PA Lookup
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
Remote in-home visit for the evaluation and management of an established patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires at least two of the following three key components: a comprehensive history; a
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
Behavioral counseling for diabetes prevention, online, 60 minutes
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
Bundled Payments for Care Improvement Advanced (BPCI Advanced) model home visit for patient assessment performed by clinical staff for an individual not considered homebound, including, but not necessarily limited to patient assessment of clinical status,
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
Medically Monitored Inpatient Withdrawal Management Service
This is an organized facility-based service that is delivered by medical and nursing professionals who provide 24-hour medically directed observation, evaluation, monitoring, and withdrawal management in a licensed facility. This is for a beneficiary whose withdrawal signs and symptoms are sufficiently severe to require 24-hour observation, monitoring, and treatment in a medically monitored inpatient setting. A beneficiary at this level of care does not need the full resources of an acute care general hospital or a medically managed intensive inpatient treatment program.
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 unit = 1 day
Exclusions
- 1. Provider shall verify each Medicaid beneficiary’s eligibility each time a service is rendered.
- 2. Clinical and administrative supervision is covered as an indirect cost and part of the rate
- 3. Service must not be billed on the same day (except day of admission or discharge) as: Residential levels of care; Other withdrawal management services; Outpatient treatment services; SAIOP; SACOT; ACT; CST; Supported Employment; Psychiatric Rehabilitation; Peer Support Services; Mobile Crisis Management; Partial Hospitalization; Facility Based Crisis (Adult)
- 4. Detoxification rating scale tables, e.g., Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Are), and flow sheets, which include tabulation of vital signs, are to be used as needed, or any other nationally normed scale.
Age Group Details
Adolescents and Adults (aged 18 and older)
Level of Care
ASAM Level 3.7 WM. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.
How to Submit
N/A - No authorization is required
Resources
State-Funded Clinically Managed Residential Withdrawal Management Service Definition
This is a facility-based service delivered by trained staff who provide 24-hour supervision, observation, and support for a member who is intoxicated or experiencing withdrawal, intended for a member who is not at risk of severe withdrawal symptoms or severe physical and psychiatric complications. Moderate withdrawal symptoms can be safely managed at this LOC. This service emphasizes the utilization of peer and social supports to safely assist a member through withdrawal. Programs must have established clinical protocols developed and supported by a physician who is available 24 hours a day. Support systems must include direct coordination with other LOC. This service is designed to achieve safe and comfortable withdrawal from alcohol and other substances to effectively facilitate the member’s transition into ongoing tx and recovery.
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 unit = 1 day
Limits
- 1. A minimum of 2 staff must be on-site at all times, and the staffing ratio must be at least 1 staff to 9 members.
- 2. Program must have staff to screen and accept admissions a minimum of 12 hours a day, 7 days a week. At least 5 of these 12 hours must occur during second shift.
- 3. Service can be received from only one provider during any active episode of care.
Exclusions
Service must not be billed on the same day (except day of admission or discharge) as Residential levels of care; Other withdrawal management services; Outpatient treatment services; SAIOP; SACOT; ACT; CST; Supported Employment; Psychiatric Rehabilitation; PSS; Mobile Crisis; Partial Hospitalization; and Facility Based Crisis.
Diagnosis Requirements
Primary Substance Use Diagnosis only
Level of Care
ASAM Level 3.2 WM. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G Section .3200
How to Submit
N/A - No authorization is required
Resources
Clinically Managed Residential Withdrawal Management Services (i.e., Social Setting Detox)
Clinically Managed Residential Withdrawal Management Services (i.e., Social Setting Detox)
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
1 Unit = 1 Day
Limits
- 1. Programs are expected to coordinate with other agencies and entities involved in the member’s care including social services, juvenile justice, medical providers, and care management providers.
- 2. Program must provide educational services (typically on-site) according to local regulations that are designed to maintain the educational and intellectual development of the adolescent. This service must provide opportunities to remedy deficits in the educational level of an adolescent who has fallen behind because of their involvement with alcohol and other drugs.
