Florida Behavioral Health - Authorization Grid Series
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1 DESCRIPTION REQUIREMENT RESPONSIBILITY AUTH PARAMETERS Interactive complexity add-on code MD,NP Psychiatric diagnostic evaluation (no medical Services) Psychiatric diagnostic evaluation with medical MD,NP Psychotherapy, 30 mins 30 min psychotherapy add on code when performed with E/M Service- (list separately) MD,NP Psychotherapy, 45 mins 45 minute psychotherapy add on code when performed with E/M Service (list separately) MD,NP Psychotherapy, 60 mins 60 min psychotherapy when performed with E/M service (list separately MD,NP Psychotherapy for crisis, first 60 min. PRO_19700E Internal Approved WellCare 2018 Page 1 of 7 FL8CADLTR19700E_0000
2 DESCRIPTION crisis code add on for each additional 30 min Psychoanalysis Family Psychotherapy, without patient present PHD, Family Psychotherapy, 45 min PHD, Multiple-family group psychotherapy PHD, Group psychotherapy PHD, Pharmacologic management, add on code MD,NP Narcosynthesis Therapeutic Repetitive Transcranial (TMS) Therapeutic Repetitive Transcranial (TMS) Therapeutic Repetitive Transcranial (TMS) Electroconvulsive Therapy REQUIREMENT RESPONSIBILITY AUTH PARAMETERS Page 2 of 7
3 DESCRIPTION REQUIREMENT RESPONSIBILITY AUTH PARAMETERS Ind psycho therapy incorporating bio feedback Ind psycho therapy incorporating bio feedback Hypnotherapy Complex care management Psych eval of hospital records Interpretation or explan of results of psych exam and procedures Outpatient Collateral, 15 min Prep of report of pt psych status Unlisted Psychiatric procedure comp.comput.motion analysis Functional brain mapping Psychological testing PHD Psychological testing PHD benefit limit of 10 hours of testing/member/fiscal year benefit limit of 10 hours of testing/member/fiscal year benefit limit of 10 hours of Psychological testing PHD testing/member/fiscal year Assessment of Aphasia of speech/lang Benefit Limit 10 Page 3 of 7
4 DESCRIPTION REQUIREMENT RESPONSIBILITY AUTH PARAMETERS Developmental screening with interp Developmental testing Benefit Limit Neurobehavioral status exam w clin assess Neuropsychological Testing per hour Neuropsych Testing Admin by Technician per hour Neuropsych Testing Admin by Computer per occurrence Standardized cognitive perf testing Brief emotional needs assessment Page 4 of 7
5 DESCRIPTION REQUIREMENT RESPONSIBILITY AUTH PARAMETERS Nursing Assessment and Care-Initial Nursing Assessment and Care-Re-Assessment H&B individual intervention H&B group intervention Health & Behavior Intervention with patient present Health & Behavior Intervention without patient Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument Medication administration Community integration counseling Services rendered after hours ice Emergency Services New Patient ice Visit Level 1 MD,NP New Patient ice Visit Level 2 MD,NP New Patient ice Visit Level 3 MD,NP New Patient ice Visit Level 4 MD,NP New Patient ice Visit Level 5 MD,NP Est Patient ice Visit Level 1 MD,NP Est Patient ice Visit Level 2 MD,NP Page 5 of 7
6 DESCRIPTION REQUIREMENT RESPONSIBILITY AUTH PARAMETERS Est Patient ice Visit Level 3 MD,NP Est Patient ice Visit Level 4 MD,NP Est Patient ice Visit Level 5 MD,NP Initial Hospital Care-comprehensive; low complexity MD,NP Initial Hospital Care-comprehensive; moderate complexityp p ; g MD,NP complexity MD,NP Subsequent observation Care Subsequent observation Care Subsequent observation Care Subsequent Hospital Care-focused; low complexity MD,NP Subsequent Hospital Care-focused; moderate complexity MD,NP Subsequent Hospital Care-focused; high complexity MD,NP Observation-comprehensive; low complexity MD,NP Observation-comprehensive; moderate complexity MD,NP Observation-comprehensive; high complexity MD,NP Discharge Day Management- 30 min or less MD,NP Discharge Day Management-more than 30 min MD,NP Problem focused; straightforward-15 min Expanded; straightforward-30 min Detailed; low complexity-40 min Comprehensive; moderate complexity-60 min Comprehensive; high complexity-80 min Page 6 of 7
7 DESCRIPTION REQUIREMENT RESPONSIBILITY AUTH PARAMETERS Initial Consultation-focused, straightforward MD,NP Initial Consultation-expanded, straightforward MD,NP Initial Consultation-detailed, low complexity MD,NP Initial Consultation-comprehensive, moderate complexity MD,NP Initial Consultation-comprehensive, high complexity MD,NP ER Consultation-focused, straightforward MD,NP ER Consultation-expanded; low complexity MD,NP ER Consultation-expanded; moderate complexity MD,NP ER Consultation-detailed; moderate complexity MD,NP ER Consultation-comprehensive; high complexity MD,NP Page 7 of 7
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
CMHC AUTHORIZATION REQUIREMENT. Non-CMHC Notes (0 = No SERVICE DESCRIPTION
Non- Notes (0 = No Non- Notes (0 = No 100 All inclusive room and board On 0 On 0 101 All inclusive room and board On 0 On 0 104 Anesthesia, ECT On 0 On 0 114 Room and Board- private psychiatric On 0 On
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
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
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
Nebraska Behavioral Health Authorization List If the procedure code is not listed here, it is not a covered benefit
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New York Medicaid BEHAVIORAL HEALTH PRIOR AUTHORIZATION GRID AUTHORIZATION IS NOT A GUARANTEE OF PAYMENT
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SERVICES HP Service Class HP Payable Service Husky A Husky B Charter Oak Husky C & Husky D CPT/SVC/REV SVC MODIFIER DESCRIPTIO Auth Req'd? Re-Auth? IPATIET PROFESSIOAL SERVICES Inpatient E & M Services
All Children s Health Insurance Program and Mental Health Providers. Subject: Coverage of Mental Health Codes for Children s Health Insurance Program
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MAGELLAN VA MEDICAID/DMAS RATES
DESCRIPTION CODE Age or Setting Modifier PHYSICIAN PSYCHOLOGIST LEVEL SPECIALIST Psychiatric Diagnostic Evaluation no medical svcs* 90791 IP w/ or w/o GT $104.18 $93.76 $70.32 $70.32 Psychiatric Diagnostic
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MAGELLAN VA MEDICAID/DMAS RATES
Psychiatric Diagnostic Evaluation no medical svcs* Psychiatric Diagnostic Evaluation no medical svcs* Psychotherapy w/ patient, 30 min* Psychotherapy w/ patient, 30 min* Psychotherapy w/ patient, 45 min*
PLACE OF SERVICE (POS)
Auth Required Key: = Required for Medical Necessity review; Off= No Required; Auto-Approve = Provider calls Intake for auto-approval but no LOCUS Assessment H0002 HE 11, 12, 99 Off Limited to 1/day Individual
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CPT//REV INPATIENT HOSPITAL Psychiatric Hospital or General Hospital Psychiatric Unit CIPFY Y Y Y Y 0114, 0124, 0134, 0144, 0154, 0204, 0190, 0224 In hospitalization Bypass: R Non-Bypass: A R HUSKY A &
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