PA Lookup

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.

Unit Value

One service code = 1 unit of service

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No. 10
• Records Management and Documentation Manual
• Person Centered Planning

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.

Unit Value

One service code = 1 unit of service.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No. 10
• Records Management and Documentation Manual
• Person Centered Planning

Neuropsychological Testing is intended to assess cognition and behavior, examining the effects of any brain injury or neuropathological process that a person may have experienced.

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.

Unit Value

One service code = 1 unit of service.

Limits

Up to 9 unmanaged units of testing administration

Length of Stay

Up to 9 unmanaged units of testing administration

Exclusions

• 1. Testing for the following is not covered: a) for the purpose of educational testing; b) if requested by the school or legal system, unless MN exists for the psych testing; c) if the proposed psych testing measures have no standardized norms or documented validity, OR; d) if the focus is not the symptoms of the DSM-5 diagnosis.
• 2. 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.
• 3. A Psychiatric Diagnostic Interview is not allowed on the same day as Psychological Testing when provided by the same provider.
• 4. May only be performed by licensed psychologists, licensed psychological associates, and qualified physicians.
• 5. Testing must include all elements detailed in the service definition.
• 6. The provider shall communicate and coordinate care with others providing care.

Level of Care

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

Psychological testing involves the culturally and linguistically appropriate administration of standardized tests to assess a recipient’s psychological or cognitive functioning. Testing results must inform treatment selection and treatment planning.

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.

Unit Value

One service code = 1 unit of service.

Limits

Up to 9 unmanaged units of testing administration

Exclusions

• 1. Testing for the following is not covered: a) for the purpose of educational testing; b) if requested by the school or legal system, unless MN exists for the psych testing; c) if the proposed psych testing measures have no standardized norms or documented validity, OR; d) if the focus is not the symptoms of the DSM-5 diagnosis.
• 2. 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.
• 3. A Psychiatric Diagnostic Interview is not allowed on the same day as Psychological Testing when provided by the same provider.
• 4. May only be performed by licensed psychologists, licensed psychological associates, and qualified physicians.
• 5. Testing must include all 9 elements detailed in the CCP.
• 6. The provider will communicate and coordinate care with other professionals providing care to the recipient.

Level of Care

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

Neuropsychological Testing is intended to assess cognition and behavior, examining the effects of any brain injury or neuropathological process that a person may have experienced.

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.

Unit Value

One service code = 1 unit of service

Limits

• 1. Psychological Testing does not cover testing for the purpose of educational testing; if requested by the school or legal system, unless MN exists for the psychological testing; if the proposed psychological testing measures have no standardized norms or documented validity, or; if the focus of assessment is not the symptoms of the current diagnosis.
• 2. 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.
• 3. Testing must include all elements detailed in the CCP.
• 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, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

Level of Care

For substance use disorders, clinical across the six ASAM criteria assessment dimensions is required.

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 testing involves the culturally and linguistically appropriate administration of standardized tests to assess a member’s psychological or cognitive functioning. Testing results must inform treatment selection and treatment planning.

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.

Unit Value

One service code = 1 unit of service.

Limits

• 1. Psychological Testing does not cover testing for the purpose of educational testing; if requested by the school or legal system, unless MN exists for the psychological testing; if the proposed psychological testing measures have no standardized norms or documented validity, or; if the focus of assessment is not the symptoms of the current diagnosis.
• 2. Limit of eight hours of Psychological Testing allowed to be billed per date of service.
• 3. 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.
• 4. Testing must include all elements detailed in the CCP.
• 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, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

Level of Care

For substance use disorders, clinical across the six ASAM criteria assessment dimensions is required.

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

Neuropsychological Testing is intended to assess cognition and behavior, examining the effects of any brain injury or neuropathological process that a person may have experienced.

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.

Unit Value

One service code = 1 unit of service.

Limits

Up to 9 unmanaged units of testing administration

Length of Stay

Up to 9 unmanaged units of testing administration

Exclusions

• 1. Testing for the following is not covered: a) for the purpose of educational testing; b) if requested by the school or legal system, unless MN exists for the psych testing; c) if the proposed psych testing measures have no standardized norms or documented validity, OR; d) if the focus is not the symptoms of the DSM-5 diagnosis.
• 2. 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.
• 3. A Psychiatric Diagnostic Interview is not allowed on the same day as Psychological Testing when provided by the same provider.
• 4. May only be performed by licensed psychologists, licensed psychological associates, and qualified physicians.
• 5. Testing must include all elements detailed in the service definition.
• 6. The provider shall communicate and coordinate care with others providing care.

Level of Care

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

Psychological testing involves the culturally and linguistically appropriate administration of standardized tests to assess a recipient’s psychological or cognitive functioning. Testing results must inform treatment selection and treatment planning.

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.

Unit Value

One service code = 1 unit of service.

