PA Lookup

Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

Service Code

97140 (CPT) Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Age Group

All

Diagnosis Group

Physical Health

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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

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

Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

Service Code

97140 (CPT) Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Age Group

Medicaid Child (Age 0-20)

Diagnosis Group

Physical Health

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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

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

Therapeutic procedure(s), group (2 or more individuals)

Service Code

97150 (CPT) Therapeutic procedure(s), group (2 or more individuals)

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Diagnosis Group

Physical Health

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

Therapeutic procedure(s), group (2 or more individuals)

Service Code

97150 (CPT) Therapeutic procedure(s), group (2 or more individuals)

Prior Authorization Required

Yes

Benefit Plan

Medicaid

Age Group

Medicaid Child (Age 0-20)

Diagnosis Group

Physical Health

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

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Service Code

97151 (CPT) Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) ad

Prior Authorization Required

Yes

Telephonic Billable

No

Telehealth Billable

Yes

Benefit Plan

Medicaid

Age Group

Medicaid Adult (Age 21+)

Diagnosis Group

Intellectual/ Developmental Disability

Researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary. RB-BHT demonstrates clinical efficacy in treating ASD: prevent or minimizes the adverse effects of ASD; and promote, to the maximum extent possible, the functioning of a beneficiary.

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.

Reauthorization Guidelines

1. TAR: Reauth must be submitted prior to initial or concurrent auth expiring.
2. Complete Tx Plan: Required, developed and signed by a LQASP and legally responsible person. Trillium approves the plan of care and may approve or reduce or deny services. At a minimum, the Tx Plan must be reviewed by:
1) The target date or expiration of each goal. Each goal must be reviewed separately, based on the target date associated with it. Short-range goals in the Tx Plan may never exceed 12 months from the Date of Plan;
2) Change in the beneficiary’s needs;
3) Change in service provider, and/or;
4) Addition of a new service. Must be reviewed no less than once every 6 months and rewritten at least annually.
3. Discharge Plan: Required, documenting a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver
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 unit = 15 minutes

Limits

1. Medicaid will not cover treatments that are not based in scientific evidence and unproven treatments.
2. RB-BHT services are not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program.
3. A qualified provider who renders services to a Medicaid beneficiary shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement.
4. Telephonic Services are reserved for circumstances when the caregiver’s physical or BH status prevents them from participating in in-person or telehealth services; or access issues prevent the caregiver from participating in in-person or telehealth services.
5. Facilities providing this service may not IMD facilities.

Length of Stay

Initial and reauth requests can be for up to180 calendar days

Diagnosis Requirements

Must have an ASD diagnosis

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.

Place of Service

Office, clinic, community, home, place of work or school.

Additional Service Specifics

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Service Code

97151 (CPT) Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) ad

Prior Authorization Required

Yes

Telephonic Billable

No

Telehealth Billable

Yes

Benefit Plan

Medicaid

Age Group

All

Diagnosis Group

Intellectual/ Developmental Disability

Researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary. RB-BHT demonstrates clinical efficacy in treating ASD: prevent or minimizes the adverse effects of ASD; and promote, to the maximum extent possible, the functioning of a beneficiary.

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.

Reauthorization Guidelines

1. TAR: Reauth must be submitted prior to initial or concurrent auth expiring.
2. Complete Tx Plan: Required, developed and signed by a LQASP and legally responsible person. Trillium approves the plan of care and may approve or reduce or deny services. At a minimum, the Tx Plan must be reviewed by:
1) The target date or expiration of each goal. Each goal must be reviewed separately, based on the target date associated with it. Short-range goals in the Tx Plan may never exceed 12 months from the Date of Plan;
2) Change in the beneficiary’s needs;
3) Change in service provider, and/or;
4) Addition of a new service. Must be reviewed no less than once every 6 months and rewritten at least annually.
3. Discharge Plan: Required, documenting a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver
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 unit = 15 minutes

Limits

1. Medicaid will not cover treatments that are not based in scientific evidence and unproven treatments.
2. RB-BHT services are not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program.
3. A qualified provider who renders services to a Medicaid beneficiary shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement.
4. Telephonic Services are reserved for circumstances when the caregiver’s physical or BH status prevents them from participating in in-person or telehealth services; or access issues prevent the caregiver from participating in in-person or telehealth services.
5. Facilities providing this service may not IMD facilities.

