2021-2022 medicaid adult mh/su benefit plan · 2021. 7. 2. · 2021-2022 medicaid adult mh/su...

2021-2022 Medicaid Adult MH/SU Benefit Plan

Service Code(s): Services Included:

90791, 90792, 90785 Clinical Assessment

T1023 Diagnostic Assessment

96132, 96133, 96137 Neuropsychological Testing

96110, 96112, 96113 Developmental testing

96130, 96131, 96116, 96132, 96133, 96136, 96137, 96138, 96139

Psychological Testing (Hourly)

90832, 90833, 90834, 90836, 90837, 90838, 90785 Individual Therapy

90846, 90847 Family Therapy

90849, 90853, 90785 Group Therapy

90839, 90840 Psychotherapy for Crisis

99201 – 99255, 99304 – 99337, 99341 – 99350 Evaluation & Management

H0038, H0038HQ Peer Support Services

All Services Code Community Support Team

H2017U5 Individual Rehabilitation, Coordination, and Support Services

H0032 Mental Health/Substance Abuse Targeted Case Management

H2017 Psychosocial Rehabilitation

H0040, H0040:22 Assertive Community Treatment Program

H0035 Partial Hospitalization


Revised: 6/30/21

Service & Code Brief Service Description Auth Submission

Requirements Authorization Parameters

Source Age Group Level of Care

Clinical

Assessment

Code(s): 90791 - Psychiatric Diagnostic Evaluation (No Medical Services) 90792 - Psychiatric Diagnostic Evaluation with Medical Services 90785 - Interactive Complexity (add on)

Clinical Assessment services are intended to determine a member’s treatment needs. In general, outpatient

behavioral health services focus on reducing

psychiatric and behavioral symptoms in order to

improve the member’s functioning in familial, social, educational, or

occupational life domains

No authorization required. Up to 2 per year, to include a maximum of 1 Diagnostic Assessment (T1023).

Units: Up to 2 per year [to include a maximum of 1 Diagnostic Assessment (T1023)] Other: 1. A CCA that demonstrates medical necessity must be completed by a licensed professional prior to provision of outpatient therapy services. 2. The provider will communicate and coordinate care with other professionals providing care to the member. 3. For services that require a PCP, a CCA must be completed prior to service delivery.

Clinical Coverage

Policy No. 8C: Outpatient Behavioral

Health Services

APSM 45-2

Records Management

and Documentation

Manuals

PCP Instruction

Manual

September 2011 Medicaid

Bulletin

Adults (age 21 and

older)

LOC: Not applicable.

Note: For members having both Medicaid and Medicare, the provider shall bill Medicare as primary before submitting a claim to Medicaid. For beneficiaries having both Medicaid and any other insurance coverage, the other insurance shall be billed prior to billing Medicaid, as Medicaid is considered the payor of last resort.

https://medicaid.ncdhhs.gov/providers/clinical-coverage-policies/behavioral-health-clinical-coverage-policies







https://www.ncdhhs.gov/documents/apsm-45-2-records-management-and-documentation-manuals






https://www.ncdhhs.gov/documents/person-centered-planning



https://medicaid.ncdhhs.gov/documents/september-2011-medicaid-bulletin




Revised: 6/30/21




Diagnostic

Assessment (DA)

Code(s): T1023

A DA is an intensive clinical and functional

evaluation of a member’s mental health, intellectual

and developmental disability, or substance use

condition. A diagnostic assessment determines

whether the member meets medical necessity

and can benefit from: mental health, intellectual disability, developmental

disability, or substance use disorder services based on the member’s diagnosis, presenting problems, and treatment and recovery

goals.

No authorization required (no more than 1 per year) Note: This assessment must be signed and dated by the MD, DO, PA, NP, or licensed psychologist and can serve as the initial order for services included in the PCP. Note: For members having both Medicaid and Medicare, the provider shall bill Medicare as primary before submitting a claim to Medicaid. For beneficiaries having both Medicaid and any other insurance coverage, the other insurance shall be billed prior to billing Medicaid, as Medicaid is considered the payor of last resort.

Units: 1 unit =1 event (an assessment equals 1 event). No more than 1 event per year. Other: 1. The DA must include all 10 elements detailed in the CCP. 2. For SU-focused DA, the DA must recommend an ASAM LOC determination. 3. The DA team must include at least 2 QPs: A) An LP that can dx MH or SU disorders, and; B) An MD, DO, NP, PA, or licensed psychologist.

