PA Lookup
If you have questions about prior authorizations, please call:
Member and Recipient Service Line: 1-877-685-2415
Provider Support Service Line: 1-855-250-1539
Clinical Assessment
A Comprehensive Clinical Assessment (CCA) is an intensive clinical and functional evaluation of an individual’s presenting mental health, developmental disability, and substance use disorder. This assessment results in the issuance of a written report that provides the clinical basis for the development of the individual’s treatment or service plan.
Authorization Guidelines
Prior authorization is not required. No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.
Unit Value
One service code = 1 unit of service.
Limits
No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.
Exclusions
- 1. A CCA is not required for medical providers billing E/M codes for medication management.
- 2. Funding will not cover Outpatient Behavioral Health Services when the service duplicates another service approved with another provider.
- 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
- 4. A Psychiatric Diagnostic Interview is not allowed on the same day as Psychological Testing when provided by the same provider.
- 5. A CCA that demonstrates medical necessity must be completed by a licensed professional prior to provision of outpatient therapy services.
- 6. The provider will communicate and coordinate care with other professionals providing care to the recipient.
- 7. The CCA must contain all 9 elements detailed in the service definition. In primary or specialty medical care settings with integrated medical and BH services, an abbreviated assessment is acceptable for the first 6 outpatient therapy sessions.
Level of Care
ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
Other Information
Modifier(s):
GT: Telehealth
How to Submit
N/A - No authorization is required
Resources
Clinical Assessment
Clinical Assessment services are intended to determine a member’s treatment needs. In general, outpatient behavioral health services focus on reducing psychiatric and behavioral symptoms in order to improve the member’s functioning in familial, social, educational, or occupational life domains
Authorization Guidelines
Maintained in the Record (not all inclusive):
- 1. CCA: Required
- 2. Tx/ Service Plan: Required. Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SU services.
- 3. Service Order: Required
- 4. Submission of applicable records that support the member has met the medical necessity criteria.
All services are subject to post-payment review.
Unit Value
One service code = 1 unit of service
Limits
- 1. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
- 2. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
- 3. A CCA that demonstrates medical necessity must be completed by a licensed professional prior to provision of outpatient therapy services.
- 4. For services that require a PCP, a CCA must be completed prior to service delivery.
- 5. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
- 6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for
Level of Care
ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services
How to Submit
N/A - No authorization is required
Resources
Psychological Services Provided by Health Departments and School-Based Health Centers to the Under 21 Population
Psychological services for children and adolescents are goal-directed interventions designed to enable children, adolescents, and their families to cope more effectively with complex problems. Services may include comprehensive psychosocial assessments and treatment planning, goal-directed psychotherapy (individual, group, or family), and referral to other mental health resources as needed. These services involve the identification of and intervention with children and adolescents who may be at risk for developing more serious emotional or behavioral problems as well as those who are already experiencing these problems.
Authorization Guidelines
Outpatient behavioral health services must be provided in accordance with the requirements and procedures documented in Clinical Coverage Policy 8C: Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers and the applicable Trillium Benefit Plan.
Note: No medical referral is needed to access this service.
Unit Value
The appropriate procedure code(s) determines the billing unit(s).
Limits
The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.
Level of Care
Outpatient behavioral health services must be provided in accordance with the requirements and procedures documented in Clinical Coverage Policy 8C: Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers and the applicable Trillium Benefit Plan.
How to Submit
N/A - No authorization is required
Resources
Psychiatric diagnostic evaluation
How to Submit
N/A - No authorization is required
Resources
Clinical Assessment
A Comprehensive Clinical Assessment (CCA) is an intensive clinical and functional evaluation of an individual’s presenting mental health, developmental disability, and substance use disorder. This assessment results in the issuance of a written report that provides the clinical basis for the development of the individual’s treatment or service plan.
Authorization Guidelines
Prior authorization is not required. No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.
Unit Value
One service code = 1 unit of service.
