New York Medicaid BEHAVIORAL HEALTH PRIOR AUTHORIZATION GRID AUTHORIZATION IS NOT A GUARANTEE OF PAYMENT

Transcription

1 NEW YORK MEDICAID HIGHER LEVEL OF CARE - BH PRIOR AUTH GRID New York Medicaid BEHAVIORAL HEALTH PRIOR AUTHORIZATION GRID AUTHORIZATION IS NOT A GUARANTEE OF PAYMENT REV CODE LEVEL OF CARE AUTHORIZATION REQUIRED 104 ANESTH, ELECTROSHOCK YES 114 ROOM AND BOARD - PRIVATE -PSYCHIATRIC YES 116 ROOM AND BOARD - PRIVATE -DETOXIFICATION YES 124 ROOM AND BOARD - SEMI PRIVATE TWO BED -PSYCHIATRIC YES 126 ROOM AND BOARD - SEMI PRIVATE TWO BED -DETOXIFICATION YES 128 ROOM AND BOARD - SEMI PRIVATE TWO BED -REHABILITATION YES 136 DETOX/3&4 BED YES 156 DETOX/WARD YES 240 ALL INCL ANCIL YES 510 CLINIC NO 513 PSYCH CLINIC NO 521 RURAL/CLINIC NO 529 OTHER FR/STD CLINIC NO 900 PSTAY TREATMENT YES 901 ELECTROSHOCK TREATMENT YES 905 BH INTENSIVE OUTPATIENT PSYCH YES 906 BH INTENSIVE OUTPATIENT CHEM DEP YES 910 PSTAY S YES

2 NEW YORK MEDICAID BEHAVIORAL HEALTH PRIOR AUTHORIZATION GRID authorization is not a guarantee of payment NOTE : For outpatient services that have yes "auth required" we will enter an authorization for the initial set of services upon submission of a registration form and without the need for MN review, all services requested beyond the initial form submission will require NEW YORK MN (medical necessity) clinical review Psychotherapy, 30 mins MD,NP,PHD, Other YES Up to 20 units of any combination of the following codes: 90887, 90853,90849,90847,90846,90832, 90834,90837,90838 of the MN benefit maximum will be approved without speaking to a clinician- MN review and prior authorization services is required beyond the 20 units. TO OBTAIN INITIAL SET OF UNITS FAX / INTERNET MEMBER REGISTRATION FORM Psychotherapy, 30 mins Interactive complexity add-on code MD,NP,PHD, Other YES Psychotherapy, 45 mins MD,NP,PHD, Other YES Psychotherapy, 45 mins Interactive complexity add-on code MD,NP,PHD, Other YES Psychotherapy, 60 mins MD,NP,PHD, Other YES Psychotherapy, 60 mins Interactive complexity add-on code MD,NP,PHD, Other YES min psychotherapy add-on code MD,NP,PHD, Other YES Family Psychotherapy, without patient present PHD, Other YES Family Psychotherapy, 45 min PHD, Other YES Multiple-family group psychotherapy PHD, Other YES Group psychotherapy Interactive complexity add-on code PHD, Other YES Group psychotherapy PHD, Other YES Outpatient Collateral, 15 min. MD,NP,PHD, Other YES

3 90870 Electroconvulsive Therapy MD,NP, YES Prior Authorization Required FAX, INTERNET PRIOR AUTH Psychological testing PHD YES Prior Authorization Required TESTING REQUEST Psychological testing PHD YES Prior Authorization Required Psychological testing PHD YES Prior Authorization Required NEUROPSYCH TST BY PSYCH/PHYS PHD, Other YES Prior Authorization Required Psychiatric diagnostic evaluation (no medical Services) MD,NP,PHD, Other NO Psychiatric diagnostic evaluation (no medical Services) Interactive complexity add-on code MD,NP,PHD, Other NO Psychiatric diagnostic evaluation with medical services MD,NP NO Psychiatric diagnostic evaluation with medical services Interactive complexity add-on Psychotherapy, 30 mins Pharmacologic management, add on Psychotherapy, 45 mins Pharmacologic management, add on Psychotherapy, 60 mins Pharmacologic management, add on TESTING REQUEST TESTING REQUEST TESTING REQUEST Psychotherapy for crisis, first 60 min. MD,NP,PHD, Other NO crisis code add on for each additional 30 min. MD,NP,PHD, Other NO New Patient Office Visit Level 1 30 min psychotherapy add-on New Patient Office Visit Level 1 45 min psychotherapy add-on New Patient Office Visit Level 1 60 min psychotherapy add-on New Patient Office Visit Level 1 30 min psychotherapy add-on code New Patient Office Visit Level 1 45 min psychotherapy add-on code New Patient Office Visit Level 1 60 min psychotherapy add-on code New Patient Office Visit Level 2 30 min psychotherapy add-on New Patient Office Visit Level 2 45 min psychotherapy add-on New Patient Office Visit Level 2 60 min psychotherapy add-on New Patient Office Visit Level 2 30 min psychotherapy add-on code New Patient Office Visit Level 2 45 min psychotherapy add-on code New Patient Office Visit Level 2 60 min psychotherapy add-on code New Patient Office Visit Level 3 30 min psychotherapy add-on New Patient Office Visit Level 3 45 min psychotherapy add-on New Patient Office Visit Level 3 60 min psychotherapy add-on New Patient Office Visit Level 3 30 min psychotherapy add-on code New Patient Office Visit Level 3 45 min psychotherapy add-on code New Patient Office Visit Level 3 60 min psychotherapy add-on code New Patient Office Visit Level 4 30 min psychotherapy add-on New Patient Office Visit Level 4 45 min psychotherapy add-on New Patient Office Visit Level 4 60 min psychotherapy add-on New Patient Office Visit Level 4 30 min psychotherapy add-on code New Patient Office Visit Level 4 45 min psychotherapy add-on code