Clinical Coverage

Policy No. 8A-5: Diagnostic Assessment

APSM 45-2

Records Management

and Documentation

Manuals

PCP Instruction

Manual

Adults (age 21 and

older)


Note: Service Exclusions – A DA cannot be billed on the same day as ACT, IIH, MST or CST services. This service cannot be provided in an institution for mental disease (IMD) (for adults) or in a public institution.
















Revised: 6/30/21




Neuropsychological

Testing

Code(s): 96132: First hour of assessment 96133: For each additional full hour of assessment 96137: For each additional 30 minutes

Neuropsychological Testing is intended to assess cognition and

behavior, examining the effects of any brain injury

or neuropathological process that a person may

have experienced.

All Requests: SAR: required if the unmanaged units have been exhausted. Providers may seek prior approval if they are unsure the member has reached their unmanaged visit limit. To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.

Units: For Medicaid members age 21 and over, outpatient services coverage is limited to 16 unmanaged outpatient visits per state fiscal year (for any combination of Clinical Assessment, Neuropsych Testing, Developmental Testing, Individual, Family or Group Therapy). Other: The provider will communicate and coordinate care with other professionals providing care to the member.

Clinical Coverage


Health Services

APSM 45-2

Records Management

and Documentation

Manuals

PCP Instruction

Manual


Bulletin

Adults (age 21 and

older)























Revised: 6/30/21




Developmental

testing

Code(s): 96110: Developmental Testing - Limited 96112: Developmental Testing administrative - first hour 96113: Developmental Testing - each additional 30 minutes

An in-depth look at a member’s development, usually done by a trained

specialist, such as a developmental

pediatrician, psychologist, speech-language

pathologist, occupational therapist, or other

specialist. The specialist may observe the member,

give the member a structured test, ask the

guardian questions, or ask them to fill out questionnaires.

All Requests: SAR: required if the unmanaged units have been exhausted. Providers may seek prior approval if they are unsure the member has reached their unmanaged visit limit. To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.

Units: Up to 6 unmanaged units of Developmental Testing – Limited (96110). For Medicaid members over the age of 21, outpatient behavioral health services coverage is limited to 16 unmanaged outpatient visits per state fiscal year (for any combination of Clinical Assessment, Developmental Testing, Individual, Family or Group Therapy). Other: The provider will communicate and coordinate care with other professionals providing care to the member.

Clinical Coverage


Health Services

APSM 45-2

Records Management

and Documentation

Manuals

PCP Instruction

Manual


Bulletin

Adults (age 21 and

older)























Revised: 6/30/21

Service & Code Brief Service Description

Auth Submission Requirements

Authorization Parameters


Psychological Testing (Hourly)

Code(s): 96130: 1st hour 96131: Additional 30 minutes, used with 96130 96116 or 96132: 1st hour 96133: Additional hour, used with 96132 96136: First 30 minutes, used with 96130 or 96132 96137: Additional 30 minutes, used with 96136 96138: First 30 minutes 96139: Additional 30 minutes, used with 96138

Psychological testing involves the culturally

and linguistically appropriate

administration of standardized tests to assess a member’s

psychological or cognitive functioning. Testing results must

inform treatment selection and

treatment planning.

All Requests: 1. SAR: required if the unmanaged units have been exhausted. Providers may seek prior approval if they are unsure the member has reached their unmanaged visit limit. To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit. 2. Submission of all records that support the member has met the medical necessity criteria. Note: For members having both Medicaid and Medicare, the provider shall bill Medicare as primary before submitting a claim to Medicaid. For beneficiaries having both Medicaid and any other insurance coverage, the other insurance shall be billed prior to billing Medicaid, as Medicaid is considered the payor of last resort.

Units: Unmanaged coverage is limited to eight hours of service per state fiscal year. Other: 1. May only be performed by licensed psychologists, licensed psychological associates, and qualified physicians. 2. Testing must include all 9 elements detailed in the CCP. 3. The provider will communicate and coordinate care with other professionals providing care to the member.

Clinical Coverage


Health Services

APSM 45-2

Records Management

and Documentation

Manuals

PCP Instruction

Manual


Bulletin

Adults (age 21 and

older)


Note: Service Exclusions – Testing for the following is not covered: a) for the purpose of educational testing; b) if requested by the school or legal system, unless MN exists for the psych testing; c) if the proposed psych testing measures have no standardized norms or documented validity, OR; d) if the focus is not the symptoms of the DSM-5 diagnosis.





