- 3. Provider shall verify each Medicaid member’s eligibility each time a service is rendered.
Exclusions
The service must not be billed on the same day (except day of admission or discharge) as Residential levels of care; Other withdrawal management services; Outpatient treatment services; SAIOP; SACOT; ACT; CST; Supported Employment; Psychiatric Rehabilitation; PSS, Mobile Crisis, Partial Hospitalization; and Facility Based Crisis
Diagnosis Requirements
An adult w/ an SUD in need of withdrawal management services who is not at risk of severe withdrawal symptoms or severe physical and psychiatric complications.
Age Group Details
Adults (aged 18+)
Level of Care
ASAM Level 3.2 WM. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G Section .3200. Refer to Tribal & Urban Indian Health Centers | HRSA when the service is provided by IHS.
Additional Service Specifics
A beneficiary may receive this service from only one provider organization during an active episode of care.
How to Submit
N/A - No authorization is required
Resources
H0012 HA-Clinically Managed Residential Services-Adolescent
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
Adolescent-State-Funded Clinically Managed Residential Services Service Definition
This LOC is for an adolescent experiencing impaired functioning across a broad range of psychosocial domains, including disruptive behaviors; delinquency; juvenile justice involvement; educational difficulties; family conflicts; developmental immaturity; and impaired psychological functioning. This LOC frequently works with adolescents who are impulsive, displaying severe conduct problems, and struggling with interpersonal relationships, hostility, and aggression. This program operates under protocols for the management of medical or behavioral health emergencies and is staffed by clinicians and professional staff who have training and experience working with an adolescent diagnosed with SUD and co-occurring mental health conditions.
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 unit = 1 day
Limits
- 1. A minimum of 2 awake staff must be onsite when a member is present.
- 2. This service must have the availability of specialized medical consultation; the ability to arrange for medical procedures, including indicated laboratory and toxicology testing; the ability to arrange for medical and psychiatric treatment through consultation; the ability to refer to off-site, concurrent treatment services or transfer to another level of care; and direct affiliations with other levels of care to effectively facilitate the member’s transition into ongoing treatment and recovery.
- 3. Programs are expected to coordinate with other agencies and entities involved in the member’s care such as social services, local school districts, juvenile justice, and medical providers.
- 4. Providers must provide or directly link to educational services that are provided according to local regulations, designed to maintain the educational and intellectual development of the member and, when indicated, provide opportunities to remedy deficits in the educational level of a member who has fallen behind because of their involvement with alcohol and other substances
- 5. Service can be received from only one provider during any active episode of care.
Exclusions
Service must not be billed on the same day (except day of admission or discharge) as Other residential levels of care; Withdrawal management services; SAIOP; SACOT; PSR; PSS; Partial Hospitalization; Facility Based Crisis; PRTF; ACT; CST.
Diagnosis Requirements
Must have a primary SUD
Age Group Details
Adolescent (aged 12-17)
Level of Care
ASAM Level 3.5. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and documented the determination for continued stay, discharge, or transfer to another LOC.
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G.5600
How to Submit
N/A - No authorization is required
Resources
Clinically Managed Medium-Intensity Residential Service - Adolescent
This level of care is for an adolescent experiencing impaired functioning that includes disruptive behaviors, delinquency, juvenile justice involvement, educational difficulties, family conflicts, developmental immaturity, and impaired psychological functioning. This level of care frequently works with adolescents who are impulsive, displaying severe conduct problems, and struggling with interpersonal relationships, hostility, and aggression. This service operates under protocols for the management of medical or behavioral health emergencies. Programs are staffed by clinicians and professional staff who have training and experience working with adolescents diagnosed with SUD and co-occurring mental health conditions. Clinicians and professional staff shall be available 24 hours a day.