Length of Stay

Initial and reauth requests can be for up to180 calendar days

Diagnosis Requirements

Must have an ASD diagnosis

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.

Place of Service

Office, clinic, community, home, place of work or school.

Additional Service Specifics

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Service Code

97152 (CPT) Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes

Prior Authorization Required

Yes

Telephonic Billable

No

Telehealth Billable

Yes

Benefit Plan

Medicaid

Age Group

Medicaid Adult (Age 21+)

Diagnosis Group

Intellectual/ Developmental Disability

Researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary. RB-BHT demonstrates clinical efficacy in treating ASD: prevent or minimizes the adverse effects of ASD; and promote, to the maximum extent possible, the functioning of a beneficiary.

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.

Reauthorization Guidelines

1. TAR: Reauth must be submitted prior to initial or concurrent auth expiring.
2. Complete Tx Plan: Required, developed and signed by a LQASP and legally responsible person. Trillium approves the plan of care and may approve or reduce or deny services. At a minimum, the Tx Plan must be reviewed by:
1) The target date or expiration of each goal. Each goal must be reviewed separately, based on the target date associated with it. Short-range goals in the Tx Plan may never exceed 12 months from the Date of Plan;
2) Change in the beneficiary’s needs;
3) Change in service provider, and/or;
4) Addition of a new service. Must be reviewed no less than once every 6 months and rewritten at least annually.
3. Discharge Plan: Required, documenting a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver
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 unit = 15 minutes

Limits

1. Medicaid will not cover treatments that are not based in scientific evidence and unproven treatments.
2. RB-BHT services are not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program.
3. A qualified provider who renders services to a Medicaid beneficiary shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement.
4. Telephonic Services are reserved for circumstances when the caregiver’s physical or BH status prevents them from participating in in-person or telehealth services; or access issues prevent the caregiver from participating in in-person or telehealth services.
5. Facilities providing this service may not IMD facilities.

Length of Stay

Initial and reauth requests can be for up to180 calendar days

Diagnosis Requirements

Must have an ASD diagnosis

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.

Place of Service

Office, clinic, community, home, place of work or school.

Additional Service Specifics

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Service Code

97152 (CPT) Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes

Prior Authorization Required

Yes

Telephonic Billable

No

Telehealth Billable

Yes

Benefit Plan

Medicaid

Age Group

All

Diagnosis Group

Intellectual/ Developmental Disability

Researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary. RB-BHT demonstrates clinical efficacy in treating ASD: prevent or minimizes the adverse effects of ASD; and promote, to the maximum extent possible, the functioning of a beneficiary.

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.

Reauthorization Guidelines

1. TAR: Reauth must be submitted prior to initial or concurrent auth expiring.
2. Complete Tx Plan: Required, developed and signed by a LQASP and legally responsible person. Trillium approves the plan of care and may approve or reduce or deny services. At a minimum, the Tx Plan must be reviewed by:
1) The target date or expiration of each goal. Each goal must be reviewed separately, based on the target date associated with it. Short-range goals in the Tx Plan may never exceed 12 months from the Date of Plan;
2) Change in the beneficiary’s needs;
3) Change in service provider, and/or;
4) Addition of a new service. Must be reviewed no less than once every 6 months and rewritten at least annually.
3. Discharge Plan: Required, documenting a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver
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 unit = 15 minutes

Limits

1. Medicaid will not cover treatments that are not based in scientific evidence and unproven treatments.
2. RB-BHT services are not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program.
3. A qualified provider who renders services to a Medicaid beneficiary shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement.
4. Telephonic Services are reserved for circumstances when the caregiver’s physical or BH status prevents them from participating in in-person or telehealth services; or access issues prevent the caregiver from participating in in-person or telehealth services.
5. Facilities providing this service may not IMD facilities.

Length of Stay

Initial and reauth requests can be for up to180 calendar days

Diagnosis Requirements

Must have an ASD diagnosis

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.

Place of Service

Office, clinic, community, home, place of work or school.

Additional Service Specifics

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Service Code

97153 (CPT) Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes

Prior Authorization Required

Yes

Telephonic Billable

No

Telehealth Billable

Yes

Benefit Plan

Medicaid

Age Group

Medicaid Adult (Age 21+)

Diagnosis Group

Intellectual/ Developmental Disability

Researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary. RB-BHT demonstrates clinical efficacy in treating ASD: prevent or minimizes the adverse effects of ASD; and promote, to the maximum extent possible, the functioning of a beneficiary.

