PA Lookup

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 8-I: Psychological Services Provided by Health Departments and School-Based Health Centers to the Under 21 Population
• Records Management and Documentation Manual
• Person Centered Planning

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.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy 10C

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• Records Management and Documentation Manual

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

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• Records Management and Documentation Manual
• Person Centered Planning

A crisis is defined as an acute disturbance of thought, mood, behavior or social relationships that requires an immediate intervention, and which, if untreated, may lead to harm to the individual or to others or have the potential to rapidly result in a catastrophic outcome. On rare occasions, licensed outpatient service providers are presented with an individual in crisis which may require unplanned extended services to manage the crisis in the office with the goal of averting more restrictive levels of care. Licensed professionals may use the “Psychotherapy for Crisis” service codes only in those situations in which an unforeseen crisis arises and additional time is required to manage the crisis event.

Authorization Guidelines

• 1. Prior authorization is not required for this service.
• 2. Psychotherapy for Crisis disposition may:
• A) Involve an immediate transfer to more restrictive emergency services.
• B) If the disposition is not an immediate transfer to acute or more intensive emergency services, the provider must offer a written copy of an individualized crisis plan to the individual. This plan must be developed in the session for the purpose of handling future crisis situations, including involvement of family and other providers as applicable. The plan must document a scheduled outpatient follow-up session.

Limits

• 1. Psychotherapy for Crisis is not covered: a) if the focus of tx does not address the symptoms of the DSM-5 dx or related symptoms; b) in emergency departments, inpatient settings, or facility-based crisis settings, OR; c) if the recipient presents with a medical, cognitive, intellectual or development issue that would not benefit from outpatient tx services.
• 2. If Psychotherapy for Crisis is billed, no other outpatient therapy services can be billed on that same day for that individual.
• 3. Psychotherapy for Crisis is only covered when the individual is experiencing an immediate, potentially life-threatening, complex crisis. The service must be provided in an outpatient therapy setting.
• 4. The provider will complete an assessment prior to the delivery of any subsequent services following the provision of this service.
• 5. When receiving multiple BH services in addition to outpatient, a PCP must be developed.
• 6. The provider will communicate and coordinate care with other professionals providing care to the recipient.
• 7. Providers must provide or have a written agreement with another entity for access to 24-hour coverage for behavioral health emergency services

How to Submit

N/A - No authorization is required

Resources

• State-Funded Outpatient Behavioral Health Services Service Definition
• Records Management and Documentation Manual

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 8-I: Psychological Services Provided by Health Departments and School-Based Health Centers to the Under 21 Population
• Records Management and Documentation Manual
• Person Centered Planning

On rare occasions, licensed outpatient service providers are presented with individuals in crisis situations which may require unplanned extended services to manage the crisis in the office with the goal of averting more restrictive levels of care. This service is used only in those extreme situations in which an unforeseen crisis situation arises, and additional time is required to manage the crisis event. Services are restricted to outpatient crisis assessment, stabilization, and disposition for acute, life-threatening situations.

Unit Value

One service code = 1 unit of service

Limits

• 1. Psychotherapy for Crisis is not covered: a) if the focus of tx does not address the symptoms of the DSM-5 dx or related symptoms; b) in emergency departments, inpatient settings, or facility-based crisis settings, OR; c) if the member presents with a medical, cognitive, intellectual or development issue that would not benefit from outpatient tx services. If Psychotherapy for Crisis is billed, no other outpatient therapy services can be billed on that same day for that member.
• 2. For members having both Medicaid and Medicare, the provider shall bill Medicare as primary before submitting a claim to Medicaid. For members having both Medicaid and any other insurance coverage, the other insurance shall be billed prior to billing Medicaid, as Medicaid is considered the payor of last resort.
• 3. The provider will complete an assessment prior to the delivery of any subsequent services following the provision of this service.
• 4. When receiving multiple BH services in addition to outpatient, a PCP must be developed.
• 5. The provider will complete an assessment prior to the delivery of any subsequent services following the provision of this service.
• 6. 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.
• 7. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• Records Management and Documentation Manual
• Person Centered Planning

A crisis is defined as an acute disturbance of thought, mood, behavior or social relationships that requires an immediate intervention, and which, if untreated, may lead to harm to the individual or to others or have the potential to rapidly result in a catastrophic outcome. On rare occasions, licensed outpatient service providers are presented with an individual in crisis which may require unplanned extended services to manage the crisis in the office with the goal of averting more restrictive levels of care. Licensed professionals may use the “Psychotherapy for Crisis” service codes only in those situations in which an unforeseen crisis arises and additional time is required to manage the crisis event.

Authorization Guidelines

• 1. Prior authorization is not required for this service.
• 2. Psychotherapy for Crisis disposition may:
• A) Involve an immediate transfer to more restrictive emergency services.
• B) If the disposition is not an immediate transfer to acute or more intensive emergency services, the provider must offer a written copy of an individualized crisis plan to the individual. This plan must be developed in the session for the purpose of handling future crisis situations, including involvement of family and other providers as applicable. The plan must document a scheduled outpatient follow-up session.