Limits

Up to 9 unmanaged units of testing administration

Exclusions

• 1. Testing for the following is not covered: a) for the purpose of educational testing; b) if requested by the school or legal system, unless MN exists for the psych testing; c) if the proposed psych testing measures have no standardized norms or documented validity, OR; d) if the focus is not the symptoms of the DSM-5 diagnosis.
• 2. 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.
• 3. A Psychiatric Diagnostic Interview is not allowed on the same day as Psychological Testing when provided by the same provider.
• 4. May only be performed by licensed psychologists, licensed psychological associates, and qualified physicians.
• 5. Testing must include all 9 elements detailed in the CCP.
• 6. The provider will communicate and coordinate care with other professionals providing care to the recipient.

Level of Care

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

Neuropsychological Testing is intended to assess cognition and behavior, examining the effects of any brain injury or neuropathological process that a person may have experienced.

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.

Unit Value

One service code = 1 unit of service

Limits

• 1. Psychological Testing does not cover testing for the purpose of educational testing; if requested by the school or legal system, unless MN exists for the psychological testing; if the proposed psychological testing measures have no standardized norms or documented validity, or; if the focus of assessment is not the symptoms of the current diagnosis.
• 2. 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.
• 3. Testing must include all elements detailed in the CCP.
• 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, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

Level of Care

For substance use disorders, clinical across the six ASAM criteria assessment dimensions is required.

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 testing involves the culturally and linguistically appropriate administration of standardized tests to assess a member’s psychological or cognitive functioning. Testing results must inform treatment selection and treatment planning.

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.

Unit Value

One service code = 1 unit of service.

Limits

• 1. Psychological Testing does not cover testing for the purpose of educational testing; if requested by the school or legal system, unless MN exists for the psychological testing; if the proposed psychological testing measures have no standardized norms or documented validity, or; if the focus of assessment is not the symptoms of the current diagnosis.
• 2. Limit of eight hours of Psychological Testing allowed to be billed per date of service.
• 3. 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.
• 4. Testing must include all elements detailed in the CCP.
• 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, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

Level of Care

For substance use disorders, clinical across the six ASAM criteria assessment dimensions is required.

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

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

N/A - No authorization is required

Dietary Evaluation and Counseling offers direction and guidance for specific nutrient needs related to a beneficiary’s diagnosis and treatment. Individualized care plans provide for diseaserelated dietary evaluation and counseling. Medical lactation services provide support and counseling, or behavioral interventions to improve breastfeeding outcomes.

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.

Limits

Medical Lactation services are limited to a maximum of six (6) units per day with a maximum of thirty-six (36) lifetime units. This service must be provided as an individual, face-to-face encounter with the mother-infant dyad. Billing shall be applied to the infant.

Exclusions

Medicaid shall not cover group medical lactation services under this policy.

Diagnosis Requirements

Medicaid shall cover a lactation evaluation and breastfeeding counseling when the breastfeeding infant has a chronic, episodic, or acute condition for which medical lactation services are a critical component of medical management.

Place of Service

Medical lactation services provided in hospital outpatient clinics, federally qualified health centers, rural health clinics, private agencies, physician or medical diagnostic clinics, health departments and physician offices

Additional Service Specifics

. Providers who bill for Medical Lactation services with codes 96156, 96158, and 96159 must append the SC modifier to denote Medical Lactation Services.

How to Submit

N/A - No authorization is required

Resources

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

Dietary Evaluation and Counseling offers direction and guidance for specific nutrient needs related to a beneficiary’s diagnosis and treatment. Individualized care plans provide for diseaserelated dietary evaluation and counseling. Medical lactation services provide support and counseling, or behavioral interventions to improve breastfeeding outcomes.

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.

Limits

Medical Lactation services are limited to a maximum of six (6) units per day with a maximum of thirty-six (36) lifetime units. This service must be provided as an individual, face-to-face encounter with the mother-infant dyad. Billing shall be applied to the infant.

Exclusions

Medicaid shall not cover group medical lactation services under this policy.

Diagnosis Requirements

Medicaid shall cover a lactation evaluation and breastfeeding counseling when the breastfeeding infant has a chronic, episodic, or acute condition for which medical lactation services are a critical component of medical management.

Place of Service

Medical lactation services provided in hospital outpatient clinics, federally qualified health centers, rural health clinics, private agencies, physician or medical diagnostic clinics, health departments and physician offices

Additional Service Specifics

. Providers who bill for Medical Lactation services with codes 96156, 96158, and 96159 must append the SC modifier to denote Medical Lactation Services.

How to Submit

N/A - No authorization is required

Resources

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

Health and Behavior Intervention provides intensive, focused counseling for pregnant and postpartum women who have serious psychosocial needs, which include individualized problemsolving, priority setting, instruction, and action planning to effect behavior modification or environmental change. It may include individualized treatment therapies designed specifically to aid in overcoming the identified problems. It may also include the involvement of the woman’s significant other or other service providers.

