Behavioral Health Authorization Requirements*

Transcription

1 100 All inclusive room and board MN 0 MN All inclusive room and board MN Use MN Criteria for IP Medically-Supervised detox MN Anesthesia, ECT MN 0 MN Room and Board- private psychiatric MN 0 MN Room and Board- private room detoxification MN 0 MN Room and Board- private rehabilitation MN 0 MN Residential Treatment NC 0 NC Room and Board -semi private psychiatric MN 0 MN Room and Board- semi- private room detoxification MN 0 MN Room and Board - semi private rehabilitation MN 0 MN Room and Board bed psychiatric MN 0 MN Room and Board- 3-4 bed detoxification MN 0 MN Room and Board bed rehabilitation MN 0 MN Room and board private psychiatric MN 0 MN Room and board private- detoxification MN 0 MN Room and Board- ward psychiatric MN 0 MN Room and Board- detoxification ward MN 0 MN Room and Board- ward rehabilitation MN 0 MN leave of absence from residential NC 0 NC Therapeutic home time NC 0 NC Sub Acute Inpatient NC 0 NC Intensive Care -psychiatric MN 0 MN 0 PRO_08637E Internal Approved WellCare 2017 Page 1 of 23 NY7CADGDE08637E_0000

2 240 Intensive Care -psychiatric MN 0 MN Emergency Room NA 0 NA Emergency Room NA 0 NA Clinic encounter all inclusive NA 0 NA Psych clinic NA 0 NA Urgent Care Clinic NA 0 NA Other clinic- med supervised withdrawal NA 0 NA Freestanding clinic NA 0 NA Rural Clinic NA 0 NA Other freestanding clinic NA 0 NA HR hold MN 0 MN BH treatment services MN 0 MN ECT- electroshock treatment MN 0 MN 0 Intensive Outpatient - providers should be 905 instructed to use proper code with 915 MN 0 MN 0 Intensive Outpatient - providers should be 906 instructed to use proper code with 915 MN 0 MN BH treatment services MN 0 MN Substance abuse rehabilitation MN 0 MN 0 Psychiatric/Psychological Services- Individual 914 therapy MN 0 NA 0 Psychiatric/Psychological Services- Family 916 therapy MN 0 NA Biofeedback MN 0 MN Testing MN 0 MN Other BH treatment services MN 0 MN 0 Page 2 of 23

3 944 Drug Rehabilitation MN 0 NC Alcohol Rehabilitation MN 0 NC Behavioral Health Residential- psychiatric MN 0 MN Detox - Docimillary (DASA) NC 0 NC Interactive complexity add-on code NA 0 NA Psychiatric diagnostic evaluation (no medical Services) NA 0 NA Psychiatric diagnostic evaluation with medical services NA 0 NA Psychotherapy, 30 mins NA 0 NA min psychotherapy add on code when performed with E/M Service- (list separately) NA 0 NA Psychotherapy, 45 mins NA 0 NA minute psychotherapy add on code when performed with E/M Service (list separately) NA 0 NA Psychotherapy, 60 mins NA 0 NA 0 60 min psychotherapy when performed with E/M service (list separately NA 0 NA Psychotherapy for crisis, first 60 min. NA 0 NA 0 Page 3 of 23

4 90840 crisis code add on for each additional 30 min. NA 0 NA Psychoanalysis NA 0 NA Family Psychotherapy, without patient present NA 0 NA Family Psychotherapy, 45 min NA 0 NA Multiple-family group psychotherapy NA 0 NA Group psychotherapy NA 0 NA Pharmacologic management, add on code NA 0 NA Narcosynthesis NC 0 MN Therapeutic Repetitive Transcranial (TMS) NC 0 MN Therapeutic Repetitive Transcranial (TMS) NC 0 MN Therapeutic Repetitive Transcranial (TMS) NC 0 MN Electroconvulsive Therapy MN 0 MN Ind psycho therapy incorporating bio feedback 30 min NC 0 MN Ind psycho therapy incorporating bio feedback 45 min NC 0 MN Hypnotherapy NC 0 NC 0 Page 4 of 23

5 90882 Complex care management NA 0 NC Psych eval of hospital records NC 0 MN Interpretation or explan of results of psych exam and procedures Outpatient Collateral, 15 min. NA 0 MN Prep of report of pt psych status NC 0 NC Unlisted Psychiatric procedure MN 0 MN comp.comput.motion analysis MN 0 MN Functional brain mapping MN 0 MN Psychological testing MN 0 MN Psychological testing MN 0 MN Psychological testing MN 0 MN Assessment of Aphasia of speech/lang MN 0 MN Developmental screening with interp NA 0 NA Developmental testing MN 0 MN Neurobehavioral status exam w clin assess NA 0 NA Neuropsychological Testing per hour MN 0 MN Neuropsych Testing Admin by Technician per hour MN 0 MN Neuropsych Testing Admin by Computer per occurrence MN 0 MN Standardized cognitive perf testing MN 0 MN 0 Page 5 of 23

6 96127 Brief emotional needs assessment NA 0 NA Nursing Assessment and Care-Initial NA 0 NA Nursing Assessment and Care-Re-Assessment NA 0 NA H&B individual intervention NA 0 NA H&B group intervention NA 0 NA Health & Behavior Intervention w pt present NA 0 NA Health & Behavior Intervention w o pt present NA 0 NA Medication administration NA 0 NA Community integration counseling NC Covered by CareCore National NC Services rendered after hours NA 0 NA Office Emergency Services NA 0 NA New Patient Office Visit Level 1 NA 0 NA New Patient Office Visit Level 2 NA 0 NA 0 Page 6 of 23

7 99203 New Patient Office Visit Level 3 NA 0 NA New Patient Office Visit Level 4 NA 0 NA New Patient Office Visit Level 5 NA 0 NA Est Patient Office Visit Level 1 NA 0 NA Est Patient Office Visit Level 2 NA 0 NA Est Patient Office Visit Level 3 NA 0 NA Est Patient Office Visit Level 4 NA 0 NA Est Patient Office Visit Level 5 NA 0 NA Initial Hospital Care-comprehensive; low complexity NA 0 NA Initial Hospital Care-comprehensive; moderate complexity NA 0 NA Initial Hospital Care-comprehensive; high complexity NA 0 NA Subsequent observation Care NA 0 NA Subsequent observation Care NA 0 NA Subsequent observation Care NA 0 NA 0 Page 7 of 23

8 Subsequent Hospital Care-focused; low complexity NA 0 NA 0 Subsequent Hospital Care-focused; moderate complexity NA 0 NA 0 Subsequent Hospital Care-focused; high complexity NA 0 NA Observation-comprehensive; low complexity NA 0 NA 0 Observation-comprehensive; moderate complexity NA 0 NA Observation-comprehensive; high complexity NA 0 NA Discharge Day Management- 30 min or less NA 0 NA Discharge Day Management-more than 30 min NA 0 NA Mental health Risk Assessment NA 0 NA Problem focused; straightforward-15 min NA 0 NA Expanded; straightforward-30 min NA 0 NA Detailed; low complexity-40 min NA 0 NA Comprehensive; moderate complexity-60 min NA 0 NA Comprehensive; high complexity-80 min NA 0 NA Initial Consultation-focused, straightforward NA 0 NA Initial Consultation-expanded, straightforward NA 0 NA 0 Page 8 of 23

9 99253 Initial Consultation-detailed, low complexity NA 0 NA Initial Consultation-comprehensive, moderate complexity NA 0 NA Initial Consultation-comprehensive, high complexity NA 0 NA ER Consultation-focused, straightforward NA 0 NA ER Consultation-expanded; low complexity NA 0 NA ER Consultation-expanded; moderate complexity NA 0 NA ER Consultation-detailed; moderate complexity NA 0 NA ER Consultation-comprehensive; high complexity NA 0 NA Nursing facility consultation 25 min NA 0 NA Nursing facility consultation 35 min NA 0 NA Nursing facility consultation 45 min NA 0 NA Evaluation Management nursing facility 10 min NA 0 NA Evaluation Management nursing facility 15 min NA 0 NA Evaluation Management nursing facility 25 min NA 0 NA Evaluation Management nursing facility 35 min NA 0 NA Home visit, new patient MN 0 MN 0 Page 9 of 23