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.

Reauthorization Guidelines

1. TAR: Reauth must be submitted prior to initial or concurrent auth expiring.
2. Complete Tx Plan: Required, developed and signed by a LQASP and legally responsible person. Trillium approves the plan of care and may approve or reduce or deny services. At a minimum, the Tx Plan must be reviewed by:
1) The target date or expiration of each goal. Each goal must be reviewed separately, based on the target date associated with it. Short-range goals in the Tx Plan may never exceed 12 months from the Date of Plan;
2) Change in the beneficiary’s needs;
3) Change in service provider, and/or;
4) Addition of a new service. Must be reviewed no less than once every 6 months and rewritten at least annually.
3. Discharge Plan: Required, documenting a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver
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 unit = 15 minutes

Limits

1. Medicaid will not cover treatments that are not based in scientific evidence and unproven treatments.
2. RB-BHT services are not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program.
3. A qualified provider who renders services to a Medicaid beneficiary shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement.
4. Telephonic Services are reserved for circumstances when the caregiver’s physical or BH status prevents them from participating in in-person or telehealth services; or access issues prevent the caregiver from participating in in-person or telehealth services.
5. Facilities providing this service may not IMD facilities.

Length of Stay

Initial and reauth requests can be for up to180 calendar days

Diagnosis Requirements

Must have an ASD diagnosis

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.

Place of Service

Office, clinic, community, home, place of work or school.

Additional Service Specifics

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Service Code

97153 (CPT) Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes

Prior Authorization Required

Yes

Telephonic Billable

No

Telehealth Billable

Yes

Benefit Plan

Medicaid

Age Group

All

Diagnosis Group

Intellectual/ Developmental Disability

Researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary. RB-BHT demonstrates clinical efficacy in treating ASD: prevent or minimizes the adverse effects of ASD; and promote, to the maximum extent possible, the functioning of a beneficiary.

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.

Reauthorization Guidelines

1. TAR: Reauth must be submitted prior to initial or concurrent auth expiring.
2. Complete Tx Plan: Required, developed and signed by a LQASP and legally responsible person. Trillium approves the plan of care and may approve or reduce or deny services. At a minimum, the Tx Plan must be reviewed by:
1) The target date or expiration of each goal. Each goal must be reviewed separately, based on the target date associated with it. Short-range goals in the Tx Plan may never exceed 12 months from the Date of Plan;
2) Change in the beneficiary’s needs;
3) Change in service provider, and/or;
4) Addition of a new service. Must be reviewed no less than once every 6 months and rewritten at least annually.
3. Discharge Plan: Required, documenting a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver
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 unit = 15 minutes

Limits

1. Medicaid will not cover treatments that are not based in scientific evidence and unproven treatments.
2. RB-BHT services are not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program.
3. A qualified provider who renders services to a Medicaid beneficiary shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement.
4. Telephonic Services are reserved for circumstances when the caregiver’s physical or BH status prevents them from participating in in-person or telehealth services; or access issues prevent the caregiver from participating in in-person or telehealth services.
5. Facilities providing this service may not IMD facilities.

Length of Stay

Initial and reauth requests can be for up to180 calendar days

Diagnosis Requirements

Must have an ASD diagnosis

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.

Place of Service

Office, clinic, community, home, place of work or school.

Additional Service Specifics

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Service Code

97154 (CPT) Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes

Prior Authorization Required

Yes

Telephonic Billable

No

Telehealth Billable

Yes

Benefit Plan

Medicaid

Age Group

Medicaid Adult (Age 21+)

Diagnosis Group

Intellectual/ Developmental Disability

Researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary. RB-BHT demonstrates clinical efficacy in treating ASD: prevent or minimizes the adverse effects of ASD; and promote, to the maximum extent possible, the functioning of a beneficiary.

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.

