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SACOT is a clinically intensive partial hospitalization program that provides skilled tx services in a structured outpatient recovery environment, for a member with a primary SUD diagnosis. SACOT consist of individual, group, and family counseling, medication management through consultation and referral, and service coordination activities. In addition, SACOT must include access to psychiatric, medical, and laboratory services, educational groups, and other therapies.

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 hour

Limits

• 1. SACOT must operate at least 20 hrs per week for at least 4 hrs of services per day, w/ the availability of in person SACOT services at least 5 days per week, with no more than 2 consecutive days w/out services available.
• 2. Provider must verify member’s Medicaid eligibility each time a service is rendered.
• 3. A member is not required to seek services through telehealth and must have access to in-person services.
• 4. Provider must provide crisis response 24-hours-a-day, 7-days-a-week, to a member who is receiving SACOT services.
• 5. A member can receive SACOT services from only one provider during any episode of care.

Length of Stay

One unit = 1 hour (member must attend at least 4 hours a day for this service to be billed).

Exclusions

SACOT must not be provided and billed during the same episode of care (except on the day of admission or discharge) as SAIOP; Individual, family or group therapy for treatment of substance use disorder; Clinically Managed Residential Withdrawal Management; Medically Monitored Inpatient Withdrawal Management; Clinically Managed Low-Intensity Residential Treatment Services; Clinically Managed Population-Specific High-Intensity Residential Programs; Clinically Managed High-Intensity Residential Services; Medically Monitored Intensive Inpatient Services; and Partial Hospitalization.

Diagnosis Requirements

Primary Substance Use Diagnosis only

Age Group Details

Adults (aged 18+)

Level of Care

ASAM Level 2.5. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the 6 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 .4500. 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

• Clinical Coverage Policy No 8A-13: Substance Abuse Comprehensive Outpatient Treatment
• Records Management and Documentation Manual

Authorization Guidelines

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

How to Submit

Please submit your request to Trillium Health Resources

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

Authorization Guidelines

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

How to Submit

N/A - No authorization is required

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

Authorization Guidelines

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

Limits

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Training and retraining sessions are reimbursed at the same rate.

Exclusions

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

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

Medicaid shall not cover the following Dialysis Services:

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

monthly capitation;

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

Department of Social Services for assistance;

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

the training facility; and

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

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

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

Place of Service

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

How to Submit

N/A - No authorization is required

Resources

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

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

Authorization Guidelines

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

Limits

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Training and retraining sessions are reimbursed at the same rate.

Exclusions

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

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

Medicaid shall not cover the following Dialysis Services:

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

monthly capitation;

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

Department of Social Services for assistance;

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

the training facility; and

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

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

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

Place of Service

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

How to Submit

N/A - No authorization is required

Resources

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

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

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

Authorization Guidelines

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

Limits

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Training and retraining sessions are reimbursed at the same rate.

Exclusions

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

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

Medicaid shall not cover the following Dialysis Services:

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

monthly capitation;

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

Department of Social Services for assistance;

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

the training facility; and

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

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

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

Place of Service

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

How to Submit

N/A - No authorization is required

Resources

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

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

Authorization Guidelines

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

Limits

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Training and retraining sessions are reimbursed at the same rate.

Exclusions

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

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

Medicaid shall not cover the following Dialysis Services:

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

monthly capitation;

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

Department of Social Services for assistance;

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

the training facility; and

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

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

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

Place of Service

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

How to Submit

N/A - No authorization is required

Resources

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

Authorization Guidelines

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

How to Submit

N/A - No authorization is required

Authorization Guidelines

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

How to Submit

N/A - No authorization is required

Authorization Guidelines

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

How to Submit

N/A - No authorization is required

Authorization Guidelines

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

How to Submit

N/A - No authorization is required

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

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

Authorization Guidelines

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

Limits

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Training and retraining sessions are reimbursed at the same rate.

Exclusions

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

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

Medicaid shall not cover the following Dialysis Services:

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

monthly capitation;

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

Department of Social Services for assistance;

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

the training facility; and

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

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

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

Place of Service

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

How to Submit

N/A - No authorization is required

Resources

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

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

Authorization Guidelines

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

Limits

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Training and retraining sessions are reimbursed at the same rate.

Exclusions

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

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

Medicaid shall not cover the following Dialysis Services:

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

monthly capitation;

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

Department of Social Services for assistance;

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

the training facility; and

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

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

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

Place of Service

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

How to Submit

N/A - No authorization is required

Resources

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

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

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

Authorization Guidelines

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

Limits

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Training and retraining sessions are reimbursed at the same rate.