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
1 Unit = 1 Day
Limits
- 1. Programs are expected to coordinate with other agencies and entities involved in the member’s care such as social services, local school districts, juvenile justice, and medical providers.
- 2. Provider shall verify each Medicaid member’s eligibility each time a service is rendered.
- 3. A minimum of 2 awake staff must be onsite when a member is present.
- 4. Provider must notify the member’s care coordinator on the first day of admission to the service to coordinate services.
Exclusions
Must not be provided or billed on the same day (except day of admission or discharge) as other residential levels of care; Withdrawal management services; SAIOP; SACOT; PSR; PSS; Partial Hospitalization; Facility Based Crisis; PRTF; ACT; CST. A beneficiary may receive Clinically Managed Residential Services from only one provider organization during an active episode of care.
Diagnosis Requirements
Must have a primary SUD.
Age Group Details
Adolescents (aged 12-17)
Level of Care
ASAM Level 3.5. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G.5600. Refer to Tribal & Urban Indian Health Centers | HRSA when the service is provided by IHS.
How to Submit
N/A - No authorization is required
Resources
Adult Clinically Managed High-Intensity Residential Service
This LOC is for an adult member with a primary SUD whose functional limitations necessitate a safe and stable living environment to develop and demonstrate sufficient recovery skills. This LOC is designed to prevent immediate relapse or continued use in an imminently dangerous manner upon transfer to a lower, less intensive LOC. An adult member meeting this LOC may have significant mental health support needs along with psychological and self-management functional limitations. The member may have a history of physical, sexual, or emotional trauma; a history of, or current involvement with, the justice system; limited education or work history; inadequate anger management skills; and extreme impulsivity. The program has protocols in place for the management of medical and behavioral health emergencies and is staffed by clinicians and professional staff who have training and experience working with adults diagnosed with primary substance use disorders and co-occurring mental health conditions.
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 unit = 1 day
Limits
- 1. A minimum of 2 staff must be on-site when a member is present.
- 2. Provider must have the availability of specialized medical consultation; the ability to arrange for medical procedures, including indicated laboratory and toxicology testing; the ability to arrange for medical and psychiatric treatment through consultation, referral to offsite concurrent treatment services, or transfer to another level of care; and direct affiliations with other levels of care to effectively facilitate the member’s transition into ongoing treatment and recovery.
- 3. Provider must have agreements in place with IPS providers and DVR offices to facilitate the direct referral of a member to these services for support in employment and education-related goals.
- 4. Providers must coordinate with housing providers and a member’s care coordinator to support the member having safe/ stable housing to transition to after discharge.
- 5. Service can be received from only one provider during any active episode of care.
Exclusions
Service must not be billed on the same day (except day of admission or discharge) as Other residential levels of care; Withdrawal management services; SAIOP; SACOT; PSR; PSS; Partial Hospitalization; Facility Based Crisis; PRTF; ACT; CST.
Diagnosis Requirements
Must have a primary SUD
Level of Care
ASAM Level 3.5. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and documented the determination for continued stay, discharge, or transfer to another LOC.
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G.5600
How to Submit
N/A - No authorization is required
Resources
Clinically Managed High-Intensity Residential Service – Adult
The member’s functional limitations necessitate a safe and stable living environment to develop and demonstrate sufficient recovery skills. This level of care is designed to prevent immediate relapse or continued use in an imminently dangerous manner upon transfer to a lower, less intensive level of care. An adult member meeting this level of care may have significant mental health support needs along with psychological and self-management functional limitations. The member may have a history of physical, sexual, or emotional trauma; a history of, or current involvement with, the justice system; limited education or work history; inadequate anger management skills; and extreme impulsiveness. The service has protocols in place for the management of medical and behavioral health emergencies. Programs are staffed by clinicians and professional staff who have training and experience working with adults diagnosed with primary substance use disorders and co-occurring mental health conditions. Clinicians and professional staff are available 24 hours a day.