Reauthorization Guidelines

1. TAR: Reauth must be submitted prior to initial or concurrent auth expiring.
2. Complete Tx Plan: Required, developed and signed by a LQASP and legally responsible person. Trillium approves the plan of care and may approve or reduce or deny services. At a minimum, the Tx Plan must be reviewed by:
1) The target date or expiration of each goal. Each goal must be reviewed separately, based on the target date associated with it. Short-range goals in the Tx Plan may never exceed 12 months from the Date of Plan;
2) Change in the beneficiary’s needs;
3) Change in service provider, and/or;
4) Addition of a new service. Must be reviewed no less than once every 6 months and rewritten at least annually.
3. Discharge Plan: Required, documenting a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver
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 unit = 15 minutes

Limits

1. Medicaid will not cover treatments that are not based in scientific evidence and unproven treatments.
2. RB-BHT services are not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program.
3. A qualified provider who renders services to a Medicaid beneficiary shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement.
4. Telephonic Services are reserved for circumstances when the caregiver’s physical or BH status prevents them from participating in in-person or telehealth services; or access issues prevent the caregiver from participating in in-person or telehealth services.
5. Facilities providing this service may not IMD facilities.

Length of Stay

Initial and reauth requests can be for up to180 calendar days

Diagnosis Requirements

Must have an ASD diagnosis

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.

Place of Service

Office, clinic, community, home, place of work or school.

Additional Service Specifics

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Service Code

97154 (CPT) Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes

Prior Authorization Required

Yes

Telephonic Billable

No

Telehealth Billable

Yes

Benefit Plan

Medicaid

Age Group

All

Diagnosis Group

Intellectual/ Developmental Disability

Researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary. RB-BHT demonstrates clinical efficacy in treating ASD: prevent or minimizes the adverse effects of ASD; and promote, to the maximum extent possible, the functioning of a beneficiary.

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.

Reauthorization Guidelines

1. TAR: Reauth must be submitted prior to initial or concurrent auth expiring.
2. Complete Tx Plan: Required, developed and signed by a LQASP and legally responsible person. Trillium approves the plan of care and may approve or reduce or deny services. At a minimum, the Tx Plan must be reviewed by:
1) The target date or expiration of each goal. Each goal must be reviewed separately, based on the target date associated with it. Short-range goals in the Tx Plan may never exceed 12 months from the Date of Plan;
2) Change in the beneficiary’s needs;
3) Change in service provider, and/or;
4) Addition of a new service. Must be reviewed no less than once every 6 months and rewritten at least annually.
3. Discharge Plan: Required, documenting a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver
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 unit = 15 minutes

Limits

1. Medicaid will not cover treatments that are not based in scientific evidence and unproven treatments.
2. RB-BHT services are not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program.
3. A qualified provider who renders services to a Medicaid beneficiary shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement.
4. Telephonic Services are reserved for circumstances when the caregiver’s physical or BH status prevents them from participating in in-person or telehealth services; or access issues prevent the caregiver from participating in in-person or telehealth services.
5. Facilities providing this service may not IMD facilities.

Length of Stay

Initial and reauth requests can be for up to180 calendar days

Diagnosis Requirements

Must have an ASD diagnosis

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.

Place of Service

Office, clinic, community, home, place of work or school.

Additional Service Specifics

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Service Code

97155 (CPT) Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes

Prior Authorization Required

Yes

Telephonic Billable

No

Telehealth Billable

Yes

Benefit Plan

Medicaid

Age Group

Medicaid Adult (Age 21+)

Diagnosis Group

Intellectual/ Developmental Disability

Researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary. RB-BHT demonstrates clinical efficacy in treating ASD: prevent or minimizes the adverse effects of ASD; and promote, to the maximum extent possible, the functioning of a beneficiary.

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.

Reauthorization Guidelines

1. TAR: Reauth must be submitted prior to initial or concurrent auth expiring.
2. Complete Tx Plan: Required, developed and signed by a LQASP and legally responsible person. Trillium approves the plan of care and may approve or reduce or deny services. At a minimum, the Tx Plan must be reviewed by:
1) The target date or expiration of each goal. Each goal must be reviewed separately, based on the target date associated with it. Short-range goals in the Tx Plan may never exceed 12 months from the Date of Plan;
2) Change in the beneficiary’s needs;
3) Change in service provider, and/or;
4) Addition of a new service. Must be reviewed no less than once every 6 months and rewritten at least annually.
3. Discharge Plan: Required, documenting a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver
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 unit = 15 minutes

Limits

1. Medicaid will not cover treatments that are not based in scientific evidence and unproven treatments.
2. RB-BHT services are not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program.
3. A qualified provider who renders services to a Medicaid beneficiary shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement.
4. Telephonic Services are reserved for circumstances when the caregiver’s physical or BH status prevents them from participating in in-person or telehealth services; or access issues prevent the caregiver from participating in in-person or telehealth services.
5. Facilities providing this service may not IMD facilities.

