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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 BH1. 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. does not cover: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. 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

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

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy 10C
• Records Management and Documentation Manual
• Person Centered Planning

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual