medicaid-authorization-guidelines-for-adult-mh_su

Vaya Health

Medicaid Authorization Guidelines for Adult MH/SU Medicaid Adult MH/SU Utilization Review Guidelines Service Clinical Assessment (E) Psychiatric Assessment Psychological Testing

Service Code(s)

Authorization Submission Requirements

Service Definition Authorization Parameters

Source

90791, H0031, H0001, T1023

No authorization required

Max of one per year of T1023

8A - T1023; 8C for the others

Two per year (one for T1023); more may trigger post-payment review

90792

No authorization required

8C

Recommend one/year/provider

96101, 96110, 96111, 96116, 96118

No authorization required. After eight units in a 12-month period: SAR, Vaya psych testing request form, (C) and service order

8C

90832, Individual Therapy 90834, 90837, (E) 90845, H0004 Individual Therapy 90833, 90836, Add-On to E/M (E) 90838 90846, 90847, Family Therapy H0004HS, H0004HR Group Therapy/ Counseling (E)

8C 8C No authorization required

8C

90849, 90853, H0004HQ, H0005

Individual Therapy 90839, 90840 for Crisis

Home-Based Therapy

Authorization Guidelines: LOCUS Level/ASAM Level Level Level Level Level One Two Three Four Five ASAM ASAM ASAM ASAM ASAM 0.5 1 2.1 2.5 3+

90837SR

No authorization required up to max When over unmanaged; SAR, (C), treatment plan (PCP if receiving other enhanced services), service order (A) and treatment record documentation of attempts to engage in traditional officebased services

Vaya Health | Medicaid Authorization Guidelines for Adult MH/SU

Max. of two per year per provider. Max. of two addons per 90839 event.

Level Six ASAM 3+

Up to eight units total per 12-month period without authorization EBPs indicate service should be provided no more than one to three times/week, with titration to biweekly and/or monthly. Any combination of these services at a higher intensity may trigger postpayment review.

8C

EBPs indicate service may be indicated one to two times/week for eight-12 weeks. A higher intensity may trigger post-payment review.

8C

90839: Up to two sessions/year/provider; 90840: up to two sessions per episode Eight unmanaged sessions. Prior to eighth session, request for up to 26 sessions for 90day period.

Clinical Operations | Rev. 2.10.2017

Service Code(s)

Authorization Submission Requirements

Service Definition Authorization Parameters

Source

H0040

Initial: SAR, (C), service order, LOCUS and ATR worksheet. Re-authorization: SAR, PCP, LOCUS worksheet, ATR worksheet, Contacts Worksheet and Transition Plan

Prospective and concurrent authorization: 180 days maximum

8A-1

Community Support Team

H2015HT

SAR, PCP including Service Order (C) (include LOCUS worksheet)

60-day authorization periods. No more than 128 units per 60-day period.

8A

MH Partial Hospitalization

H0035

SAR, PCP including Service Order (C) (include LOCUS worksheet)

Prospective and concurrent authorization: seven-day maximum

8A

Service

Assertive Community Treatment Team

H0038U4 (ind), H0038HQU4 (group)

No authorization required

(b)(3): Supported Employment/ Long-Term Vocational Support

H2023U4HH (initial individual), H2026U4HH (individual maintenance/ LTVS)

SAR, PCP/Tx Plan with service order, IPSSE ACH In/At-Risk Checklist (if applicable) with initial SAR

(b)(3): Physician Consultation

99214U4 (brief), 99242U4 (intermediate ), 99244U4 (extensive)

(b)(3): Peer Support

(b)(3): Individual Support

Psychosocial Rehabilitation

No authorization required

T1019U4

SAR, PCP including Service Order

H2017

SAR, PCP including Service Order (C)

Vaya Health | Medicaid Authorization Guidelines for Adult MH/SU

Limited funding. Not an entitlement. See Vaya website for service definition.

Prospective authorization: 90 days, 2nd authorization: 90 days, subsequent authorization.

Maintenance: Up to one year. Limited funding. Not an entitlement. See Vaya website for service definition.

Limited funding. Not an entitlement. See Vaya website for service definition.

