CMHC AUTHORIZATION REQUIREMENT. Non-CMHC Notes (0 = No SERVICE DESCRIPTION
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1 Non- Notes (0 = No Non- Notes (0 = No 100 All inclusive room and board On 0 On All inclusive room and board On 0 On Anesthesia, ECT On 0 On Room and Board- private psychiatric On 0 On Room and Board- private room detoxification On 0 On Room and Board- private rehabilitation On 0 On Room and Board -semi private psychiatric On 0 On Room and Board- semi- private room detoxification On 0 On Room and Board - semi private rehabilitation On 0 On Room and Board bed psychiatric On 0 On Room and Board- 3-4 bed detoxification On 0 On Room and Board bed rehabilitation On 0 On Room and board private psychiatric On 0 On Room and board private- detoxification On 0 On Room and Board- ward psychiatric On 0 On Room and Board- detoxification ward On 0 On Room and Board- ward rehabilitation On 0 On leave of absence from residential On 0 On Intensive Care -psychiatric On 0 On Intensive Care -psychiatric On 0 On 0 PRO_14531E State Approved WellCare 2018 Page 1 of 17 KY8PROLTR14531E_0000
2 Notes (0 = No Non- Non- Notes (0 = No 450 Emergency Room Off 0 Off Emergency Room Off 0 Off Clinic encounter all inclusive Off 0 Off Psych clinic Off 0 Off Urgent Care Clinic On 0 On Other clinic- med supervised withdrawal- NY ONLY??What does this mean if all states are listed as "NA"? On 0 On Freestanding clinic Off 0 Off Rural Clinic Off 0 Off Other freestanding clinic Off 0 Off BH treatment services Off 0 Off ECT- electroshock treatment On 0 On Intensive Outpatient - providers should be instructed to use proper code with 915 On 0 On Intensive Outpatient - providers should be instructed to use proper code with 915 On 0 On BH treatment services On 0 On Substance abuse rehabilitation Off 0 Off Psychiatric/Psychological Services- Individual therapy Off 0 Off 0 Page 2 of 17
3 Notes (0 = No Non- Non- Notes (0 = No 916 Psychiatric/Psychological Services- Family therapy Off 0 Off Biofeedback On 0 On Testing Off 0 Off Other BH treatment services Off 0 Off Drug Rehabilitation Off 0 Off Alcohol Rehabilitation Off 0 Off Behavioral Health Residential- psychiatric On 0 On Interactive complexity add-on code Off 0 Off Psychiatric diagnostic evaluation (no medical Services) Off 0 Off Psychiatric diagnostic evaluation with medical services Off 0 Off Psychotherapy, 30 mins Off Off 30 min psychotherapy add on code when performed with E/M Service- (list separately) Off 0 Off Psychotherapy, 45 mins Off 0 Off 0 45 minute psychotherapy add on code when performed with E/M Service (list separately) Off 0 Off 0 Page 3 of 17
4 Notes (0 = No Non- Non- Notes (0 = No Psychotherapy, 60 mins Off 0 Off 0 60 min psychotherapy when performed with E/M service (list separately Off 0 Off Psychotherapy for crisis, first 60 min. Off 0 Off crisis code add on for each additional 30 min. Off 0 Off Psychoanalysis Off 0 Off Family Psychotherapy, without patient present Off 0 Off Family Psychotherapy, 45 min Off 0 Off Multiple-family group psychotherapy Off 0 Off Group psychotherapy Off 0 Off Pharmacologic management, add on code Off 0 Off Narcosynthesis Off 0 Off 0 Page 4 of 17
5 Notes (0 = No Non- Non- Notes (0 = No Electroconvulsive Therapy On 0 On Ind psycho therapy incorporating bio feedback 30 min Off 0 Off Ind psycho therapy incorporating bio feedback 45 min Off 0 Off Interpretation or explan of results of psych exam and procedures Outpatient Collateral, 15 min. Off 0 Off Unlisted Psychiatric procedure On 0 On Functional brain mapping Off 0 Off Psychological testing On On after 5 Hours On On after 5 Hours Psychological testing On On after 5 Hours On On after 5 Hours Psychological testing On On after 5 Hours On On after 5 Hours Assessment of Aphasia of speech/lang On 0 On Developmental screening with interp Off 0 Off Developmental testing On On after 5 Hours On On after 5 Hours Neurobehavioral status exam w clin assess On On after 5 Hours On On after 5 Hours Neuropsychological Testing per hour On On after 5 Hours On On after 5 Hours Neuropsych Testing Admin by Technician per hour On On after 5 Hours On On after 5 Hours Page 5 of 17