Length of Stay

Initial and reauth requests can be for up to180 calendar days

Diagnosis Requirements

Must have an ASD diagnosis

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.

Place of Service

Office, clinic, community, home, place of work or school.

Additional Service Specifics

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Service Code

97155 (CPT) Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes

Prior Authorization Required

Yes

Telephonic Billable

No

Telehealth Billable

Yes

Benefit Plan

Medicaid

Age Group

All

Diagnosis Group

Intellectual/ Developmental Disability

Researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary. RB-BHT demonstrates clinical efficacy in treating ASD: prevent or minimizes the adverse effects of ASD; and promote, to the maximum extent possible, the functioning of a beneficiary.

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.

Reauthorization Guidelines

1. TAR: Reauth must be submitted prior to initial or concurrent auth expiring.
2. Complete Tx Plan: Required, developed and signed by a LQASP and legally responsible person. Trillium approves the plan of care and may approve or reduce or deny services. At a minimum, the Tx Plan must be reviewed by:
1) The target date or expiration of each goal. Each goal must be reviewed separately, based on the target date associated with it. Short-range goals in the Tx Plan may never exceed 12 months from the Date of Plan;
2) Change in the beneficiary’s needs;
3) Change in service provider, and/or;
4) Addition of a new service. Must be reviewed no less than once every 6 months and rewritten at least annually.
3. Discharge Plan: Required, documenting a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver
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 unit = 15 minutes

Limits

1. Medicaid will not cover treatments that are not based in scientific evidence and unproven treatments.
2. RB-BHT services are not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program.
3. A qualified provider who renders services to a Medicaid beneficiary shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement.
4. Telephonic Services are reserved for circumstances when the caregiver’s physical or BH status prevents them from participating in in-person or telehealth services; or access issues prevent the caregiver from participating in in-person or telehealth services.
5. Facilities providing this service may not IMD facilities.

Length of Stay

Initial and reauth requests can be for up to180 calendar days

Diagnosis Requirements

Must have an ASD diagnosis

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.

Place of Service

Office, clinic, community, home, place of work or school.

Additional Service Specifics

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Service Code

97156 (CPT) Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes

Prior Authorization Required

Yes

Telephonic Billable

Yes

Telehealth Billable

Yes

Benefit Plan

Medicaid

Age Group

Medicaid Adult (Age 21+)

Diagnosis Group

Intellectual/ Developmental Disability

Researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary. RB-BHT demonstrates clinical efficacy in treating ASD: prevent or minimizes the adverse effects of ASD; and promote, to the maximum extent possible, the functioning of a beneficiary.

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.

Reauthorization Guidelines

1. TAR: Reauth must be submitted prior to initial or concurrent auth expiring.
2. Complete Tx Plan: Required, developed and signed by a LQASP and legally responsible person. Trillium approves the plan of care and may approve or reduce or deny services. At a minimum, the Tx Plan must be reviewed by:
1) The target date or expiration of each goal. Each goal must be reviewed separately, based on the target date associated with it. Short-range goals in the Tx Plan may never exceed 12 months from the Date of Plan;
2) Change in the beneficiary’s needs;
3) Change in service provider, and/or;
4) Addition of a new service. Must be reviewed no less than once every 6 months and rewritten at least annually.
3. Discharge Plan: Required, documenting a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver
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 unit = 15 minutes

Limits

1. Medicaid will not cover treatments that are not based in scientific evidence and unproven treatments.
2. RB-BHT services are not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program.
3. A qualified provider who renders services to a Medicaid beneficiary shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement.
4. Telephonic Services are reserved for circumstances when the caregiver’s physical or BH status prevents them from participating in in-person or telehealth services; or access issues prevent the caregiver from participating in in-person or telehealth services.
5. Facilities providing this service may not IMD facilities.

Length of Stay

Initial and reauth requests can be for up to180 calendar days

Diagnosis Requirements

Must have an ASD diagnosis

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.

Place of Service

Office, clinic, community, home, place of work or school.

