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1 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 Therapy Counseling H0004 Blank or HO 11,12,99 Off Limited to 8 units (2 hours) per day Group Therapy H0004 HQ or HO-HQ 11,12,99 Off Limited to 12 units (3 hours) per day Family Therapy H0004 HR or HO-HR 11,12,99 Off Limited to 12 units (3 hours) per day Mental Health Blank HN, HO, or Assessment H0031 TG 11,12,99 Off Limited to 8 units (2 hours) per day Psychological Evaluation H0031 Blank or HN 11,12,99 Off Limited to 8 units (2 hours) per day Treatment Plan Development, Review, and Modification H0032 Blank or HN 11,12,99 Off Limited to 8 units (2 hours) per day Monitoring H0034 Blank, SA, HQ, or HQ-SA 11,12,99 Off Limited to 4 units (1 hour) per day Assertive Community Treatment (ACT) H0039 Blank or HQ 11, 12, 99 Units based on medical necessity Monitoring H2010 Blank, 52, or SA 11, 12, 99 Off Limited to 2 units (30 minutes) per day Crisis Intervention H , 12, 99 Off Limited to 16 units (4 hours) per day
2 Auth Required Key: = Required for Medical Necessity review; Off= No Required; Auto-Approve = Provider calls Intake for auto-approval but no Crisis Intervention: State Ops H2011 HT or HK 03,04,12,13,14,31,32,33,49,50,71,7 2, or 99 Off Limited to 16 units (4 hours) per day Group (CSG) HM-HQ, HN-HQ, or HO-HQ 11, 12, 99 Individual (CSI) HM,HN, or HO 11, 12, 99 Residential (CSR) Individual HE-HM, HE-HN, or HE-HO 11 Reisential (CSR) Group HE-HM-HQ, HE-HN- HQ, or HE-HO-HQ 11
3 Auth Required Key: = Required for Medical Necessity review; Off= No Required; Auto-Approve = Provider calls Intake for auto-approval but no Team (CST) HT 11, 12, 99 Psychosocial Rehabilitation (PSR) Group H2017 HM-HQ, HN-HQ, or HO-HQ 11 Mental Health Intensive Outpatient S9480 HO or HO-HA 11,99 Limited to 1 per day Limited to 32 units (8 hours) per day Psychosocial Rehabilitation (PSR) Inidividual H2017 HM, HN, or HO 11 Limited to 32 units (8 hours) per day Telepsychiatry - Originating State Q ,12,99 Off Limited to 1 per day Oral Interpretation and Sign Language T , 12, 99 Off 0
4 Auth Required Key: = Required for Medical Necessity review; Off= No Required; Auto-Approve = Provider calls Intake for auto-approval but no Client Centered Consultation T1016 TG or HN-TG 11, 12, 99 Off Limited to 12 units (3 hours) per day Mental Health T1016 Blank or TF 11, 12, 99 Off Limited to 12 units (3 hours) per day Transition, Linkage & Aftercare T1016 HN or HO 11, 12, 99 Off Limited to 12 units (3 hours) per day Transition, Linkage & Aftercare (Nursing Facility) T1016 HN-HK or HO-HK 11, 12, 99 Off Limited to 12 units (3 hours) per day Crisis Intervention: Pre- Hospitalization Screening T1023 Blank or HT 11,12,99 Off Limited to 1 per day Administration T1502 Blank or SA 11,12,99 Off Limited to 3 events per day
5 Auth Required Key: = Required for Medical Necessity review; Off= No Required; Auto-Approve = Provider calls Intake for auto-approval but no This material is for educational purposes only and is not intended to dictate what codes should be used in submitting claims. Health care providers are instructed to use the most appropriate codes based upon the medical record documentation and coding guidelines. Please note that the fact that a guideline is available and/or a service has been preauthorized/pre-certified is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member s eligibility and the terms of the member s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member s ID card for assistance. PRO_14254E Internal Approved WellCare 2018 IL8PROLTR14254E_0000
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PROCEDURE CODES & UNIT CPT Valid and its modifiers, which is billable to SAMH or Medicaid 90801 HW B No Yes Psychiatric Evaluation (Evaluation and management) when funded by the state mental health authority
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
Community Behavioral Health Services. Fee Schedule
Assessment s Psychiatric evaluation by physician Psychiatric evaluation by physician Psychiatric evaluation by nonphysician Brief behavioral health status exam Brief behavioral health status exam Community
PROCEDURE CODES & UNIT
PROCEDURE CODES & UNIT CPT Procedure Valid Procedure and its modifiers, which is billable to SAMH or Medicaid Modifiers Programs 1 MEDICAID SAMH/DCF Long Description Recommended cost Comments 90801 HW
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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
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*
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
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
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DESCRIPTION REQUIREMENT RESPONSIBILITY AUTH PARAMETERS 90785 Interactive complexity add-on code MD,NP Psychiatric diagnostic evaluation (no medical 90791 Services) 90792 Psychiatric diagnostic evaluation
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
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