Prior Authorization Services

Initial: No Prior Authorization first 72 hours. Concurrent: 3 days(State Facilties can request 7 days)

• State Funded Policy

Initial: 7 days, Concurrent: 3 day max limit of 10 days 

• Medicaid Policy
• State Funded Policy

Brief Service Description: An ACT team assists a member in advancing toward personal goals with a focus on enhancing community integration and regaining valued roles (example: worker, daughter, resident, spouse, tenant, or friend). A fundamental charge of ACT is to be the first line (and generally sole provider) of all the services that an ACT member needs. A member who is appropriate for ACT does not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, homelessness, substance use, victimization, and incarceration.

Auth Submission Requirements
Initial Requests:
1. TAR: Prior authorization is required.  
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable
3. Complete PCP, to include all required signatures and the 3-page crisis plan: Specific interventions, duration, and frequency for each of the ACT Team staff must be included.  PCP must address the role of all team members including frequency and duration of each role. 
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP (including above detailed requirements): recently reviewed detailing the member’s progress with the service. 
3. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Length of Stay: Up to 180 days per authorization.  

Units:
1. One unit = 1 event 
2. One unit is authorized per month, although a shadow claim should be billed every time an encounter occurs.
3. The expectation is most ACT members will receive more than 4 contacts per month, with most seeing at least 3 team members in a given month.

Age Group: Adults (age 18 and older)

Level of Care: While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): Members with a primary dx of a SU, IDD, TBI, borderline personality disorder, or an autism spectrum disorder are not the intended member group for ACT and should not be referred if they do not have a co-occurring psychiatric disorder. ACT cannot be provided concurrently w/: Outpatient therapy, Med Management, or Psych Services; Mobile Crisis; PSR (after a 30-day transition period); CST; Partial Hospitalization; Tenancy Support Services; Nursing home facility, or IPS-Supported Employment or LTVS.

• Clinical Coverage Policy 8A-1: Assertive Community Treatment (ACT) Program
• Trillium CCB 007 (5/10/2016): Medicaid Funded Services Plan Benefit Changes
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manuals

Brief Service Description: An Assertive Community Treatment (ACT) team consists of a community-based group of medical, behavioral health, and rehabilitation professionals who use a team approach to meet the needs of an individual with severe and persistent mental illness. An individual who is appropriate for ACT does not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, homelessness, substance use, victimization, and incarceration.
Auth Submission Requirements
Initial Requests:
1. TAR: Prior authorization is required.  
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable.
3. Complete PCP: Required, to include all required signatures and the 3-page crisis plan. Specific interventions, duration, and frequency for each of the ACT Team staff must be included.  PCP must address the role of all team individuals including frequency and duration of each role. 
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP (including above detailed requirements): recently reviewed detailing the individual’s progress with the service. 
3. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status. 
4. Submission of all records that support the individual has met the medical necessity criteria.

Authorization Parameters
Length of Stay: 
1. Up to 30 days for all authorization requests.
2. No more than 5 months in a rolling year will be authorized.
3. Team must see individuals, on average, 1.5 times per week for at least 60 minutes per week. It is expected that additional face-to-face and phone contacts are made with individuals, their natural supports, and other providers on their behalf.

Units: 
1. One unit = 1 event.  
2. One unit is auth’d per month, although a shadow claim should be billed every time an encounter occurs.
3. The expectation is most ACT individuals will receive more than 4 contacts per month, with most seeing at least 3 team individuals in a given month.

Age Group: Adults (age 18 and older)

Level of Care: While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. ACT cannot be provided concurrently with: Individual, Group, or Family Outpatient; OPT Med Management; Outpatient Psychiatric Services; d. Mobile Crisis Management; PSR or CST (after a 30-day transition period; Partial Hospitalization; Tenancy Support Services; Nursing home facility, IPS-SE or LTVS.
2. State funds will not cover services provided to individuals with a primary dx of a SU disorder, IDD, ASD, personality disorders, or TBI.

• State-Funded Assertive Community Treatment Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manuals

Brief Service Description: An ACT team assists a member in advancing toward personal goals with a focus on enhancing community integration and regaining valued roles (example: worker, daughter, resident, spouse, tenant, or friend). A fundamental charge of ACT is to be the first line (and generally sole provider) of all the services that an ACT member needs. A member who is appropriate for ACT does not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, homelessness, substance use, victimization, and incarceration.
 