Revised: 6/30/21





Individual Therapy

Code(s): 90832: 30 Minutes 90833: 30 Minute add on to E&M. 90834: 45 Minutes 90836: 45 Minute add on to E&M. 90837: 60 Minutes 90838: 60 Minute add on to E&M. 90785: Interactive Complexity (Add on to codes 90832 thru 90838

Service is focus on reducing

psychiatric and behavioral

symptoms to improve the member’s

functioning in familial, social, educational, or

occupational life domains. The

member’s needs and preferences determine the

treatment goals, frequency, and

duration of services, as well as

measurable and desirable outcomes.

Initial Requests: SAR: required if the unmanaged units have been exhausted. Providers may seek prior approval if they are unsure the member has reached their unmanaged visit limit. To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit. Reauthorization Requests: 1. SAR: required after unmanaged visits. Requests should be submitted prior to the last unauthorized visit. 2. Submission of all records that support the member has met the medical necessity criteria. Note: Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.

Units: 1. For Medicaid members age 21 and over, outpatient services coverage is limited to 16 unmanaged outpatient visits per state fiscal year (for any combination of Clinical Assessment, Neuropsych Testing, Developmental Testing, Individual, Family or Group Therapy). 2. LOCUS or ASAM Level 1 - 6: See LOC section Other: 1. When receiving multiple BH services in addition to outpatient, a PCP must be developed. 2. The provider will communicate and coordinate care with other professionals providing care to the member.

Clinical Coverage


Health Services

APSM 45-2

Records Management

and Documentation

Manuals

PCP Instruction

Manual


Bulletin

Adults (age 21 and

older) Note: Service Exclusions – Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.

1. ASAM or LOCUS Level 1: Up to an additional 8 sessions per state fiscal year after the unmanaged units have been exhausted (for any combination of Individual, Family or Group Therapy) 2. ASAM Level 1 or LOCUS Level 2 thru 6: Up to an additional 13 sessions per state fiscal year after the unmanaged units have been exhausted (for any combination of Individual, Family or Group Therapy).





















Revised: 6/30/21





Family Therapy

Code(s): 90846: Family Therapy w/o member. May not be used with 90785. 90847: Family Therapy with member. May not be used with 90785.






member’s needs and preferences

determine the treatment goals, frequency, and


measurable and desirable

outcomes.



Clinical Coverage


Health Services

APSM 45-2

Records Management

and Documentation

Manuals

PCP Instruction

Manual


Bulletin

Adults (age 21 and

older) Note: Service Exclusions –Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.

1. ASAM or LOCUS Level 1: Up to an additional 8 sessions per state fiscal year after the unmanaged units have been exhausted (for any combination of Individual, Family or Group Therapy) 2. ASAM Level 1 or LOCUS Level 2 thru 6: Up to an additional 13 sessions per state fiscal year after the unmanaged units have been exhausted (for any combination of Individual, Family or Group Therapy).





















Revised: 6/30/21





Group Therapy

Code(s): 90849: Group Therapy (multi-family). May not be used with 90785. 90853: Group Therapy 90785: Interactive Complexity






member’s needs and preferences determine the

treatment goals, frequency, and


measurable and desirable outcomes.



Clinical Coverage


Health Services

APSM 45-2

Records Management

and Documentation

Manuals

PCP Instruction

Manual


Bulletin

Adults (age 21 and

older) Note: Service Exclusions –Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.

1. ASAM or LOCUS Level 1: Up to an additional 16 sessions per state fiscal year after the unmanaged units have been exhausted (of Group Therapy) 2. ASAM Level 1 or LOCUS Level 2 thru 6: Up to an additional 26 sessions per state fiscal year after the unmanaged units have been exhausted (of Group Therapy).





















Revised: 6/30/21




Psychotherapy for

Crisis

Code(s): 90839: First 60 Minutes 90840: For each additional 30 minutes. Must be used with 90839. Up to two addons per 90839 event.

On rare occasions, licensed outpatient service

providers are presented with individuals in crisis situations which may

require unplanned extended services to

manage the crisis in the office with the goal of

averting more restrictive levels of care. This service

is used only in those extreme situations in which

an unforeseen crisis situation arises, and

additional time is required to manage the crisis event. Services are restricted to

outpatient crisis assessment, stabilization, and disposition for acute, life-threatening situations.