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.

Limits

Pregnant and postpartum women who receive Medicaid and have one or more of the specified intensive psychosocial needs are eligible for this service.Service is for pregnant and postpartum women.

Service should be provided face-to-face in the home or clinic, not the area mental health center.

Service may begin during pregnancy and continue only through the end of the month in which the 60th postdelivery day occurs.

First 30 minutes are reimbursed as one service segment; each additional 15 minutes may be reimbursed only after the initial 30 minutes has been billed.

Total reimbursable time cannot exceed 60 minutes per day.

Total allowed service time is 11 hours per pregnancy and postpartum period; additional units are considered only through adjustment when coverage conditions are met and documentation supports medical necessity.

Must be billed per date of service.

Long-term counseling needs may necessitate referrals to other providers.

Exclusions

Health and Behavior Intervention services for pregnant and postpartum women should be face-to-face in the home or clinic (not the area mental health center). It can be provided by telephone when life-threatening situations exist. Health and Behavior Intervention services may be provided in addition to services provided by the area mental health center. The two agencies may not provide the same service for the same reason or criteria. Counseling services must be coordinated to ensure continuity of care. This short-term service may begin during the pregnancy and continue through the end of the month in which the 60th postdelivery day occurs. Long-term counseling needs may necessitate referrals to other providers.

Place of Service

Beneficiary’s home, office. Telehealth claims should be filed with the provider’s usual place of service code

How to Submit

N/A - No authorization is required

Resources

• 1M-3 Health and Behavior Intervention
• Records Management and Documentation Manual

Dietary Evaluation and Counseling offers direction and guidance for specific nutrient needs related to a beneficiary’s diagnosis and treatment. Individualized care plans provide for diseaserelated dietary evaluation and counseling. Medical lactation services provide support and counseling, or behavioral interventions to improve breastfeeding outcomes.

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.

Limits

Medical Lactation services are limited to a maximum of six (6) units per day with a maximum of thirty-six (36) lifetime units. This service must be provided as an individual, face-to-face encounter with the mother-infant dyad. Billing shall be applied to the infant.

Exclusions

Medicaid shall not cover group medical lactation services under this policy.

Diagnosis Requirements

Medicaid shall cover a lactation evaluation and breastfeeding counseling when the breastfeeding infant has a chronic, episodic, or acute condition for which medical lactation services are a critical component of medical management.

Place of Service

Medical lactation services provided in hospital outpatient clinics, federally qualified health centers, rural health clinics, private agencies, physician or medical diagnostic clinics, health departments and physician offices

Additional Service Specifics

. Providers who bill for Medical Lactation services with codes 96156, 96158, and 96159 must append the SC modifier to denote Medical Lactation Services.

How to Submit

N/A - No authorization is required

Resources

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

Health and Behavior Intervention provides intensive, focused counseling for pregnant and postpartum women who have serious psychosocial needs, which include individualized problemsolving, priority setting, instruction, and action planning to effect behavior modification or environmental change. It may include individualized treatment therapies designed specifically to aid in overcoming the identified problems. It may also include the involvement of the woman’s significant other or other service providers.

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.

Limits

Pregnant and postpartum women who receive Medicaid and have one or more of the specified intensive psychosocial needs are eligible for this service.Service is for pregnant and postpartum women.

Service should be provided face-to-face in the home or clinic, not the area mental health center.

Service may begin during pregnancy and continue only through the end of the month in which the 60th postdelivery day occurs.

First 30 minutes are reimbursed as one service segment; each additional 15 minutes may be reimbursed only after the initial 30 minutes has been billed.

Total reimbursable time cannot exceed 60 minutes per day.

Total allowed service time is 11 hours per pregnancy and postpartum period; additional units are considered only through adjustment when coverage conditions are met and documentation supports medical necessity.

Must be billed per date of service.

Long-term counseling needs may necessitate referrals to other providers.

Exclusions

Health and Behavior Intervention services for pregnant and postpartum women should be face-to-face in the home or clinic (not the area mental health center). It can be provided by telephone when life-threatening situations exist. Health and Behavior Intervention services may be provided in addition to services provided by the area mental health center. The two agencies may not provide the same service for the same reason or criteria. Counseling services must be coordinated to ensure continuity of care. This short-term service may begin during the pregnancy and continue through the end of the month in which the 60th postdelivery day occurs. Long-term counseling needs may necessitate referrals to other providers.

Place of Service

Beneficiary’s home, office. Telehealth claims should be filed with the provider’s usual place of service code

How to Submit

N/A - No authorization is required

Resources

• 1M-3 Health and Behavior Intervention
• Records Management and Documentation Manual

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

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

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

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

N/A - No authorization is required