Limits

• 1. Psychotherapy for Crisis is not covered: a) if the focus of tx does not address the symptoms of the DSM-5 dx or related symptoms; b) in emergency departments, inpatient settings, or facility-based crisis settings, OR; c) if the recipient presents with a medical, cognitive, intellectual or development issue that would not benefit from outpatient tx services.
• 2. If Psychotherapy for Crisis is billed, no other outpatient therapy services can be billed on that same day for that individual.
• 3. Psychotherapy for Crisis is only covered when the individual is experiencing an immediate, potentially life-threatening, complex crisis. The service must be provided in an outpatient therapy setting.
• 4. The provider will complete an assessment prior to the delivery of any subsequent services following the provision of this service.
• 5. When receiving multiple BH services in addition to outpatient, a PCP must be developed.
• 6. The provider will communicate and coordinate care with other professionals providing care to the recipient.
• 7. Providers must provide or have a written agreement with another entity for access to 24-hour coverage for behavioral health emergency services

Additional Service Specifics

Must be used with 90839

How to Submit

N/A - No authorization is required

Resources

• State-Funded Outpatient Behavioral Health Services Service Definition
• Records Management and Documentation Manual

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 8-I: Psychological Services Provided by Health Departments and School-Based Health Centers to the Under 21 Population
• Records Management and Documentation Manual
• Person Centered Planning

On rare occasions, licensed outpatient service providers are presented with individuals in crisis situations which may require unplanned extended services to manage the crisis in the office with the goal of averting more restrictive levels of care. This service is used only in those extreme situations in which an unforeseen crisis situation arises, and additional time is required to manage the crisis event. Services are restricted to outpatient crisis assessment, stabilization, and disposition for acute, life-threatening situations.

Unit Value

One service code = 1 unit of service

Limits

• 1. Psychotherapy for Crisis is not covered: a) if the focus of tx does not address the symptoms of the DSM-5 dx or related symptoms; b) in emergency departments, inpatient settings, or facility-based crisis settings, OR; c) if the member presents with a medical, cognitive, intellectual or development issue that would not benefit from outpatient tx services. If Psychotherapy for Crisis is billed, no other outpatient therapy services can be billed on that same day for that member.
• 2. For members having both Medicaid and Medicare, the provider shall bill Medicare as primary before submitting a claim to Medicaid. For members having both Medicaid and any other insurance coverage, the other insurance shall be billed prior to billing Medicaid, as Medicaid is considered the payor of last resort.
• 3. The provider will complete an assessment prior to the delivery of any subsequent services following the provision of this service.
• 4. When receiving multiple BH services in addition to outpatient, a PCP must be developed.
• 5. The provider will complete an assessment prior to the delivery of any subsequent services following the provision of this service.
• 6. 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.
• 7. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• Records Management and Documentation Manual
• Person Centered Planning

How to Submit

N/A - No authorization is required

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. Family therapy must be billed once per date of service for the identified family recipient only. No separate billing for participating recipient(s) of the therapy session is permissible.
• 3. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
• 4. 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.
• 5. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
• 6. 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.
• 7. 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.
• 8. The provider will communicate and coordinate care with other professionals providing care to the recipient.
• 9. Provider must verify individual’s eligibility each time a service is rendered
• 10. 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
• 11. 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.

How to Submit

N/A - No authorization is required

Resources

• State-Funded Enhanced Mental Health and Substance Abuse Service Definition
• Records Management and Documentation Manual

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. 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.
• 5. 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.
• 6. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

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

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• Records Management and Documentation Manual
• Person Centered Planning

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.

Additional Service Specifics

May not be used with 90785.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy 8-I: Psychological Services Provided by Health Departments and School-Based Health Centers to the Under 21 Population
• Records Management and Documentation Manual
• Person Centered Planning

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. Family therapy must be billed once per date of service for the identified family recipient only. No separate billing for participating recipient(s) of the therapy session is permissible.
• 3. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
• 4. 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.
• 5. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
• 6. 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.
• 7. 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.
• 8. The provider will communicate and coordinate care with other professionals providing care to the recipient.
• 9. Provider must verify individual’s eligibility each time a service is rendered
• 10. 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
• 11. 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.

How to Submit

N/A - No authorization is required

Resources

• State-Funded Enhanced Mental Health and Substance Abuse Service Definition
• Records Management and Documentation Manual

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. 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.
• 5. 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.
• 6. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

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

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• Records Management and Documentation Manual
• Person Centered Planning

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.

Additional Service Specifics

May not be used with 90785.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy 8-I: Psychological Services Provided by Health Departments and School-Based Health Centers to the Under 21 Population
• Records Management and Documentation Manual
• Person Centered Planning

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy 10-C
• Records Management and Documentation Manual

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

Modifier(s):

GT: Telehealth KX: Telephonic

How to Submit

N/A - No authorization is required

Resources

• State-Funded Outpatient Behavioral Health Services Definition
• Records Management and Documentation Manual

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.

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

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• Records Management and Documentation Manual
• Person Centered Planning