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
1 Unit = 1 Day
Limits
- 1. Provider must have agreements in place with IPS providers and DVR offices to facilitate the direct referral of a member to these services for support in employment and education-related goals.
- 2. Provider must coordinate with housing providers and a member’s care coordinator to support member having safe/ stable housing to transition to at time of discharge.
- 3. Provider shall verify each Medicaid member’s eligibility each time a service is rendered.
- 4. A minimum of 2 staff shall be on-site when a member is present.
- 5. Provider must notify the member’s care coordinator on the first day of admission to the service to coordinate services.
Exclusions
Must not be provided or billed on the same day (except day of admission or discharge) as other residential levels of care; Withdrawal management services; SAIOP; SACOT; PSR; PSS; Partial Hospitalization; Facility Based Crisis; PRTF; ACT; CST
Diagnosis Requirements
Adults w/ a primary SUD.
Age Group Details
Adults (aged 18+)
Level of Care
ASAM Level 3.5. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G.5600. Refer to Tribal & Urban Indian Health Centers | HRSA when the service is provided by IHS.
How to Submit
N/A - No authorization is required
Resources
Pregnant & Parenting State-Funded Clinically Managed Residential Services Service Definition
This LOC is for a member with substance use, or co-occurring mental health issues, who would benefit from a structured, residential LOC providing support to strengthen the parent-child dyad. Services must be designed to provide a safe and healthy environment for parents and their children. A member meeting this LOC can benefit from targeted SU interventions that increase the incidence of prenatal visits; improve birth outcomes, lower overall health costs; and improve health outcomes for the member, infant, and other children.
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 unit = 1 day
Limits
- 1. A minimum of 2 staff must be on-site when a member is present.
- 2. Providers must ensure that children receive age and developmentally appropriate screening and assessments, and evidence-based tx, and therapies based on MN needs.
- 3. Providers must directly link to education services for children and adolescents residing in the program. Education services must be provided according to local regulations.
- 4. Providers must coordinate with the local DSS office when working with a member who has DSS involvement.
- 5. Provider must coordinate with housing providers and a member’s care coordinator to support the member in having safe/ stable housing to transition to after discharge.
- 6. Service can be received from only one provider during any active episode of care.
Exclusions
Service must not be billed on the same day (except day of admission or discharge) as Other residential levels of care; Withdrawal management services; SAIOP; SACOT; PSR; PSS; Partial Hospitalization; Facility Based Crisis; PRTF; ACT; CST.
Diagnosis Requirements
Must have a primary SUD and be pregnant or a parenting member with a dependent minor child(ren) in their physical custody
Age Group Details
Adolescent or Adult (aged 12+)
Level of Care
ASAM Level 3.5. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and documented the determination for continued stay, discharge, or transfer to another LOC.
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G .4100
How to Submit
N/A - No authorization is required
Resources
Clinically Managed High-Intensity Residential Services - Pregnant and Parenting
Clinically Managed High-Intensity Residential Services - Pregnant and Parenting
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
1 Unit = 1 Day
Limits
- 1. Providers must ensure that children receive age and developmentally appropriate screening and assessments, and evidence-based tx, and therapies based on MN needs.
- 2. Service must directly link to medical care (prenatal, postpartum, pediatric, and primary) to support both the member and the infant and other children.
- 3. Service must directly link to education services for children and adolescents residing in the program. Education services must be provided according to local regulations.
- 4. Provider must coordinate with the local DSS office when working with a member who has DSS involvement.
- 5. Provider must coordinate with housing providers and a member’s care coordinator to support the member in having safe/ stable housing to transition to after discharge.
- 6. Provider shall verify each Medicaid member’s eligibility each time a service is rendered.
- 7. A minimum of 2 staff shall be on-site at all times when a member is present.
- 8. Provider must notify the member’s care coordinator on the first day of admission to the service to coordinate services.