6 Notes (0 = No Non- Non- Notes (0 = No Neuropsych Testing Admin by Computer per occurrence On On after 5 Hours On On after 5 Hours Standardized cognitive perf testing On On after 5 Hours On On after 5 Hours Brief emotional needs assessment Off 0 Off Nursing Assessment and Care-Initial Off 0 Off Nursing Assessment and Care-Re-Assessment Off 0 Off H&B individual intervention Off 0 Off H&B group intervention Off 0 Off Health & Behavior Intervention w pt present Off 0 Off Health & Behavior Intervention w o pt present Off 0 Off Health & Behavior Intervention w o pt present Off 0 Off Health & Behavior Intervention w o pt present Off 0 Off 0 Page 6 of 17
7 Notes (0 = No Non- Non- Notes (0 = No Medication administration Off 0 Off Office Emergency Services Off 0 Off New Patient Office Visit Level 1 Off 0 Off New Patient Office Visit Level 2 Off 0 Off New Patient Office Visit Level 3 Off 0 Off New Patient Office Visit Level 4 Off 0 Off New Patient Office Visit Level 5 Off 0 Off Est Patient Office Visit Level 1 Off 0 Off Est Patient Office Visit Level 2 Off 0 Off Est Patient Office Visit Level 3 Off 0 Off 0 Page 7 of 17
8 Notes (0 = No Non- Non- Notes (0 = No Est Patient Office Visit Level 4 Off 0 Off Est Patient Office Visit Level 5 Off 0 Off Initial Hospital Care-comprehensive; low complexity Off 0 Off 0 Initial Hospital Care-comprehensive; moderate complexity Off 0 Off Initial Hospital Care-comprehensive; high complexity Off 0 Off Subsequent observation Care Off 0 Off Subsequent observation Care Off 0 Off Subsequent observation Care Off 0 Off Subsequent Hospital Care-focused; low complexity Off 0 Off Subsequent Hospital Care-focused; moderate complexity Off 0 Off Subsequent Hospital Care-focused; high complexity Off 0 Off Observation-comprehensive; low complexity Off 0 Off Observation-comprehensive; moderate complexity Off 0 Off 0 Page 8 of 17
9 Notes (0 = No Non- Non- Notes (0 = No Observation-comprehensive; high complexity Off 0 Off Discharge Day Management- 30 min or less Off 0 Off Discharge Day Management-more than 30 min Off 0 Off Problem focused; straightforward-15 min Off 0 Off Expanded; straightforward-30 min Off 0 Off Detailed; low complexity-40 min Off 0 Off Comprehensive; moderate complexity-60 min Off 0 Off Comprehensive; high complexity-80 min Off 0 Off Initial Consultation-focused, straightforward Off 0 Off Initial Consultation-expanded, straightforward Off 0 Off Initial Consultation-detailed, low complexity Off 0 Off 0 Initial Consultation-comprehensive, moderate complexity Off 0 Off Initial Consultation-comprehensive, high complexity Off 0 Off ER Consultation-focused, straightforward Off 0 Off ER Consultation-expanded; low complexity Off 0 Off ER Consultation-expanded; moderate complexity Off 0 Off ER Consultation-detailed; moderate complexity Off 0 Off ER Consultation-comprehensive; high complexity Off 0 Off Nursing facility consultation 25 min Off 0 Off 0 Page 9 of 17