Additional Service Specifics

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Service Code

97156 (CPT) Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes

Prior Authorization Required

Yes

Telephonic Billable

Yes

Telehealth Billable

Yes

Benefit Plan

Medicaid

Age Group

All

Diagnosis Group

Intellectual/ Developmental Disability

Researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary. RB-BHT demonstrates clinical efficacy in treating ASD: prevent or minimizes the adverse effects of ASD; and promote, to the maximum extent possible, the functioning of a beneficiary.

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.

Reauthorization Guidelines

1. TAR: Reauth must be submitted prior to initial or concurrent auth expiring.
2. Complete Tx Plan: Required, developed and signed by a LQASP and legally responsible person. Trillium approves the plan of care and may approve or reduce or deny services. At a minimum, the Tx Plan must be reviewed by:
1) The target date or expiration of each goal. Each goal must be reviewed separately, based on the target date associated with it. Short-range goals in the Tx Plan may never exceed 12 months from the Date of Plan;
2) Change in the beneficiary’s needs;
3) Change in service provider, and/or;
4) Addition of a new service. Must be reviewed no less than once every 6 months and rewritten at least annually.
3. Discharge Plan: Required, documenting a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver
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 unit = 15 minutes

Limits

1. Medicaid will not cover treatments that are not based in scientific evidence and unproven treatments.
2. RB-BHT services are not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program.
3. A qualified provider who renders services to a Medicaid beneficiary shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement.
4. Telephonic Services are reserved for circumstances when the caregiver’s physical or BH status prevents them from participating in in-person or telehealth services; or access issues prevent the caregiver from participating in in-person or telehealth services.
5. Facilities providing this service may not IMD facilities.

Length of Stay

Initial and reauth requests can be for up to180 calendar days

Diagnosis Requirements

Must have an ASD diagnosis

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.

Place of Service

Office, clinic, community, home, place of work or school.

Additional Service Specifics

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Service Code

97157 (CPT) Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes

Prior Authorization Required

Yes

Telephonic Billable

Yes

Telehealth Billable

Yes

Benefit Plan

Medicaid

Age Group

Medicaid Adult (Age 21+)

Diagnosis Group

Intellectual/ Developmental Disability

Researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary. RB-BHT demonstrates clinical efficacy in treating ASD: prevent or minimizes the adverse effects of ASD; and promote, to the maximum extent possible, the functioning of a beneficiary.

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.

Reauthorization Guidelines

1. TAR: Reauth must be submitted prior to initial or concurrent auth expiring.
2. Complete Tx Plan: Required, developed and signed by a LQASP and legally responsible person. Trillium approves the plan of care and may approve or reduce or deny services. At a minimum, the Tx Plan must be reviewed by:
1) The target date or expiration of each goal. Each goal must be reviewed separately, based on the target date associated with it. Short-range goals in the Tx Plan may never exceed 12 months from the Date of Plan;
2) Change in the beneficiary’s needs;
3) Change in service provider, and/or;
4) Addition of a new service. Must be reviewed no less than once every 6 months and rewritten at least annually.
3. Discharge Plan: Required, documenting a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver
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 unit = 15 minutes

Limits

1. Medicaid will not cover treatments that are not based in scientific evidence and unproven treatments.
2. RB-BHT services are not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program.
3. A qualified provider who renders services to a Medicaid beneficiary shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement.
4. Telephonic Services are reserved for circumstances when the caregiver’s physical or BH status prevents them from participating in in-person or telehealth services; or access issues prevent the caregiver from participating in in-person or telehealth services.
5. Facilities providing this service may not IMD facilities.

Length of Stay

Initial and reauth requests can be for up to180 calendar days

Diagnosis Requirements

Must have an ASD diagnosis

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.

Place of Service

Office, clinic, community, home, place of work or school.

Additional Service Specifics

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Service Code

97157 (CPT) Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes

Prior Authorization Required

Yes

Telephonic Billable

Yes

Telehealth Billable

Yes

Benefit Plan

Medicaid

Age Group

All

Diagnosis Group

Intellectual/ Developmental Disability

Researched-based behavioral intervention services that prevent or minimize the disabilities and behavioral challenges associated with Autism Spectrum Disorder (ASD) and promote, to the extent practicable, the adaptive functioning of a beneficiary. RB-BHT demonstrates clinical efficacy in treating ASD: prevent or minimizes the adverse effects of ASD; and promote, to the maximum extent possible, the functioning of a beneficiary.

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.