10 99342 Home visit, new patient MN 0 MN Home visit, new patient MN 0 MN Home visit, new patient MN 0 MN Home visit, new patient MN 0 MN Home visit, est patient MN 0 MN Home visit, est patient MN 0 MN Home visit, est patient MN 0 MN Home visit, est patient MN 0 MN 0 Prolonged evaluation and mgmt psycho therapy svs NA 0 NA 0 Prolonged evaluation and mgmt psycho therapy svs NA 0 NA Medical team conference NA 0 NA Medical team conference with family NA 0 NA Medical team conference without family NA 0 NA Preventive counseling, individual NA 0 NA Preventive counseling, individual 30 min NA 0 NA Preventive counseling, individual 45 min NA 0 NA Preventive counseling, individual NA 0 NA Smoking cessation NA 0 NA Smoking cessation NA 0 NA 0 Alcohol substance abuse BH change intervention NA 0 NA 0 Alcohol and substance abuse screening and brief intervention NA 0 NA Preventive counseling, individual 60 min NA 0 NA 0 Page 10 of 23

11 99412 Preventive medicine group counseling- 60 min NA 0 NA Health risk assessment interpretation NA 0 NA Home visit, single, family counseling MN 0 MN T Behavior Identification Assessment (ABA) NC 0 NC 0 Observational Behavioral Follow-up 0360T & 0361TAssessment NC 0 NC T, 0363T Exposure Behavioral Follow-up Assessment NC 0 NC T, 0365T Adaptive Behavior Treatment By Protocol NC 0 NC 0 Adaptive Behavior Treatment With Protocol 0368T & 0369TModification NC 0 NC T Family Adaptive Behavior Treatment Guidance NC 0 NC 0 907, H2012 Community behavioral program (day treatment) MN 0 NC or G0411 Partial Hospitalization MN 0 MN 0 915, H0015 BH intensive outpatient substance abuse MN 0 MN 0 915, S9480 BH intensive outpatient psychiatric MN 0 MN 0 G0176 Recreation, related to the care and treatment of patients disabling mental health problems; per session (45 minutes or more) MN 0 MN 0 Page 11 of 23

12 Training and educational services related to the care and treatment of patients disabling mental health problems per session (45 G0177 minutes or more) MN 0 MN 0 G0396 Alcohol/subs interv 15-30mn MN 0 MN 0 G0397 Alcohol/subs interv >30 min MN 0 MN 0 Social work and psychological services, directly relating to and/or furthering the patient s G0409 rehabilitation goals MN 0 MN 0 G0431 Qualitative drug screen NA 0 NA 0 G0436 Tobacco-use counsel 3-10 min NA 0 NA 0 G0437 Tobacco-use counsel>10min NA 0 NA 0 G0442 Annual alcohol misuse screening 15 min NA 0 NA 0 G0443 Alcohol mis use and screening -various markets; Iowa=face to face BH counseling-15 min NA 0 NA 0 G0444 Depression Screening NA 0 NA 0 G0445 High intensity BH counseling 30 min NA 0 NA 0 G0446 Intensive BH therapy NA 0 NA 0 G0447 face to face behavioral counseling-15 min NA 0 NA 0 G0449 annual face to face obesity screening NA 0 NA 0 G0450 screening for sexually transmitted disease NA 0 NA 0 G0451 Developmental testing with I & R NA 0 NA 0 G0463 Hospital outpatient clinic visit NA 0 NA 0 G0473 face to face behavioral counseling 15 min NC 0 NA 0 Page 12 of 23