10 Notes (0 = No Non- Non- Notes (0 = No Nursing facility consultation 35 min Off 0 Off Nursing facility consultation 45 min Off 0 Off Evaluation Management nursing facility 10 min Off 0 Off Evaluation Management nursing facility 15 min Off 0 Off Evaluation Management nursing facility 25 min Off 0 Off Evaluation Management nursing facility 35 min Off 0 Off Home visit, new patient Off 0 Off Home visit, new patient Off 0 Off Home visit, new patient Off 0 Off Home visit, new patient Off 0 Off Home visit, new patient Off 0 Off Home visit, est patient Off 0 Off Home visit, est patient Off 0 Off Home visit, est patient Off 0 Off Home visit, est patient Off 0 Off Prolonged evaluation and mgmt psycho therapy svs Off 0 Off Prolonged evaluation and mgmt psycho therapy svs Off 0 Off Medical team conference Off 0 Off 0 Page 10 of 17
11 Notes (0 = No Non- Non- Notes (0 = No Medical team conference with family Off 0 Off Medical team conference without family Off 0 Off Preventive counseling, individual Off 0 Off Preventive counseling, individual 30 min Off 0 Off Preventive counseling, individual 45 min Off 0 Off Preventive counseling, individual Off 0 Off Smoking cessation Off 0 Off Smoking cessation Off 0 Off Alcohol substance abuse BH change intervention Off 0 Off 0 Alcohol and substance abuse screening and brief intervention Off 0 Off 0 Page 11 of 17
12 Notes (0 = No Non- Non- Notes (0 = No Preventive counseling, individual 60 min Off 0 Off Preventive medicine group counseling- 60 min Off 0 Off 0 907, H2012 Community behavioral program (day treatment) On 0 On and G0410 or G0411/ or Partial Hospitalization On 0 On 0 915, H0015 BH intensive outpatient substance abuse On 0 On 0 915, S9480 BH intensive outpatient psychiatric On 0 On 0 G0410 Partial Hospitalization On 0 On 0 G0411 BH intensive outpatient substance abuse On 0 On 0 H0001 Alcohol and/or drug assessment Off 0 Off 0 H0002 Behavioral Health Screen to determine eligibility for admission to treatment program Off 0 Off 0 H0004 behavioral health counseling and therapy; per 15 minutes Off 0 Off 0 H0006 Alcohol and/or drug services; case management Off 0 On 0 Page 12 of 17
13 Notes (0 = No Non- Non- Notes (0 = No H0010 Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient) On No auth requirement up to 200 units. Prior Authorization Request =ON after 200 Units Total of identified HCPC Series Codes. On No auth requirement up to 200 units. Prior Authorization Request =ON after 200 Units Total of identified HCPC Series Codes. H0012 H0015 H0018 Alcohol and/or drug services; sub-acute detoxification (residential addiction program outpatient) Off 0 Off 0 Alcohol and/or drug services; intensive outpatient treatment (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan) including assessment, counseling, crisis intervention, and activity therapies or education On 0 On 0 Behavioral health; short-term residential (non hospital residential treatment program), without room and board; per diem On 0 On 0 Page 13 of 17
14 H0019 H0020 H0024 Notes (0 = No Non- Non- Notes (0 = No Behavioral health; long term residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board; per diem On 0 On 0 Alcohol and/or drug services; methadone administration and/or service (provisions of the drug by a licensed program) Off 0 On 0 Behavioral health prevention information dissemination service (one way direct or non-direct contact with service audiences to affect knowledge and attitude); 15 minutes Off 0 On 0 H0025 Behavioral health prevention education service (delivered of services with target population to affect knowledge, attitude and/or behavior); 15 minutes Off 0 Off 0 H0031 Mental health assessment, by non-physician Off 0 Off 0 H0032 Mental health service plan development by nonphysician Off 0 Off 0 H0035 Mental health partial hospitalization, treatment, less than 24 hours On 0 On 0 Page 14 of 17