Prior approval is not required for Psychotherapy for Crisis. A provider shall provide no more than two Psychotherapy for Crisis services per member, per state fiscal year. Note: For members having both Medicaid and Medicare, the provider shall bill Medicare as primary before submitting a claim to Medicaid. For beneficiaries having both Medicaid and any other insurance coverage, the other insurance shall be billed prior to billing Medicaid, as Medicaid is considered the payor of last resort.

Units: Up to two events per calendar year per attending provider Other: 1. The provider will complete an assessment prior to the delivery of any subsequent services following the provision of this service. 2. When receiving multiple BH services in addition to outpatient, a PCP must be developed. 3. The provider will communicate and coordinate care with other professionals providing care to the member.

Clinical Coverage


Health Services

APSM 45-2

Records Management

and Documentation

Manuals

PCP Instruction

Manual


Bulletin

Adults (age 21 and

older)


Note: Service Exclusions – Psychotherapy for Crisis is not covered: a) if the focus of tx does not address the symptoms of the DSM-5 dx or related symptoms; b) in emergency departments, inpatient settings, or facility-based crisis settings, OR; c) if the member presents with a medical, cognitive, intellectual or development issue that would not benefit from outpatient tx services.





















Revised: 6/30/21




Evaluation & Management

Code(s): 99201 – 99255 99304 – 99337 99341 – 99350

Evaluation and Management provided by a Psychiatrist / MD or a

Psych NP/PA.

No SAR required. E/M codes are not specific to mental health and are not subject to prior approval. Note: For members having both Medicaid and Medicare, the provider shall bill Medicare as primary before submitting a claim to Medicaid. For beneficiaries having both Medicaid and any other insurance coverage, the other insurance shall be billed prior to billing Medicaid, as Medicaid is considered the payor of last resort.

Units: A member 21 years of age and over is allowed 22 unmanaged visits counted separately from outpatient behavioral health services visit limits Other: 1. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service. 2. The provider will communicate and coordinate care with other professionals providing care to the member.

Clinical Coverage


Health Services

APSM 45-2

Records Management

and Documentation

Manuals

PCP Instruction

Manual


Bulletin

Adults (age 21 and

older)


Note: Service Exclusions – Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.





















Revised: 6/30/21



Authorization Parameters Source Age Group Level of Care

Peer Support

Services

Code(s):

H0038: Peer Support, Individual H0038HQ: Peer Support, Group

An evidenced-based mental health model of care that provides

community-based recovery services

directly to a Medicaid-eligible

adult member diagnosed with an MH or SU disorder.

PSS provides structured, scheduled services that promote

recovery, self-determination, self-

advocacy, engagement in self-care and wellness

and enhancement of community living

skills of beneficiaries

Initial Requests: 1. SAR: Prior approval is required beyond the unmanaged limit. 2. CCA: Required 3. Complete PCP: Required 4. Service Order: Required, signed by physician or other licensed clinician, per their scope of practice. 5. Submission of all records that support the member has met the medical necessity criteria. Reauthorization Requests: 1. SAR: prior approval required 2. Complete PCP: recently reviewed detailing the member’s progress with the service 3. Submission of all records that support the member has met the medical necessity criteria.

Length of Stay: Providers will seek prior approval if member is engaged in other MH or SU services. Providers shall seek prior approval if they are uncertain that the member has reached the unmanaged unit limit. Units: 1. Units are billed in 15-increments. 2. For unmanaged visit Eastpointe will continue to authorize 270 units for 90 days for initial requests. This will include services with the SE modifier for services engagement. 3. Up to 270 units for 90 days for the initial auth period. Up to 270 units for 90 days for reauth periods, if medically necessary. Additional units may be auth’d as clinically appropriate.

Clinical Coverage

Policy No 8G: Peer Support

Services

LME-MCO Joint

Communication Bulletin # J344

APSM 45-2

Records Management

and Documentation

Manuals

PCP Instruction Manual

Adults (age 18 and

older)

ASAM or LOCUS Level of 1 or higher

Note: Service Exclusions - May not be provided during the same auth period as ACTT or CST. Member with a sole diagnosis of IDD is not eligible this service.






https://www.ncdhhs.gov/divisions/mental-health-developmental-disabilities-and-substance-abuse/joint-communication-bulletins-2019#november-2019-(j344---j347)













Revised: 6/30/21



Authorization Parameters Source Age

Group Level of

Care

Community

Support Team (CST)

Code(s): All Services (used in place of the following individual codes) H2015 HT: CST H2015HTHO: Licensed Team Lead H2015HTHF: LCAS, LCAS-A, CCS, CSAC H2015 HTHNSE: QP, AP H2015HTU1: NC Peer Support Specialist H2015HTHM: Paraprofessional

Provides direct support to adults with

a MH, SU, or co-morbid disorder and who have complex

and extensive treatment needs.