13 Autism Program- Case oversight and management of treatment team by licensed MH professional or certified BCBA, 15 min. Autism Progam- Home care training to home G0912 care client, per 15 min NC 0 NC 0 H0001 Alcohol and/or drug assessment NA Use IOP MN Criteria NA Use IOP MN Criteria H0002 H0003 H0004 H0005 H0006 H0007 H0008 H0009 Behavioral Health Screen to determine eligibility for admission to treatment program NA Use MN Criteria for PROS admission NA 0 Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol or drugs NC 0 NA 0 behavioral health counseling and therapy; per 15 minutes NA 0 NC 0 Alcohol and/or drug services; group counseling by a clinician NA 0 NC 0 Alcohol and/or drug services; case management NC 0 NC 0 Alcohol and/or drug services; crisis intervention (outpatient) NA 0 NC 0 Alcohol and/or drug services; sub acute detoxification (outpatient) NC 0 NC 0 Alcohol and/or drug services; acute detoxification (hospital inpatient) NC 0 NC 0 Page 13 of 23

14 Alcohol and/or drug services; sub-acute detoxification (residential addiction program H0010 inpatient) MN 0 NC 0 Alcohol and/or drug services; acute detoxification (residential addiction program H0011 inpatient) NC 0 NC 0 Alcohol and/or drug services; sub-acute detoxification (residential addiction program H0012 outpatient) NC 0 NC 0 Alcohol and/or drug services; acute detoxification (residential addiction program H0013 outpatient) NC 0 NC 0 Alcohol and/or drug services; ambulatory H0014 detoxification NA 0 NC 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 H0015 therapies or education MN 0 MN 0 H0016 Alcohol and/or drug services; medical/somatic (medical intervention in ambulatory setting) NC 0 NC 0 Page 14 of 23

15 Behavioral health; residential (hospital residential treatment program), without room H0017 and board; per diem NC 0 NC 0 H0018 Behavioral health; short-term residential (non hospital residential treatment program), without room and board; per diem MN 0 NC 0 Behavioral health; long term residential (nonmedical, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board; H0019 per diem MN Service is carved out to FFS NC 0 Alcohol and/or drug services; methadone administration and/or service (provisions of H0020 the drug by a licensed program) NA 0 NC 0 H0021 Alcohol and Drug training service for staff NC 0 NC 0 H0022 Alcohol and/or drug intervention service (planned facilitation) NC 0 NC 0 H0023 H0024 Behavioral health outreach service (planned approach to reach a targeted population) NC 0 NC 0 Behavioral health prevention information dissemination service (one way direct or nondirect contact with service audiences to affect knowledge and attitude); 15 minutes NC 0 NC 0 Page 15 of 23

16 Behavioral health prevention education service (delivered of services with target population to affect knowledge, attitude and/or behavior); H minutes NC 0 NC 0 Alcohol and/or drug intervention service H0026 (planned facilitation) NC 0 NC 0 H0027 Alcohol and drug prevention service NC 0 NC 0 Alcohol and/or drug prevention problem H0028 identification and referral service NC 0 NC 0 Alcohol and/or drug prevention alternatives service (services for populations that exclude alcohol and other drug use e.g. alcohol free H0029 social events) NC 0 NC 0 H0030 Behavioral health hotline service NC 0 NC 0 H0031 Mental health assessment, by non-physician NA 0 NA 0 H0032 Mental health service plan development by non-physician NA 0 NA 0 H0033 Oral medication administration, direct observation NA 0 NA 0 H0034 Medication training and support; per 15 minutes NA 0 NA 0 H0035 Mental health partial hospitalization, treatment, less than 24 hours MN 0 MN 0 H0036 Community psychiatric supportive treatment, face to face NC 0 NC 0 Page 16 of 23