Exclusions
Must not be provided or billed on the same day (except day of admission or discharge) as other residential levels of care; Withdrawal management services; SAIOP; SACOT; PSR; PSS; Partial Hospitalization; Facility Based Crisis; PRTF; ACT; CST
Diagnosis Requirements
Adults w/ a primary SUD.
Age Group Details
Adults (aged 18+)
Level of Care
ASAM Level 3.5. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G Section .4100. Refer to Tribal & Urban Indian Health Centers | HRSA when the service is provided by IHS.
How to Submit
N/A - No authorization is required
Resources
Substance Abuse Medically Monitored Community Residential Treatment Services
A nonhospital rehab facility for adults, with twenty-four hour a day medical or nursing monitoring, where a planned program of professionally directed evaluation, care and tx for the restoration of functioning for individuals with alcohol and other drug problems or addiction occurs. The expected outcome is abstinence.
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: prior approval required
- 2. CCA: Required
- 3. Complete PCP: recently reviewed detailing the member’s progress with the service.
- 4. Service Order: Required, signed by a physician, licensed psychologist, PA, or NP.
- 5. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 6. Submission of all records that support the individual has met the medical necessity criteria.
Unit Value
One unit = 1 day
Length of Stay
- 1. Up to 10 days per authorization.
- 2. This is a short-term service that may not exceed more than 45 days in a 12-month period.
Exclusions
- 1. This service may not be billed the same day as any other mental health or substance abuse service except CST or ACT.
- 2. When furnished in a Facility that does not exceed 16 beds and is not an Institution for Mental Diseases [IMD], room and board are not included.
- 3. Upon completion of the service there will be successful linkage to the community of the member’s choice for ongoing step down or support services.
Diagnosis Requirements
Primary Substance Use Diagnosis only
Level of Care
ASAM Level 3.7 Medically Monitored Intensive Inpatient Services. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Medically Monitored Intensive Inpatient Services - Adult
This is an organized service delivered by clinical and support staff in a 24-hour facility. This service provides professionally directed evaluation, observation, medical monitoring, and addiction treatment. This LOC is for an adult member aged 18 and over who is experiencing functional limitations in dimensions one, two, or three. This service operates under protocols for the management of medical or behavioral health emergencies. Programs are staffed by an interdisciplinary team that includes physicians, nurses, addiction counselors, and behavioral health specialists who are available 24 hours a day. Staff must be trained and experienced in working with adults diagnosed with substance use disorders. This service is for a member whose subacute biomedical and emotional, behavioral, or cognitive problems are so severe that they require inpatient treatment. A member meeting this LOC does not need the full resources of an acute care general hospital or a medically managed inpatient treatment program.
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
1 Unit = 1 Day
Limits
- 1. Service must coordinate with services to support the members’ transition to safe and stable housing after discharge.
- 2. Provider shall verify each Medicaid member’s eligibility each time a service is rendered.
Exclusions
This service must not be provided and billed on the same day (except day of admission or discharge) as other residential levels of care; withdrawal management services; Outpatient Behavioral Health Services; SAIOP; SACOT; ACT; CST; Supported Employment; PSR; PSS; Partial Hospitalization; Facility Based Crisis; Mobile Crisis.
Diagnosis Requirements
Adults w/ a substance use disorder
Age Group Details
Adults (aged 18+)
Level of Care
ASAM Level 3.7. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G Section .3400. Refer to Tribal & Urban Indian Health Centers | HRSA when the service is provided by IHS.
How to Submit
N/A - No authorization is required
Resources
State-Funded Medically Monitored Intensive Inpatient Services Service Definition
This service provides professionally directed evaluation, observation, medical monitoring, and SUD tx for an adult member who is experiencing functional limitations in ASAM dimensions one, two, or three. This program operates under protocols for the management of medical or behavioral health emergencies and is staffed by an interdisciplinary team that includes physicians, nurses, addiction counselors, and behavioral health specialists who are available 24 hours a day. Staff must be trained and experienced in working with adults diagnosed with substance use disorders. This service is for a member whose subacute biomedical and emotional, behavioral, or cognitive problems are so severe that they require inpatient treatment. A member meeting this level of care does not need the full resources of an acute care general hospital or a medically managed inpatient treatment program.