Limits
No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.
Exclusions
- 1. A CCA is not required for medical providers billing E/M codes for medication management.
- 2. Funding will not cover Outpatient Behavioral Health Services when the service duplicates another service approved with another provider.
- 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
- 4. A Psychiatric Diagnostic Interview is not allowed on the same day as Psychological Testing when provided by the same provider.
- 5. A CCA that demonstrates medical necessity must be completed by a licensed professional prior to provision of outpatient therapy services.
- 6. The provider will communicate and coordinate care with other professionals providing care to the recipient.
- 7. The CCA must contain all 9 elements detailed in the service definition. In primary or specialty medical care settings with integrated medical and BH services, an abbreviated assessment is acceptable for the first 6 outpatient therapy sessions.
Level of Care
ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
Other Information
Modifier(s):
GT: Telehealth
How to Submit
N/A - No authorization is required
Resources
Clinical Assessment
Clinical Assessment services are intended to determine a member’s treatment needs. In general, outpatient behavioral health services focus on reducing psychiatric and behavioral symptoms in order to improve the member’s functioning in familial, social, educational, or occupational life domains
Authorization Guidelines
Maintained in the Record (not all inclusive):
- 1. CCA: Required
- 2. Tx/ Service Plan: Required. Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SU services.
- 3. Service Order: Required
- 4. Submission of applicable records that support the member has met the medical necessity criteria.
All services are subject to post-payment review.
Unit Value
One service code = 1 unit of service
Limits
- 1. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
- 2. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
- 3. A CCA that demonstrates medical necessity must be completed by a licensed professional prior to provision of outpatient therapy services.
- 4. For services that require a PCP, a CCA must be completed prior to service delivery.
- 5. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
- 6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for
Level of Care
ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services
How to Submit
N/A - No authorization is required
Resources
Individual Therapy
Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains. The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.
Authorization Guidelines
Prior authorization is not required. No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.
Unit Value
One service code = 1 unit of service.
Limits
- 1. Maximum benefit of 12 visits for adults & 24 visits for children/ adolescents.
- 2. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
- 3. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 4. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
- 5. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
- 6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
- 7. The provider will communicate and coordinate care with other professionals providing care to the recipient.
- 8. Provider must verify individual’s eligibility each time a service is rendered
- 9. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
- 10. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
Length of Stay
No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.
Level of Care
ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
Other Information
Modifiers:
GT: Telehealth KX: Telephonic
Telephonic Services (KX) are reserved for when physical or BH status or access issues (transportation, telehealth technology) prevent the recipient from participating in-person or telehealth services.
How to Submit
N/A - No authorization is required
Resources
Individual Therapy
Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains. The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.
Authorization Guidelines
Maintained in the Record (not all inclusive):
- 1. CCA: Required
- 2. Tx/ Service Plan: Required. Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
- 3. Service Order: Required
- 4. Submission of applicable records that support the member has met the medical necessity criteria.
All services are subject to post-payment review.
Unit Value
One service code = 1 unit of service.
Limits
- 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
- 3. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
- 4. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
- 5. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
- 6. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
Level of Care
ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services
Additional Service Specifics
Telephonic Services (KX) are reserved for when physical or BH status or access issues (transportation, telehealth technology) prevent the member from participating in-person or telehealth services.
How to Submit
N/A - No authorization is required
Resources
Psychological Services Provided by Health Departments and School-Based Health Centers to the Under 21 Population
Psychological services for children and adolescents are goal-directed interventions designed to enable children, adolescents, and their families to cope more effectively with complex problems. Services may include comprehensive psychosocial assessments and treatment planning, goal-directed psychotherapy (individual, group, or family), and referral to other mental health resources as needed. These services involve the identification of and intervention with children and adolescents who may be at risk for developing more serious emotional or behavioral problems as well as those who are already experiencing these problems.