120 units (30 hours) per month may be provided without prior authorization.

Specific authorization must be obtained to exceed limits greater than 120 units per month.

Prospective authorization: 90 days Concurrent authorization: 180 days

Vaya (b)(3) service definition

Level One ASAM 0.5

Level Two ASAM 1

Level Three ASAM 2.1

Level Level Four Five ASAM ASAM 2.5 3+ Four units max. per month 60-day authorization periods. Up to 128 units per 60day period.

Up to seven days on initial and reauth.

Up to 960 units per 90 days, initial. Up to 720 units per 90 days re-authorization; 960 units/180 days for subsequent requests. Max. 20 units in 24-hour period*

Vaya (b)(3) service definition

Up to 344 units (86 hours)/month, initial. Up to 172 units (43 hours)/month, second and subsequent authorizations. Maintenance: Up to 40 units (10 hours)/month, maintenance/480 units/per year*

Vaya (b)(3) service definition

Justification, including the amount, duration and frequency of the service, must be included in the Individual Support Plan for persons using Innovations Waiver services or the Person-Centered Plan/Treatment Plan for individuals with SMI/SPMI.

Vaya (b)(3) service definition

8A

Level Six ASAM 3+

No more than 240 units per month

Up to 1560 units per 90 days

Clinical Operations | Rev. 2.10.2017

Level One ASAM 0.5

Level Two ASAM 1

Level Three ASAM 2.1

Level Four ASAM 2.5

Level Five ASAM 3+

Service

Service Code(s)

Authorization Submission Requirements

Service Definition Authorization Parameters

Source

Outpatient Opioid Treatment

H0020

SAR, PCP including service order. Reauthorization: same as above and include last three UDS results.

Prospective authorization: 60 units per 60 days.

Concurrent authorization: 180 days per six months

8A

SAIOP

H0015

No authorization required

8A

SACOT

H2035

No authorization required

8A

H0012HB

SAR, PCP with service order

Max. 10 days on initial authorization. Max. 10 days on reauthorization. Max. 30 days in 12-month period.

8A

ASAM 3.5

SAR, PCP with service order

Max. 10 days on initial authorization. Max. 10 days on reauthorization. Max. 30 days in 12-month period.

8A

ASAM 3.7

SAR, PCP with service order

Max. seven days initial authorization. Max. three days on reauthorization.

Max. 10 days overall.

8A

SU Non-Medical Community Residential Treatment SA Med Mon Community Residential Treatment Ambulatory Detox

H0013

H0014

Level Six ASAM 3+

Prospective authorization: 60 units per 60 days. Concurrent authorization: 180 days per six months Up to two rounds of treatment per year (recommended) Up to two rounds of treatment per year (recommended)

ASAM 1-D

(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 member's service record.

(E) Interactive Therapy (90785) may be used in conjunction with the following codes: 90791, 90792, 90832 - 90838, 90853.

* 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 Level of Care 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 care managers. 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 member 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.

Previous effective date: New effective date:

11.09.2016 02.10.2017

Vaya Health | Medicaid Authorization Guidelines for Adult MH/SU

Clinical Operations | Rev. 2.10.2017

REVISION INFORMATION: Date 4/15/2014 4/15/2014 6/1/2014 6/1/2014 6/1/2014 6/1/2014 6/1/2014 6/1/2014 7/1/2014 9/1/2014 9/15/2014 9/15/2014 9/15/2014

Section revised Psychological Testing – Auth Submission Requirements Opioid Replacement Therapy – Auth Submission Requirements Clinical Assessment – Auth submission requirements Individual Therapy – Auth submission requirements Individual Therapy add-on to E/M – Auth submission requirements 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

1/1/2015

Header and individual score references throughout grid.

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

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)

5/9/2016 5/9/2016 7/12/2016 7/12/2016 11/9/2016 2/10/2017

Vaya Health | Medicaid Authorization Guidelines for Adult MH/SU

Change Added (C) – CCA is required Deleted (C) – CCA is not required.

No auth required No auth required No auth required 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 former 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

Clinical Operations | Rev. 2.10.2017