4 New Patient Office Visit Level 4 60 min psychotherapy add-on code New Patient Office Visit Level 5 30 min psychotherapy add-on New Patient Office Visit Level 5 45 min psychotherapy add-on New Patient Office Visit Level 5 60 min psychotherapy add-on New Patient Office Visit Level 5 30 min psychotherapy add-on code New Patient Office Visit Level 5 45 min psychotherapy add-on code New Patient Office Visit Level 5 60 min psychotherapy add-on code Est Patient Office Visit Level 1 30 min psychotherapy add-on Est Patient Office Visit Level 1 30 min psychotherapy add-on code Est Patient Office Visit Level 1 45 min psychotherapy add-on code Est Patient Office Visit Level 1 60 min psychotherapy add-on code Est Patient Office Visit Level 2 30 min psychotherapy add-on Est Patient Office Visit Level 2 45 min psychotherapy add-on Est Patient Office Visit Level 2 60 min psychotherapy add-on Est Patient Office Visit Level 2 30 min psychotherapy add-on code Est Patient Office Visit Level 2 45 min psychotherapy add-on code Est Patient Office Visit Level 2 60 min psychotherapy add-on code Est Patient Office Visit Level 3 30 min psychotherapy add-on Est Patient Office Visit Level 3 45 min psychotherapy add-on Est Patient Office Visit Level 3 60 min psychotherapy add-on Est Patient Office Visit Level 3 30 min psychotherapy add-on code Est Patient Office Visit Level 3 45 min psychotherapy add-on code Est Patient Office Visit Level 3 60 min psychotherapy add-on code Est Patient Office Visit Level 4 30 min psychotherapy add-on Est Patient Office Visit Level 4 45 min psychotherapy add-on Est Patient Office Visit Level 4 60 min psychotherapy add-on Est Patient Office Visit Level 4 30 min psychotherapy add-on code Est Patient Office Visit Level 4 45 min psychotherapy add-on code Est Patient Office Visit Level 4 60 min psychotherapy add-on code Est Patient Office Visit Level 5 30 min psychotherapy add-on Est Patient Office Visit Level 5 45 min psychotherapy add-on Est Patient Office Visit Level 5 60 min psychotherapy add-on Est Patient Office Visit Level 5 30 min psychotherapy add-on code Est Patient Office Visit Level 5 45 min psychotherapy add-on code Est Patient Office Visit Level 5 60 min psychotherapy add-on code Est Patient Office Visit Level 5 30 min psychotherapy add-on code Est Patient Office Visit Level 5 45 min psychotherapy add-on code Est Patient Office Visit Level 5 60 min psychotherapy add-on code Est Patient Office Visit Level 5 30 min psychotherapy add-on code Est Patient Office Visit Level 5 45 min psychotherapy add-on code Est Patient Office Visit Level 5 60 min psychotherapy add-on code