Authorization Guidelines
Outpatient behavioral health services must be provided in accordance with the requirements and procedures documented in Clinical Coverage Policy 8C: Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers and the applicable Trillium Benefit Plan.
Note: No medical referral is needed to access this service.
Unit Value
The appropriate procedure code(s) determines the billing unit(s).
Limits
The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.
Level of Care
Outpatient behavioral health services must be provided in accordance with the requirements and procedures documented in Clinical Coverage Policy 8C: Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers and the applicable Trillium Benefit Plan.
How to Submit
N/A - No authorization is required
Resources
Clinical Coverage Policy 10C
How to Submit
N/A - No authorization is required
Resources
Individual Therapy
Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains. The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.
Authorization Guidelines
Prior authorization is not required. No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.
Unit Value
One service code = 1 unit of service.
Limits
- 1. Maximum benefit of 12 visits for adults & 24 visits for children/ adolescents.
- 2. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
- 3. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 4. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
- 5. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
- 6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
- 7. The provider will communicate and coordinate care with other professionals providing care to the recipient.
- 8. Provider must verify individual’s eligibility each time a service is rendered
- 9. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
- 10. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
Length of Stay
No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.
Level of Care
ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
Other Information
Modifiers:
GT: Telehealth KX: Telephonic
Telephonic Services (KX) are reserved for when physical or BH status or access issues (transportation, telehealth technology) prevent the recipient from participating in-person or telehealth services.
How to Submit
N/A - No authorization is required
Resources
Individual Therapy
Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains. The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.
Authorization Guidelines
Maintained in the Record (not all inclusive):
- 1. CCA: Required
- 2. Tx/ Service Plan: Required. Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
- 3. Service Order: Required
- 4. Submission of applicable records that support the member has met the medical necessity criteria.
All services are subject to post-payment review.
Unit Value
One service code = 1 unit of service.
Limits
- 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
- 3. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
- 4. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
- 5. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
- 6. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
Level of Care
ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services
Additional Service Specifics
Telephonic Services (KX) are reserved for when physical or BH status or access issues (transportation, telehealth technology) prevent the member from participating in-person or telehealth services.
How to Submit
N/A - No authorization is required
Resources
Individual Therapy
Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains. The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.
Authorization Guidelines
Prior authorization is not required. No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.
Unit Value
One service code = 1 unit of service.
Limits
- 1. Maximum benefit of 12 visits for adults & 24 visits for children/ adolescents.
- 2. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
- 3. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 4. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
- 5. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
- 6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
- 7. The provider will communicate and coordinate care with other professionals providing care to the recipient.
- 8. Provider must verify individual’s eligibility each time a service is rendered
- 9. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
- 10. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
Length of Stay
No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.
Level of Care
ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
Other Information
Modifiers:
GT: Telehealth KX: Telephonic
Telephonic Services (KX) are reserved for when physical or BH status or access issues (transportation, telehealth technology) prevent the recipient from participating in-person or telehealth services.
How to Submit
N/A - No authorization is required
Resources
Individual Therapy
Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains. The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.
Authorization Guidelines
Maintained in the Record (not all inclusive):
- 1. CCA: Required
- 2. Tx/ Service Plan: Required. Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
- 3. Service Order: Required
- 4. Submission of applicable records that support the member has met the medical necessity criteria.
All services are subject to post-payment review.
Unit Value
One service code = 1 unit of service.
Limits
- 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
- 3. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
- 4. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
- 5. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
- 6. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
Level of Care
ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services
Additional Service Specifics
Telephonic Services (KX) are reserved for when physical or BH status or access issues (transportation, telehealth technology) prevent the member from participating in-person or telehealth services.
How to Submit
N/A - No authorization is required
Resources
Psychological Services Provided by Health Departments and School-Based Health Centers to the Under 21 Population
Psychological services for children and adolescents are goal-directed interventions designed to enable children, adolescents, and their families to cope more effectively with complex problems. Services may include comprehensive psychosocial assessments and treatment planning, goal-directed psychotherapy (individual, group, or family), and referral to other mental health resources as needed. These services involve the identification of and intervention with children and adolescents who may be at risk for developing more serious emotional or behavioral problems as well as those who are already experiencing these problems.
