health. All rights reserved. Version 6.0
Service Service Code Age(s) Documentation Requirements Guidelines
Non-Medical Community Residential Treatment
Substance Abuse
(CCP 8A) H0012 HB
Ambulatory Detoxification (CCP 8A)
H0014 18+ N/A
Tobacco Cessation 99406 (Intermediate visit) 99407 (Intensive visit) 18+ N/A Prior authorization not required Peer Support (CCP 8G) H0038 (Individual) H0038 HQ (Group) 18+ N/A Prior authorization not rsequired
Initial: one unit per day for 10 days
ACRONYM DEFINITION
ASAM American Society of Addiction Medicine
ATR ACT Transition Readiness Scale
CCA Comprehensive Clinical Assessment
CCP (NC Medicaid) Clinical Coverage Policy
LOC Level of Care
MH Mental Health
SAR Service Authorization Request
SO Service Order
SU Substance Use
Vaya Health | Authorization Guidelines: Medicaid 1915(b) MH/SU Services – Adult Clinical Strategies| Rev. 04-18-2023 Copyright © 2023 Vaya Health. All rights reserved. Version 6.0