17 Community psychiatric supportive treatment Use MN Criteria for Interim H0037 program; per diem NA crisis visit NC 0 H0038 Self-help/peer services; per 15 minutes NA 0 NC 0 H0039 Assertive Community Treatment; per 15 min MN 0 NC 0 H0040 Assertive Community Treatment; per diem NC 0 NC 0 H0041 Foster Care child, non therapeutic per diem NC 0 NC 0 H0042 Foster Care child, non therapeutic per month NC 0 NC 0 H0043 Supported housing; per diem NC 0 NC 0 H0044 Supported housing; per month NC 0 NC 0 H0045 Respite care services, not in the home; per diem NC 0 NC 0 H0046 Mental Health Services NOS NC 0 NC 0 Alcohol and drug services not otherwise H0047 specified NC 0 NC 0 H0048 Alcohol and/or other drug testing: collection and handling only, specimens other than blood NC 0 NC 0 H0049 Alcohol and/or drug Screening NA 0 NC 0 H0050 Alcohol and/or Drug Service, Brief Intervention; per 15 minutes NA 0 NC 0 H1000 Prenatal care, at-risk assessment NA 0 NC 0 Page 17 of 23

18 Prenatal care, at-risk enhanced service; H1001 antepartum management NA 0 NC 0 Prenatal care, at risk enhanced service; care H1002 coordination NA 0 NC 0 Prenatal care, at-risk enhanced service; H1003 education NA 0 NC 0 Prenatal care, at-risk enhanced service; followup H1004 home visit NA 0 NC 0 Prenatal care, at-risk enhanced service package H1005 (includes H1001-H NA 0 NC 0 Non-medical family planning education; per H1010 session NC 0 NC 0 H1011 Family assessment by licensed behavioral health professional for state defined purposes NC 0 NC 0 H2000 Comprehensive multidisciplinary evaluation NA 0 NA 0 H2001 Rehab program 1/2 day NA 0 NC 0 H2010 Comprehensive medication services; per 15 minutes NA 0 NA 0 H2011 Crisis Intervention Services; per 15 Minutes NA 0 NA 0 H2012 Behavioral health day treatment; per hour MN 0 NC 0 H2013 In Nebraska Residential Psychiatric service hospital based; others hospital base, per diem; other markets psychiatric health facility service per diem MN 0 NC 0 Page 18 of 23

19 Skills training and development; per 15 H2014 minutes NC 0 NC 0 Comprehensive community support services; H2015 per 15 minutes NC 0 NC 0 Comprehensive community support services; H2016 per diem NC 0 NC 0 Psychosocial rehabilitation services; per 15 H2017 minutes NC 0 NC 0 Use MN Criteria for PROS Initial H2018 Psychosocial rehabilitation services; per diem MN Rehab NC 0 Therapeutic behavioral services; per 15 Use MN Criteria for PROS H2019 minutes MN Community Rehab NC 0 Therapeutic behavioral services; per diem In H2020 NE Therapuetic group home NC 0 NC 0 Community-based wrap-around services; per H min NC 0 NC 0 Community-based wrap-around services; per H2022 diem (intensive in-home services) NC 0 NC 0 H2023 Supported employment; per 15 minutes NC 0 NC 0 H2024 Supported employment; per diem NC 0 NC 0 Ongoing support to maintain employment; per Use MN Criteria for Ongoing H minutes MN Rehab NC 0 Ongoing support to maintain employment; per H2026 diem NC 0 NC 0 H2027 See Notes - per 15 minutes NC 0 NC 0 Page 19 of 23

20 Sexual offender treatment service, per 15 H2028 minutes NC 0 NC 0 H2029 Sex Offend Tx Svc, Per Diem NC 0 NC 0 H2030 Clubhouse services ; per 15 min NC 0 NC 0 H2031 Clubhouse services; per diem NC 0 NC 0 H2032 Activity Therapy NC 0 NC 0 H2033 Multi-systemic Therapy for Juveniles; per 15 minutes NC 0 NC 0 H2034 Alcohol and/or drug abuse halfway house services; per diem MN 0 NC 0 H2035 Alcohol and/or drug treatment program; per hour NC 0 NC 0 Alcohol and/or other drug treatment program; H2036 per diem MN Use IOP MN Criteria NC Use IOP MN Criteria Developmental delay prevention activities, H2037 dependent child of cli NC 0 NC 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 NA 0 NA 0 Q3014 Telehealth original site facility MN 0 NA 0 S0109 Methadone, oral, 5mg NA 0 NC 0 S0201 Alcohol and/or drug treatment program; per hour NC 0 NC 0 S5145 Behavioral health specialized foster care NC 0 NC 0 S9110 In home telemonitoring NC 0 NC 0 Page 20 of 23