Authorization Guidelines
Outpatient behavioral health services must be provided in accordance with the requirements and procedures documented in Clinical Coverage Policy 8C: Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers and the applicable Trillium Benefit Plan.
Note: No medical referral is needed to access this service.
Unit Value
The appropriate procedure code(s) determines the billing unit(s).
Limits
The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.
Level of Care
Outpatient behavioral health services must be provided in accordance with the requirements and procedures documented in Clinical Coverage Policy 8C: Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers and the applicable Trillium Benefit Plan.
How to Submit
N/A - No authorization is required
Resources
Clinical Coverage Policy 10C
How to Submit
N/A - No authorization is required
Resources
Individual Therapy
Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains. The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.
Authorization Guidelines
Prior authorization is not required. No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.
Unit Value
One service code = 1 unit of service.
Limits
- 1. Maximum benefit of 12 visits for adults & 24 visits for children/ adolescents.
- 2. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
- 3. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 4. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
- 5. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
- 6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
- 7. The provider will communicate and coordinate care with other professionals providing care to the recipient.
- 8. Provider must verify individual’s eligibility each time a service is rendered
- 9. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
- 10. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
Length of Stay
No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.
Level of Care
ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
Other Information
Modifiers:
GT: Telehealth KX: Telephonic
Telephonic Services (KX) are reserved for when physical or BH status or access issues (transportation, telehealth technology) prevent the recipient from participating in-person or telehealth services.
How to Submit
N/A - No authorization is required
Resources
Individual Therapy
Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains. The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.
Authorization Guidelines
Maintained in the Record (not all inclusive):
- 1. CCA: Required
- 2. Tx/ Service Plan: Required. Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
- 3. Service Order: Required
- 4. Submission of applicable records that support the member has met the medical necessity criteria.
All services are subject to post-payment review.
Unit Value
One service code = 1 unit of service.
Limits
- 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
- 3. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
- 4. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
- 5. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
- 6. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
Level of Care
ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services
Additional Service Specifics
Telephonic Services (KX) are reserved for when physical or BH status or access issues (transportation, telehealth technology) prevent the member from participating in-person or telehealth services.
How to Submit
N/A - No authorization is required
Resources
Individual Therapy
Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains. The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.
Authorization Guidelines
Prior authorization is not required. No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.
Unit Value
One service code = 1 unit of service.
Limits
- 1. Maximum benefit of 12 visits for adults & 24 visits for children/ adolescents.
- 2. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
- 3. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 4. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
- 5. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
- 6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
- 7. The provider will communicate and coordinate care with other professionals providing care to the recipient.
- 8. Provider must verify individual’s eligibility each time a service is rendered
- 9. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
- 10. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
Length of Stay
No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.
Level of Care
ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
Other Information
Modifiers:
GT: Telehealth KX: Telephonic
Telephonic Services (KX) are reserved for when physical or BH status or access issues (transportation, telehealth technology) prevent the recipient from participating in-person or telehealth services.
How to Submit
N/A - No authorization is required
Resources
Individual Therapy
Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains. The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.
Authorization Guidelines
Maintained in the Record (not all inclusive):
- 1. CCA: Required
- 2. Tx/ Service Plan: Required. Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
- 3. Service Order: Required
- 4. Submission of applicable records that support the member has met the medical necessity criteria.
All services are subject to post-payment review.
Unit Value
One service code = 1 unit of service.
Limits
- 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
- 3. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
- 4. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
- 5. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
- 6. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
Level of Care
ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services
Additional Service Specifics
Telephonic Services (KX) are reserved for when physical or BH status or access issues (transportation, telehealth technology) prevent the member from participating in-person or telehealth services.
How to Submit
N/A - No authorization is required
Resources
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