15 Notes (0 = No Non- Non- Notes (0 = No H0038 Self-help/peer services; per 15 minutes Off 0 Off 0 H0040 Assertive Community Treatment; per diem On 0 On 0 H1000 Prenatal care, at-risk assessment Off 0 Off 0 H1001 Prenatal care, at-risk enhanced service; antepartum management Off 0 Off 0 H1002 Prenatal care, at risk enhanced service; care coordination Off 0 Off 0 H1003 Prenatal care, at-risk enhanced service; education Off 0 Off 0 H1004 Prenatal care, at-risk enhanced service; follow-up home visit Off 0 Off 0 H1005 Prenatal care, at-risk enhanced service package (includes H1001-H Off 0 Off 0 H1011 Family assessment by licensed behavioral health professional for state defined purposes Off 0 Off 0 H2010 Comprehensive medication services; per 15 minutes Off 0 Off 0 H2011 Crisis Intervention Services; per 15 Minutes Off 0 Off 0 H2012 Behavioral health day treatment; per hour On 0 On 0 Page 15 of 17
16 Notes (0 = No Non- Non- Notes (0 = No H2015 Comprehensive community support services; per 15 minutes Off 0 On 0 H2018 Psychosocial rehabilitation services; per diem Off 0 Off 0 H2019 Therapeutic behavioral services; per 15 minutes On 0 On 0 H2021 Community-based wrap-around services; per 15 min Off 0 On 0 H2027 See Notes - per 15 minutes Off 0 Off 0 M0064 Brief Office Visit for the Sole Purpose of Monitoring or Changing Drug Prescriptions Used in the Treatment of Mental Psychoneurotic and Personality Disorders Off 0 Off 0 Q3014 Telehealth original site facility Off 0 Off 0 S5108 Home care training to home care client, per 15 minutes On 0 On 0 S5110 Home care training, family; per 15 minutes On 0 On 0 S5150 Unskilled respite care, not hospice; per 15 minutes On 0 On 0 Intensive outpatient psychiatric services; per diem; in IL S9480 use 913 in combination with this code On 0 On 0 S9484 Crisis intervention mental health services; per hour Off 0 Off 0 Page 16 of 17
17 Notes (0 = No Non- Non- Notes (0 = No S9485 Crisis intervention mental health services; per diem Off 0 Off 0 T1001 Nursing Assessment/ Evaluation On 0 On 0 T1002 RN services up to 15 minutes Off 0 Off 0 T1003 LPN/ LVN services up to 15 minutes On 0 On 0 T1007 Alcohol and/or substance abuse services, treatment plan development and/or modification Off 0 Off 0 T1016 Case management, each 15 minutes Off 0 Off 0 T2001 Non emergency transportation; patient attendant/escort On 0 On 0 T2002 Non-emergency transportation; per diem On 0 On 0 T2003 Non-emergency transportation; encounter/trip On 0 On 0 T2004 Non-emergency transport; commercial carrier, multipass On 0 On 0 T2005 Non-emergency transportation; stretch van On 0 On 0 T2023 Targeted Case Management- per month On 0 On 0 Page 17 of 17
Page 1 of 11. Effective 9/15/2018 AUTHORIZATION REQUIREMENT LEVEL OF CARE. Notes (0 = No Additional Comments)
100 All inclusive room and board On 0 101 All inclusive room and board On 0 104 Anesthesia, ECT On 0 114 Room and Board- private psychiatric On 0 116 Room and Board- private room detoxification On 0 118
Behavioral Health Authorization Requirements*
100 All inclusive room and board MN 0 MN 0 101 All inclusive room and board MN Use MN Criteria for IP Medically-Supervised detox MN 0 104 Anesthesia, ECT MN 0 MN 0 114 Room and Board- private psychiatric
AUTHORIZATION RQUIREMENTS Notes (0= No Additional Comments) 101 All inclusive room and board On 0
100 All inclusive room and board 0 101 All inclusive room and board 0 114 Room and Board- private psychiatric 0 116 Room and Board- private room detoxification 0 118 Room and Board- private rehabilitation
Revenue/Procedure Code Service Group Matrix
0 114 Room and Board- private psychiatric 0 118 Room and Board- private rehabilitation 0 124 Room and Board -semi private psychiatric 0 128 Room and Board - semi private rehabilitation 0 134 Room and Board
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