Consists of community-based MH and SU services, and

structured rehab interventions intended

to increase and restore a member’s

ability to live successfully in the

community. The team approach involves structured, face-to-

face therapeutic interventions that

assist in reestablishing the members

community roles related to life domains.

Initial Requests: 1. SAR: Prior approval is required beyond the unmanaged limit 2. CCA: Required 3. Complete PCP: Required 4. Service Order: Required, signed by a physician, licensed psychologist, PA, or NP. 5. Submission of all records that support the member has met the medical necessity criteria. Reauthorization Requests: 1. SAR: prior approval required 2. Complete PCP: recently reviewed detailing the member’s progress with the service 3. CCA: For services lasting more than six months, a new CCA or an addendum must be submitted. 4. Service Order: Service must be ordered at least annually. 5. Submission of all records that support the member has met the medical necessity criteria.

Units and Length of Stay: 1. One unit = 15 minutes 2. Up to 36 unmanaged units for an initial 30 calendar days. Exception: SE codes providers are allowed 128 unmanaged units for 90 days. 3. Initial Request: 128 units for 60-calendar days. Members searching for stable housing requiring permanent supportive housing interventions, 420 units for 60 days. 4. Reauth Request: up to 192 units for 90-days. Members searching for stable housing requiring permanent supportive housing interventions, up to 630 units for 90-days. Exception: When helping a member transition to and from a service, CST services may be provided for a max of eight units for the first and last 30-day period for members auth’d for: ACTT, SAIOP, SACOT. 5. It is expected that service intensity titrates down as the member demonstrates improvement.

Clinical Coverage

Policy No 8A-6: Community

Support Team

APSM 45-2 Records

Management and

Documentation Manuals

PCP Instruction

Manual

Adults (age 18

and older)

LOCUS Level of 3 or higher. For members

with an SU diagnosis, an ASAM score

of 2.1 is required.

Note: Service Exclusions - May not be provided in conjunction with ACTT or during the same auth period as any other State Plan service that contains duplicative service components.















Revised: 6/30/21




Individual

Rehabilitation, Coordination, and

Support (IRCS) Services

Code(s): H2017U5

The purpose of this service is to enhance, restore

and/or strengthen the skills needed to promote and

sustain independence and stability within the

individual’s living, learning, social, and work

environments. IRCS assist individuals in achieving rehabilitative, resiliency and recovery goals. The

service consists of therapeutic interventions that facilitate illness self-

management, skill building, identification and

use of adaptive and compensatory strategies, identification and use of

natural supports, and use of community resources.

IRCS services help clients develop and practice skills

in their home and community. IRCS is a skill building service, not a form

of psychotherapy or counseling.

Initial Requests: 1. SAR: Prior approval is required. 2. CCA: Required, to include the info required in Admission Criteria E1-4. 3. Complete PCP: Required. The number of hours that participant receives IRCS services are to be specified in the PCP. 4. Service Order: Required. Reauthorization Requests: 1. SAR: Prior approval required. 2. Complete PCP: Required. Active treatment and discharge planning must be present. IRCS must be listed on the PCP, to include a description of the intervention, member's response to the intervention, and progress toward goals/objectives in the PCP. PCP must clearly reflect the specific need of the member and the interventions/ support rendered to address the need(s) of the individual.