Exclusions

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

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

Medicaid shall not cover the following Dialysis Services:

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

monthly capitation;

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

Department of Social Services for assistance;

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

the training facility; and

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

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

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

Place of Service

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

How to Submit

N/A - No authorization is required

Resources

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

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

Authorization Guidelines

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

Limits

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Training and retraining sessions are reimbursed at the same rate.

Exclusions

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

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

Medicaid shall not cover the following Dialysis Services:

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

monthly capitation;

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

Department of Social Services for assistance;

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

the training facility; and

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

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

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

Place of Service

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

How to Submit

N/A - No authorization is required

Resources

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

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

Authorization Guidelines

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

Limits

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Training and retraining sessions are reimbursed at the same rate.

Exclusions

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

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

Medicaid shall not cover the following Dialysis Services:

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

monthly capitation;

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

Department of Social Services for assistance;

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

the training facility; and

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

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

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

Place of Service

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

How to Submit

N/A - No authorization is required

Resources

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

Human gene therapy aims to manipulate gene expression or alter cellular properties for therapeutic purposes. Gene therapy involves modifying a beneficiary’s genetic makeup to combat or eradicate diseases. This can be achieved through various methods: a. Replacement of a defective gene with a healthy version; b. Deactivation of a malfunctioning gene; or c. Introduction of a new or modified gene to address a specific condition.

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

Prior authorization may be required. Check North Carolina clinical coverage policy 1S-10, Genetic Testing for Carrier and Prenatal for more information

Limits

Medicaid shall not cover Cell & Gene Therapies for ANY one of the following:

• a. The Cell or Gene Therapy has not received approval from the U.S. FDA;
• b. The Cell or Gene Therapy is being administered outside the U.S. FDA label regarding:
• 1. Indications and usage;
• 2. Dosage and administration; or
• 3. Dosage forms and strengths;
• c. The Cell or Gene Therapy is being administered at a facility that has not been approved as a QTC or ATC for that therapy, when required by the manufacturer;
• d. Repeat treatment in a beneficiary who has received the same or another Cell or Gene Therapy previously, except for therapies that require multiple infusions or doses as part of a single treatment course;
• e. When the beneficiary’s psychosocial history limits the beneficiary’s ability to comply with pre- and post-infusion medical care; or
• f. When there is current beneficiary or caretaker non-compliance that would make compliance with a disciplined medical regime improbable.

Medicaid shall also not cover:

• a. Fertility preservation services associated with Cell & Gene Therapy

administration; and

• b. Non-Emergency Medical Transportation (NEMT) for fertility preservation

service appointments.

Exclusions

Billed per treatment.

Administration is limited to inpatient or outpatient settings.

Continued therapy is not authorized because cell and gene therapy is intended as a one-time, lifetime treatment, although some therapies may involve multiple infusions or doses within a single treatment course. It is not covered if the therapy has not received U.S. FDA approval, is administered outside the U.S. FDA label for indications and usage, dosage and administration, or dosage forms and strengths, or is administered at a facility not approved as a Qualified Treatment Center or Authorized Treatment Center when manufacturer approval is required. Repeat treatment after a beneficiary has previously received the same or another cell or gene therapy is not covered, except where multiple infusions or doses are part of a single treatment course. Coverage is also excluded when psychosocial history limits the beneficiary's ability to comply with pre- and post-infusion medical care, or when current beneficiary or caretaker non-compliance makes compliance with a disciplined medical regimen improbable. Fertility preservation services associated with cell and gene therapy administration, and NEMT for fertility preservation appointments, are not covered.

Diagnosis Requirements

This service falls under the cell and gene therapy policy, which is directed to FDA-approved gene therapies and, within the CMS CGT Access Model definitions, to FDA-approved gene therapy for sickle cell disease. Exagamglogene autotemcel is identified by NC Medicaid as a State-Selected Model Drug under the CGT Access Model. A Candidate Beneficiary must have a documented medical diagnosis of sickle cell disease, and Medicaid coverage requires the service to be medically necessary, individualized, specific, and consistent with symptoms or a confirmed diagnosis, safely furnished, and not primarily for convenience. Specific coverage criteria require that the therapy be FDA approved, administered in accordance with the FDA-approved label for indications and usage, dosage and administration, dosage forms and strengths, and warnings and precautions, and administered at a manufacturer-approved QTC or ATC if required. If specific PA criteria exist, those criteria take precedence over the FDA label; otherwise, the FDA label governs.

Place of Service

Inpatient, Outpatient.

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• 1S-13, Genetic Testing - Next Generation Sequencing (NGS)
• Records Management and Documentation Manual