5 99221 Initial Hospital Carecomprehensive; low Initial Hospital Carecomprehensive; moderate Initial Hospital Carecomprehensive; high Subsequent Hospital Care-focused; low Subsequent Hospital Care-focused; moderate Subsequent Hospital Care-focused; high Observation-comprehensive; low Observation-comprehensive; moderate Observation-comprehensive; high Discharge Day Management- 30 min or less MD, NP NO Discharge Day Management-more than 30 min MD, NP NO Initial Consultation-focused, straightforward MD, NP NO Initial Consultation-expanded, straightforward MD, NP NO Initial Consultation-detailed, low Initial Consultation-comprehensive, moderate complexity MD,NP NO Initial Consultation-comprehensive, high complexity MD,NP NO ER Consultation-focused, straightforward MD,NP NO ER Consultation-expanded; low complexity MD,NP NO ER Consultation-expanded; moderate complexity MD,NP NO ER Consultation-detailed; moderate complexity ER Consultation-comprehensive; MD,NP NO high complexity MD,NP NO

6 NEW YORK BEHAVIORAL HEALTH PRIOR AUTHORIZATION GRID AUTHORIZATION IS NOT A GUARANTEE OF PAYMENT APG PROC CODE DESCRIPTION 2012 CPT Codes 2013 CPT Codes AUTHORIZATION REQUIRED REGISTRATION ALLOWED AUTHORIZATION PARAMETERS INSTRUCTIONS 324 Alcohol and/or Drug, brief intervention, per 15 mins H0050 YES YES 315 Psychotherapy - Indiv 30 mins YES YES 316 Psychotherapy - Indiv 45 mins YES YES 317 Psychotherapy - Family 30 mins YES YES 317 Psychotherapy - Family&Client 1 hr YES YES 318 Psychotherapy - Family Group 1hr YES YES 318 Psychotherapy - Group 1 hr YES YES 318 School Based - Group <1 hr YES YES 490 Complex Care Management - 15 mins YES YES 321 Crisis Intervention - 15 min H2011 YES--AFTER 3 DAYS NO Prior auth after 3 days 321 Crisis Intervention - per hour S9484 YES--AFTER 3 DAYS NO Prior auth after 3 days 312 Crisis Intervention - per diem S9485 YES--AFTER 3 DAYS NO Prior auth after 3 days 310 Developmental Testing - limited YES NO PRIOR AUTHORIZATION REQUIRED 310 Developmental Testing - extended YES NO PRIOR AUTHORIZATION REQUIRED 310 Psychological Testing - Various YES NO PRIOR AUTHORIZATION REQUIRED 310 Psychological Testing - Neurobehavioral YES NO PRIOR AUTHORIZATION REQUIRED 310 Psychological Testing - Various YES NO PRIOR AUTHORIZATION REQUIRED 323 Initial Assessment Diagnostic & Treatment Plan NO NO Initial Assessment Diagnostic & Treatment Plan with 323 Medical Services NO NO Code Psychiatric Assessment - 30 mins Range NO NO 315 Psychiatric Assessment - 30 mins - ADD ON NO NO Code Psychiatric Assessment mins Range NO NO 316 Psychiatric Assessment mins - ADD ON NO NO Up to 36 units of any combination of the following codes: 324,315,316,317,318,490 of the MN benefit TO OBTAIN INITIAL SET maximum will be approved without speaking to a OF UNITS FAX / clinician- MN review and prior authorization INTERNET MEMBER services is required beyond the 36 units. REGISTRATION FORM FAX OR SUBMIT FORMS ELECTRONICALLY FAX OR SUBMIT FORMS ELECTRONICALLY FAX OR SUBMIT FORMS ELECTRONICALLY

7 Psychiatric Consultation Code Range NO NO 490 Injectable Med Admin with Monit & Edu H2010 NO NO Injection Only NO NO Code Psychotropic Medication Treatment Range NO NO Health Physicals - New/Estab Patient Code Range NO NO 490 Health Monitoring - 15 mins NO NO 490 Health Monitoring - 30 mins NO NO 490 Health Monitoring - 45 mins NO NO 490 Health Monitoring - 60 mins NO NO 490 Health Monitoring Group - 30 mins NO NO 490 Health Monitoring Group - 60 mins NO NO 451 Smoking Cessation Treatment mins; requires Dx code NO NO 451 Smoking Cessation Treatment - >10 mins; requires Dx code NO NO 451 Smoking Cessation Treatment (Group) - >10 mins; requires HQ Dx code (req HQ modifier) NO NO 324 Alcohol and/or Drug Screening H0049 NO NO APGS for Psych Assessments, Consultations & Health Physicals are dependent on diagnostic categories as 820 Schizophrenia 821 Major Depressive Disorders & Other Psychoses 822 Disorders of Personality & Impulse Control 823 Bipolar Disorders 824 Depression Except Major Depressive Disorder 825 Adjustment Disorders & Neuroses 826 Acute Anxiety & Delirium States 827 Organic Mental Health Disturbances 829 Childhood Behavioral Disorders 830 Eating Disorders 831 Other Mental Health Disorders