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 unit = 1 day
Limits
Service must coordinate with services to support the members’ transition to safe and stable housing after discharge.
Exclusions
Service must not be billed on the same day (except day of admission or discharge) as Other residential levels of care; Withdrawal management services; Outpatient Behavioral Health Services; SAIOP; SACOT; ACT; CST; Supported Employment; PSR; PSS; Partial Hospitalization; Facility Based Crisis; and Mobile Crisis.
Diagnosis Requirements
Must have a primary SUD
Level of Care
ASAM Level 3.7. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and documented the determination for continued stay, discharge, or transfer to another LOC.
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G .3400
How to Submit
N/A - No authorization is required
Resources
Medically Monitored High-Intensity Inpatient Services - Adolescent
This service provides professionally directed evaluation, observation, medical monitoring, and SUD tx for an adolescent who is experiencing impaired functioning in ASAM dimensions one, two, or three. These impairments may include co-occurring psychiatric disorders (such as depressive disorders, bipolar disorders, and attention deficit hyperactivity disorder) or symptoms (such as hypomania, severe lability, mood dysregulation, disorganization or impulsiveness, or aggressive behaviors). This program operates under protocols for the management of medical or behavioral health emergencies and is staffed by an interdisciplinary team that includes physicians, nurses, addiction counselors, and behavioral health specialists. This team can assess and treat the member and obtain and interpret information regarding the member’s psychiatric and substance use disorders.
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 unit = 1 day
Limits
- 1. Programs are expected to coordinate with other agencies and entities involved in the member’s care including social services, juvenile justice, medical providers, and care management providers.
- 2. Program must provide educational services (typically on-site) according to local regulations that are designed to maintain the educational and intellectual development of the adolescent. This service must provide opportunities to remedy deficits in the educational level of an adolescent who has fallen behind because of their involvement with alcohol and other drugs.
Exclusions
Service must not be billed on the same day (except day of admission or discharge) as Other residential levels of care; Withdrawal management services; Outpatient Behavioral Health Services; SAIOP; SACOT; ACT; CST; Supported Employment; PSR; PSS; Partial Hospitalization; Facility Based Crisis; and Mobile Crisis.
Diagnosis Requirements
Must have a primary SUD
Age Group Details
Adolescent (aged 12-17)
Level of Care
ASAM Level 3.7. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and documented the determination for continued stay, discharge, or transfer to another LOC.
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G .3400
How to Submit
N/A - No authorization is required
Resources
Medically Monitored High-Intensity Inpatient Services - Adolescent
This service provides professionally directed evaluation, observation, medical monitoring, and addiction treatment. This LOC is for an adolescent member aged 12 to 17 who is experiencing impaired functioning in dimensions one, two, or three. These impairments may include co-occurring psychiatric disorders (such as depressive disorders, bipolar disorders, and attention deficit hyperactivity disorder) or symptoms (such as hypomania, severe lability, mood dysregulation, disorganization or impulsiveness, or aggressive behaviors). The service operates under protocols for the management of medical or behavioral health emergencies. Programs are staffed by an interdisciplinary team that includes physicians, nurses, addiction counselors, and behavioral health specialists. This team can assess and treat the member and obtain and interpret information regarding the member’s psychiatric and substance use disorders.
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
1 Unit = 1 Day
Limits
- 1. Provider shall verify each Medicaid member’s eligibility each time a service is rendered
- 2. A minimum of 2 staff shall be on-site at all times when a member is present.
- 3. Must be staffed to screen and accept admissions a minimum of eight (8) hours a day, five (5) days a week.