Reauthorization Guidelines

1. TAR: Reauth must be submitted prior to initial or concurrent auth expiring.
2. Complete Tx Plan: Required, developed and signed by a LQASP and legally responsible person. Trillium approves the plan of care and may approve or reduce or deny services. At a minimum, the Tx Plan must be reviewed by:
1) The target date or expiration of each goal. Each goal must be reviewed separately, based on the target date associated with it. Short-range goals in the Tx Plan may never exceed 12 months from the Date of Plan;
2) Change in the beneficiary’s needs;
3) Change in service provider, and/or;
4) Addition of a new service. Must be reviewed no less than once every 6 months and rewritten at least annually.
3. Discharge Plan: Required, documenting a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver
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 unit = 15 minutes

Limits

1. Medicaid will not cover treatments that are not based in scientific evidence and unproven treatments.
2. RB-BHT services are not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program.
3. A qualified provider who renders services to a Medicaid beneficiary shall bill all other third-party payers, including Medicare, before submitting a claim for Medicaid reimbursement.
4. Telephonic Services are reserved for circumstances when the caregiver’s physical or BH status prevents them from participating in in-person or telehealth services; or access issues prevent the caregiver from participating in in-person or telehealth services.
5. Facilities providing this service may not IMD facilities.

Length of Stay

Initial and reauth requests can be for up to180 calendar days

Diagnosis Requirements

Must have an ASD diagnosis

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.

Place of Service

Office, clinic, community, home, place of work or school.

Additional Service Specifics

Tx Plan: Must have measurable goals over a specific timeline developed by a LQASP. Person-centered planning uses a blend of paid, unpaid, natural and public specialty resources. The Tx Plan must include the following:

A. Be person-centered with individualized goals
B. Describe the BH or developmental skills and challenges to be treated
C. Interventions must include: 1) the service type; 2) number of hours of direct service and supervision; 3) location of the service;
4) Caregiver participation needs;
5) frequency progress is to be evaluated and reported, and;
6) Identifies those responsible for delivering the services.
D. Intervention plans must utilize research-based practices, with demonstrated clinical efficacy in treating ASD and that are specific to the individual’s needs and developmental level.
E. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives and goals identified in the intervention plan
F. Update goals when the tx goals and objectives are achieved or no longer appropriate
G. Must be signed and dated by Plan Developer and Legally Responsible Person prior to delivery of services

Note: For Individuals over the age of 21 the intervention provided must be supported by credible scientific or clinical evidence, as appropriate for the treatment of ASD and the individuals age range.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements f

Service Code

97161 (CPT) Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements f

Prior Authorization Required

No

Benefit Plan

Medicaid

Age Group

All

Diagnosis Group

Physical Health

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

Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements f

Service Code

97161 (CPT) Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements f

Prior Authorization Required

No

Benefit Plan

Medicaid

Age Group

Medicaid Child (Age 0-20)

Diagnosis Group

Physical Health

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

If you have questions about prior authorizations, please call:

Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

Authorization Guidelines

Conditional Requirements

How to Submit

Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

Authorization Guidelines

Conditional Requirements

How to Submit

Therapeutic procedure(s), group (2 or more individuals)

Authorization Guidelines

How to Submit

Therapeutic procedure(s), group (2 or more individuals)

Authorization Guidelines

How to Submit

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Authorization Guidelines

Reauthorization Guidelines

Unit Value

Limits

Length of Stay

Diagnosis Requirements

Level of Care

Place of Service

Additional Service Specifics

How to Submit

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Authorization Guidelines

Reauthorization Guidelines

Unit Value

Limits

Length of Stay

Diagnosis Requirements

Level of Care

Place of Service

Additional Service Specifics

How to Submit

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Authorization Guidelines

Reauthorization Guidelines

Unit Value

Limits

Length of Stay

Diagnosis Requirements

Level of Care

Place of Service

Additional Service Specifics

How to Submit

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Authorization Guidelines

Reauthorization Guidelines

Unit Value

Limits

Length of Stay

Diagnosis Requirements

Level of Care

Place of Service

Additional Service Specifics

How to Submit

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Authorization Guidelines

Reauthorization Guidelines

Unit Value

Limits

Length of Stay

Diagnosis Requirements

Level of Care

Place of Service

Additional Service Specifics

How to Submit

Resources

Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)

Authorization Guidelines

Reauthorization Guidelines

Unit Value