Length of Stay: 1. Initial: Up to 90 days. 2. Reauth: Up to 180 days. 3. Services are generally more intensive and frequent at the beginning of tx and are expected to decrease as the member’s skills develop. 4. This service is to be available for at least 15 minutes per day, five days per week. 5. Service can be provided for no more five hours in a single day and may be provided on weekends or in the evening. Units: 1. Units are billed in 15-increments. 2. Maximum of 10 hours week, 5 days per week with no more than 5 hours in a single day. 3. Maximum 2,080 units per individual per 12 months

Individual Rehabilitation, Coordination, and Support

(IRCS) Services

Alternative Service

Definition

APSM 45-2 Records

Management and


PCP Instruction

Manual

LME-MCO

Communication Bulletin #J334

(JCB 334)

Adults (Age 18

and older)

LOCUS Level of 3 or higher

Note: Service Exclusions - IRCS cannot be provided during the same authorization period as PSR-Group, ACTT, CST, Partial Hospitalization, Day Tx, Residential Tx, Supervised Living, IIH, FCT, MST, HFW, and Young Adults in Transition.









https://www.ncdhhs.gov/divisions/mental-health-developmental-disabilities-and-substance-abuse/joint-communication-bulletins-2019#july-2019-(j331---335)




Revised: 6/30/21





Mental

Health/Substance Abuse Targeted

Case Management

Code(s): H0032

Case management (MH/SA TCM) is an activity that assists

members to gain access to necessary care:

medical, behavioral, social, and other services appropriate to their needs.

Case management is individualized, person-centered, empowering,

comprehensive, strengths-based, and outcome-

focused. This service is targeted at member’s who

have either a serious emotional disturbance,

mental illness or a substance related

disorder.

Initial Requests: 1. SAR: Prior approval is required 2. Complete PCP: Required 3. Service Order: Required, signed by a physician, licensed psychologist, or PA, or NP. 4. Submission of all records that support the member has met the medical necessity criteria. Reauthorization Requests: 1. SAR: prior approval required 2. Complete PCP: recently reviewed detailing the member’s progress with the service. 3. Submission of all records that support the member has met the medical necessity criteria.

Units and Length of Stay: 1. Weekly case rate of 1 unit per calendar week [Sunday-Saturday]. 2. Initial requests up to 13 units over 90 days. 3. Reauthorization up to 9 units over 60 days. 4. This is a short-term service. The functions of case management include: a) Case Management Assessment; b) Person-Centered Planning; c) Referral and linkage; and d) Monitoring and follow-up.

Clinical Coverage Policy 8-L:

Mental Health/Substance Abuse Targeted

Case Management

APSM 45-2

Records Management and Documentation

Manuals

PCP Instruction Manual

Adults LOCUS score of 3 or higher

Note: Service Exclusions - MH/SA TCM cannot be provided during the same auth period as: IIHS, CST, ACTT, MST, CADT, SAIOP, SACOT, or Substance Abuse Non-Medical Community Residential Treatment. Case Management is a component of these services.
















Revised: 6/30/21




Psychosocial Rehabilitation

Code(s): H2017

Service is designed to help adults with psychiatric

disabilities increase their functioning so that they can be successful and

satisfied in the environments of their choice with the least amount of ongoing

professional intervention. PSR focuses on skill and

resource development related to life in the community and to

increasing the participant’s ability to live as

independently as possible, to manage their illness and

their lives with as little professional intervention

as possible, and to participate in community opportunities related to

functional, social, educational, and vocational goals.

Initial Requests: 1. SAR: Prior approval is required. 2. CCA: Required 3. Complete PCP: Required. The amount, duration, and frequency of services must be included. If limited information is available at admission, staff shall document on the PCP whatever is known and update it when additional information becomes available. 4. Service Order: Required, signed by an MD, DO, NP, PA, or a Licensed Psychologist. 5. Submission of all records that support the member has met the medical necessity criteria. Reauthorization Requests: 1. SAR: prior approval required 2. Complete PCP: recently reviewed detailing the member’s progress with the service. For PSR, the PCP shall be reviewed at least every 6 months. The amount, duration, and frequency of services must be included in a member’s PCP. 3. Submission of all records that support the member has met the medical necessity criteria.

Length of Stay: Initial authorization for services must not exceed 90 days. Reauthorization must not exceed 180 days. This service is to be AVAILABLE for a period of five or more hours per day at least five days per week and it may be provided on weekends or in the evening. Units: 1. Units are billed in 15-increments. 2. Up to 2080 units per 90 days. 3. The number of hours that a member receives PSR services are to be specified in his or her PCP.