21 S9123 In home psychiatric nursing NC 0 NC 0 S9475 S9480 Ambulatory setting substance abuse treatment or detoxification services; per diem NC 0 NC 0 Intensive outpatient psychiatric services; per diem; in IL use 913 in combination with this code NA 0 MN 0 S9482 Family stabilization services; per 15 minutes NC 0 NC 0 S9484 Crisis intervention mental health services; per hour NA 0 NA 0 Use MN Criteria for Comp S9485 Crisis intervention mental health services; per diem NA Psych Emergency Program (CPEP) - 3 day Max NA 0 T1001 Nursing Assessment/ Evaluation NA 0 NA 0 T1002 RN services up to 15 minutes NA 0 NA 0 T1003 LPN/ LVN services up to 15 minutes NA 0 NA 0 T1005 Respite care services, up to 15 minutes NC 0 NC 0 T1006 Alcohol and/or substance abuse services, family/couple counseling NA 0 NC 0 T1007 Alcohol and/or substance abuse services, treatment plan development and/or modification NC 0 NC 0 T1012 Alcohol and/or substance abuse services, skills development NC 0 NC 0 Page 21 of 23

22 Sign language or oral interpretive services; per T minutes NA 0 NA 0 T1014 telehealth telemedicine MN 0 MN 0 T1015 Clinic encounter all inclusive MN Use MN Criteria for PROS clinical add on NA 0 T1016 Case management, each 15 minutes NC 0 NC 0 T1017 Targeted case management, each 15 minutes NC 0 NC 0 T1019 Personal care services; per 15 minutes NC 0 NC 0 T1020 Personal care services; per diem NC 0 NC 0 T1023 Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol; per encounter NA 0 NC 0 T1024 Team evaluation & management NC 0 NC 0 T1027 Family training & counseling NC 0 NC 0 T1502 Psychotropic Medication Administration NC 0 NC 0 T2001 Non emergency transportation; patient attendant/escort NC 0 NC 0 T2002 Non-emergency transportation; per diem NC 0 NC 0 T2003 Non-emergency transportation; encounter/trip NC 0 NC 0 Non-emergency transport; commercial carrier, T2004 multi-pass NC 0 NC 0 Page 22 of 23

23 T2005 Non-emergency transportation; stretch van NC 0 NC 0 Preadmission screening and resident review (pasrr) level i identification screening; per T2010 screen NC 0 NC 0 Preadmission screening and resident review T2011 level ii evaluation; per evaluation NC 0 NC 0 T2012 Children s Day Treatment NC 0 NC 0 T2014 Pre-vocational Services - per diem NC 0 NC 0 T2015 Pre-Vocational Services - per hour NC 0 NC 0 T2017 NY ONLY - community integration counseling MN 0 NC 0 T2018 Supported Employment Job Development NC 0 NC 0 T2019 Supported Employment NC 0 NC 0 T2020 Day Habiliitation NC 0 NC 0 T2021 Pre admission PASSR assessment NC 0 NC 0 T2022 Other specified case management service not elsewhere classified NC 0 NC 0 T2023 Targeted Case Management- per month NC 0 NC 0 T2024 Service Assessment Plan of Care Dev NC 0 NC 0 T2033 Psychiatric residential treatment facility- per diem NC 0 NC 0 T2048 Behavioral health; long-term care residential (non-acute care in a residential treatment program community based per diem NC 0 NC 0 Page 23 of 23