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If you have questions about prior authorizations, please call:

Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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99292 25 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE UNSTABLE CRITICALLY ILL OR

Service Code
99292 (CPT) 99292 25 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE UNSTABLE CRITICALLY ILL OR
Prior Authorization Required
No
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

N/A - No authorization is required

99304 25 Initial nursing facility care, per day, for the evaluation and management of a patient. Physicians time approximate 25 minutes;SEPARATELY IDENTIFIABLE E/M SERVICE BY THE SAME PROVIDER SAME DAY OF PROCEDURE

Service Code
99304 (CPT) 99304 25 Initial nursing facility care, per day, for the evaluation and management of a patient. Physicians time approximate 25 minutes;SEPARATELY IDENTIFIABLE E/M SERVICE BY THE SAME PROVIDER SAME DAY OF PROCEDURE
Prior Authorization Required
No
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

N/A - No authorization is required

Evaluation & Management

Service Code
99305 (CPT) Evaluation & Management
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
State-funded
Age Group
All
Diagnosis Group
Mental Health

Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

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 CPT code = 1 unit of service.

Limits

  • 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
  • 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
  • 4. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 5. The provider will communicate and coordinate care with other professionals providing care to the recipient.
  • 6. Telehealth, Virtual Communication, and Hybrid Telehealth services must follow the guidelines and requirements detailed in the State-Funded Telehealth and Virtual Services service definition.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99305 (CPT) Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coor
Prior Authorization Required
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Intellectual/ Developmental Disability, Mental Health, Substance Use

Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

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. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. 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. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 4. The provider will communicate and coordinate care with other professionals providing care to the member.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99306 (CPT) Evaluation & Management
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
State-funded
Age Group
All
Diagnosis Group
Mental Health

Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

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 CPT code = 1 unit of service.

Limits

  • 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
  • 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
  • 4. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 5. The provider will communicate and coordinate care with other professionals providing care to the recipient.
  • 6. Telehealth, Virtual Communication, and Hybrid Telehealth services must follow the guidelines and requirements detailed in the State-Funded Telehealth and Virtual Services service definition.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99306 (CPT) Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordina
Prior Authorization Required
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Intellectual/ Developmental Disability, Mental Health, Substance Use

Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

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. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. 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. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 4. The provider will communicate and coordinate care with other professionals providing care to the member.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99307 (CPT) Evaluation & Management
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
State-funded
Age Group
All
Diagnosis Group
Mental Health

Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

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 CPT code = 1 unit of service.

Limits

  • 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
  • 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
  • 4. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 5. The provider will communicate and coordinate care with other professionals providing care to the recipient.
  • 6. Telehealth, Virtual Communication, and Hybrid Telehealth services must follow the guidelines and requirements detailed in the State-Funded Telehealth and Virtual Services service definition.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99307 (CPT) Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Cou
Prior Authorization Required
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Intellectual/ Developmental Disability, Mental Health, Substance Use

Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

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. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. 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. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 4. The provider will communicate and coordinate care with other professionals providing care to the member.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99308 (CPT) Evaluation & Management
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
State-funded
Age Group
All
Diagnosis Group
Mental Health

Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

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 CPT code = 1 unit of service.

Limits

  • 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
  • 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
  • 4. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 5. The provider will communicate and coordinate care with other professionals providing care to the recipient.
  • 6. Telehealth, Virtual Communication, and Hybrid Telehealth services must follow the guidelines and requirements detailed in the State-Funded Telehealth and Virtual Services service definition.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99308 (CPT) Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making
Prior Authorization Required
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Intellectual/ Developmental Disability, Mental Health, Substance Use

Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

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. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. 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. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 4. The provider will communicate and coordinate care with other professionals providing care to the member.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99309 (CPT) Evaluation & Management
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
State-funded
Age Group
All
Diagnosis Group
Mental Health

Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

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 CPT code = 1 unit of service.

Limits

  • 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
  • 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
  • 4. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 5. The provider will communicate and coordinate care with other professionals providing care to the recipient.
  • 6. Telehealth, Virtual Communication, and Hybrid Telehealth services must follow the guidelines and requirements detailed in the State-Funded Telehealth and Virtual Services service definition.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99309 (CPT) Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling
Prior Authorization Required
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Intellectual/ Developmental Disability, Mental Health, Substance Use

Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

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. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. 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. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 4. The provider will communicate and coordinate care with other professionals providing care to the member.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99310 (CPT) Evaluation & Management
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
State-funded
Age Group
All
Diagnosis Group
Mental Health

Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

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 CPT code = 1 unit of service.

Limits

  • 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
  • 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
  • 4. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 5. The provider will communicate and coordinate care with other professionals providing care to the recipient.
  • 6. Telehealth, Virtual Communication, and Hybrid Telehealth services must follow the guidelines and requirements detailed in the State-Funded Telehealth and Virtual Services service definition.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99310 (CPT) Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Coun
Prior Authorization Required
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Intellectual/ Developmental Disability, Mental Health, Substance Use

Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

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. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. 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. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 4. The provider will communicate and coordinate care with other professionals providing care to the member.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99315 (CPT) Evaluation & Management
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
State-funded
Age Group
All
Diagnosis Group
Mental Health

Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

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 CPT code = 1 unit of service.

Limits

  • 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
  • 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
  • 4. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 5. The provider will communicate and coordinate care with other professionals providing care to the recipient.
  • 6. Telehealth, Virtual Communication, and Hybrid Telehealth services must follow the guidelines and requirements detailed in the State-Funded Telehealth and Virtual Services service definition.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99315 (CPT) Nursing facility discharge day management; 30 minutes or less
Prior Authorization Required
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Intellectual/ Developmental Disability, Mental Health, Substance Use

Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

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. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. 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. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 4. The provider will communicate and coordinate care with other professionals providing care to the member.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99316 (CPT) Evaluation & Management
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
State-funded
Age Group
All
Diagnosis Group
Mental Health

Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

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 CPT code = 1 unit of service.

Limits

  • 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
  • 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
  • 4. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 5. The provider will communicate and coordinate care with other professionals providing care to the recipient.
  • 6. Telehealth, Virtual Communication, and Hybrid Telehealth services must follow the guidelines and requirements detailed in the State-Funded Telehealth and Virtual Services service definition.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99316 (CPT) Nursing facility discharge day management; more than 30 minutes
Prior Authorization Required
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Intellectual/ Developmental Disability, Mental Health, Substance Use

Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

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. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. 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. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 4. The provider will communicate and coordinate care with other professionals providing care to the member.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99341 (CPT) Evaluation & Management
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
State-funded
Age Group
All
Diagnosis Group
Mental Health

Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

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 CPT code = 1 unit of service.

Limits

  • 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
  • 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
  • 4. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 5. The provider will communicate and coordinate care with other professionals providing care to the recipient.
  • 6. Telehealth, Virtual Communication, and Hybrid Telehealth services must follow the guidelines and requirements detailed in the State-Funded Telehealth and Virtual Services service definition.

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99341 (CPT) Home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other
Prior Authorization Required
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Intellectual/ Developmental Disability, Mental Health, Substance Use

Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

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. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. 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. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 4. The provider will communicate and coordinate care with other professionals providing care to the member.

How to Submit

N/A - No authorization is required

Resources