Clinical Coverage Policy 8A: Enhanced

Mental Health and Substance

Abuse Services,

Psychosocial Rehabilitation

section

APSM 45-2 Records

Management and


PCP Instruction

Manual

Adults (Age 21 and

older)


Note: Service Exclusions - PSR cannot be provided during the same authorization period as Partial Hospitalization and ACTT





















Revised: 6/30/21





Assertive

Community Treatment (ACT)

Program

Code(s): H0040 H0040:22 - for Encounter Claims

An ACT team assists a member in advancing toward personal goals

with a focus on enhancing community

integration and regaining valued roles

(example: worker, daughter, resident, spouse, tenant, or

friend). A fundamental charge of ACT is to be

the first-line (and generally sole provider) of all the services that

an ACT member needs. A member who is appropriate for ACT does not benefit from

receiving services across multiple, disconnected

providers, and may become at greater risk

of hospitalization, homelessness, substance use,

victimization, and incarceration.

Initial Requests: 1. SAR: Prior approval is required. 2. CCA: Required 3. Complete PCP: Required. If limited information is available at admission, staff shall document on the PCP whatever is known and update it when additional information becomes available. 4. Service Order: Required, signed by an NP, PA, physician, or a Licensed Psychologist. 5. An LME Consumer Admission and Discharge Form 6. Submission of all records that support the member has met the medical necessity criteria. Reauthorization Requests: 1. SAR: prior approval required 2. Complete PCP: recently reviewed detailing the member’s progress with the service. 3. An LME Consumer Admission and Discharge Form 4. Submission of all records that support the member has met the medical necessity criteria.

Length of Stay: Max of 30 days without a complete PCP. A PCP must be completed within 15 days of the initial auth date. Up to 180 days for the initial and reauthorization period when the supporting docs (specifically the PCP), are present. Units: 1. One unit = 1 event. 2. Four units are auth’d per month, although an encounter claim should be billed every time an encounter occurs. 3. The expectation is most ACT members will receive more than 4 contacts per month, with most seeing at least 3 team members in a given month.

Clinical Coverage

Policy 8A-1: Assertive

Community Treatment

(ACT) Program

APSM 45-2

Records Management

and Documentation

Manuals

PCP Instruction

Manual

LME Consumer

Admission and Discharge

Form

Adults (Age 18 and

older)


Note: Service Exclusions – Members with a primary dx of a SU, IDD, TBI, borderline personality disorder, or an autism spectrum disorder are not the intended member group for ACT and should not be referred if they do not have a co-occurring psychiatric disorder. ACT cannot be provided concurrently w/: Outpatient therapy, Med Mngmnt, or Psych Services; Mobile Crisis; PSR (after a 30-day transition period); CST; Partial Hospitalization; Tenancy Support Services; Nursing home facility, or IPS-Supported Employment or LTVS.


















https://files.nc.gov/ncdhhs/documents/files/LME-Consumer-Admission-and-Discharge-Form-033115-640.pdf






Revised: 6/30/21





Partial

Hospitalization

Code(s): H0035

A short-term service for acutely mentally ill children or adults,

which provides a broad range of intensive

therapeutic approaches which may include: group activities

or therapy, individual therapy, recreational therapy, community

living skills or training, increases the

individual’s ability to relate to others and to function appropriately, coping skills, medical services. This service is designed to prevent

hospitalization or to serve as an interim

step for those leaving an inpatient facility.

Initial Requests: 1. SAR: Prior approval is required. 2. CCA: Required 3. Complete PCP: Required. The amount, duration, and frequency of services must be included. If limited information is available at admission, staff shall document on the PCP whatever is known and update it when additional information becomes available. 4. Service Order: Required, signed by a physician, doctoral level licensed psychologist, psychiatric NP, psychiatric clinical nurse specialist. 5. Submission of all records that support the member has met the medical necessity criteria. Reauthorization Requests: 1. SAR: prior approval required. 2. Complete PCP: recently reviewed detailing the member’s progress with the service. 3. Submission of all records that support the member has met the medical necessity criteria.

Length of Stay: Initial and Reauthorization requests shall not exceed seven calendar days. Units: 1. One unit = 1 event. 2. This is day or night service provided a minimum of 4 hrs/day, 5 days/week, and 12 months/year (excluding transportation time). Excludes legal or governing body designated holidays.

Clinical Coverage Policy 8A: Enhanced

Mental Health and Substance

Abuse Services,

Partial Hospitalization

section

APSM 45-2 Records

Management and


PCP

Instruction Manual

Adults LOCUS Level of 4 or higher





















2021-2022 medicaid adult mh/su benefit plan · 2021. 7. 2. · 2021-2022 medicaid adult mh/su...

Documents