Exclusions
Must not be provided and billed on the same day (except day of admission or discharge) as: Other residential levels of care, Withdrawal management services, Outpatient treatment services, SAIOP, SACOT, ACT, CST, Supported Employment, PSR, PSS, Partial Hospitalization, Facility Based Crisis (Adult), or TBI State-funded program services.
Diagnosis Requirements
Must have both a substance use disorder and TBI diagnosis
Age Group Details
Adults (aged 18+)
Level of Care
ASAM Level 3.3. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G.5600. Refer to Tribal & Urban Indian Health Centers | HRSA when the service is provided by IHS.
How to Submit
N/A - No authorization is required
Resources
Ambulatory Withdrawal Management (WM) without Extended On-Site Monitoring
This is a service for an individual who is assessed to be at minimal risk of severe withdrawal, free of severe physical and psychiatric complications, and can be safely managed at this level. These services are designed to treat the individual’s level of clinical severity and to achieve safe and comfortable withdrawal from alcohol and other substances to effectively facilitate the individual’s transition into ongoing treatment and recovery.
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: Prior approval required
- 2. CIWA-Ar score, or other comparable standardized scoring system: Required, supporting this LOC
- 3. Updated Service Plan: recently reviewed detailing the recipient’s progress with the service
- 4. Submission of all records that support the recipient has met the medical necessity criteria.
Unit Value
One unit = 15 minutes
Limits
- 1. Service may not be provided on the same day as Substance Use Disorder Withdrawal Management or Residential Services, except on day of admission or discharge
- 2. This facility must be in operation a minimum of 8 hours per day, all 5 weekdays (Monday through Friday), and a minimum of 4 hours daily on the weekend (Saturday and Sunday). The hours of operation must be extended based on an individual’s need. This service must be available for admission seven days per week.
- 3. Discharge planning beginning at admission
- 4. Provider(s) shall verify eligibility each time a service is rendered
- 5. State funds shall not cover clinical and administrative supervision of Level 1 WM staff, which is covered as an indirect cost and part of the rate
- 6. Detoxification rating scale tables, e.g., Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Are), and flow sheets, which include tabulation of vital signs, are to be used as needed, or any other nationally normed scale.
Diagnosis Requirements
Primary Substance Use Diagnosis only
Age Group Details
Adults (age 18 and older)
Level of Care
ASAM Level 1-WM. The ASAM Criteria, Third Edition uses six dimensions to create a holistic, biopsychosocial assessment to be used for service planning and treatment. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.
Resources
Ambulatory Withdrawal Management (WM) WITHOUT Extended On-Site Monitoring
This service is an organized outpatient service that provides medically supervised evaluation, withdrawal management, and referral in a licensed facility. Services are provided in regularly scheduled sessions to be delivered under a defined set of policies and procedures or medical protocols. This is a service for a member who is assessed to be at minimal risk of severe withdrawal, free of severe physical and psychiatric complications, and can be safely managed at this level.
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
1 unit = 15 minutes
Limits
- 1. Provider shall verify each Medicaid member’s eligibility each time a service is rendered
- 2. Facility must operate a minimum of 8 hours per day, all 5 weekdays (Monday through Friday), and a minimum of 4 hours daily on the weekend (Saturday and Sunday). The hours of operation must be extended based on member need. This service must be available for admission seven days per week.
- 3. Services may not be provided on the same day as Substance Use Disorder Withdrawal Management or Residential Services, except on day of admission or discharge.
- 4. Clinical and administrative supervision is covered as an indirect cost and part of the rate
- 5. Detoxification rating scale tables, e.g., Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Are), and flow sheets, which include tabulation of vital signs, are to be used as needed, or any other nationally normed scale.
Diagnosis Requirements
Primary Substance Use Diagnosis only
Age Group Details
Adolescents & Adults (Aged 18 and older)
Level of Care
ASAM Level 1-WM. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.
Place of Service
Services are provided in an outpatient licensed facility
How to Submit
N/A - No authorization is required
Resources
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