Auth Submission Requirements
Initial Requests:
1. TAR: Prior authorization is required.  
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable
3. Complete PCP, to include all required signatures and the 3-page crisis plan: Specific interventions, duration, and frequency for each of the ACT Team staff must be included.  PCP must address the role of all team members including frequency and duration of each role. 
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP (including above detailed requirements): recently reviewed detailing the member’s progress with the service. 
3. Submission of applicable records that support the member has met the medical necessity criteria.
 

Authorization Parameters
Length of Stay: Up to 180 days per authorization.  

Units:
1. One unit = 1 event 
2. One unit is auth’d per month, although a shadow claim should be billed every time an encounter occurs.
3. The expectation is most ACT members will receive more than 4 contacts per month, with most seeing at least 3 team members in a given month.

Age Group: Adults (age 18 and older)

Level of Care: While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): Members with a primary dx of a SU, IDD, TBI, borderline personality disorder, or an autism spectrum disorder are not the intended member group for ACT and should not be referred if they do not have a co-occurring psychiatric disorder. ACT cannot be provided concurrently w/: Outpatient therapy, Med Management, or Psych Services; Mobile Crisis; PSR (after a 30-day transition period); CST; Partial Hospitalization; Tenancy Support Services; Nursing home facility, or IPS-Supported Employment or LTVS.

• Clinical Coverage Policy 8A-1: Assertive Community Treatment (ACT) Program
• Trillium CCB 007 (5/10/2016): Medicaid Funded Services Plan Benefit Change
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manuals

Brief Service Description: An Assertive Community Treatment (ACT) team consists of a community-based group of medical, behavioral health, and rehabilitation professionals who use a team approach to meet the needs of an individual with severe and persistent mental illness. An individual who is appropriate for ACT does not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, homelessness, substance use, victimization, and incarceration.
 

Auth Submission Requirements
Initial Requests:
1. TAR: Prior authorization is required.  
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable.
3. Complete PCP: Required, to include all required signatures and the 3-page crisis plan. Specific interventions, duration, and frequency for each of the ACT Team staff must be included.  PCP must address the role of all team individuals including frequency and duration of each role. 
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP (including above detailed requirements): recently reviewed detailing the individual’s progress with the service. 
3. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status. 
4. Submission of all records that support the individual has met the medical necessity criteria.

Authorization Parameters
Length of Stay: 
1. Up to 30 days for all authorization requests.
2. No more than 5 months in a rolling year will be authorized.
3. Team must see individuals, on average, 1.5 times per week for at least 60 minutes per week. It is expected that additional face-to-face and phone contacts are made with individuals, their natural supports, and other providers on their behalf.

Units: 
1. One unit = 1 event.  
2. One unit is auth’d per month, although a shadow claim should be billed every time an encounter occurs.
3. The expectation is most ACT individuals will receive more than 4 contacts per month, with most seeing at least 3 team individuals in a given month.

Age Group: Adults (age 18 and older)

Level of Care: While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. ACT cannot be provided concurrently with: Individual, Group, or Family Outpatient; OPT Med Management; Outpatient Psychiatric Services; d. Mobile Crisis Management; PSR or CST (after a 30-day transition period; Partial Hospitalization; Tenancy Support Services; Nursing home facility, IPS-SE or LTVS.
2. State funds will not cover services provided to individuals with a primary dx of a SU disorder, IDD, ASD, personality disorders, or TBI.

• State-Funded Assertive Community Treatment Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manuals

$50,000 limit over the course of five years (the duration of the waiver) when combined with Home Modifications 

• Clinical Coverage Policy

No Prior Authorization

• Policy

No Prior Authorization

• Policy

Initial 60 calendar days of treatment without prior authorization to completed comprehensive battery nof assessments. Services provided after this initial 60 day "pass through" period require authorization. This pass through is only available once per fiscal year. Average length of stay is 9 months. Services may continue beyond 12 months with preapproval

• Policy

Initial 60 calendar days of treatment without prior authorization to completed comprehensive battery nof assessments. Services provided after this initial 60 day "pass through" period require authorization. This pass through is only available once per fiscal year. Average length of stay is 9 months. Services may continue beyond 12 months with preapproval

• Policy

28 hours/week (Indiv or Group; or combination of Indiv & group)

• State Funded Policy

28 hours/week (Indiv or Group; or combination of Indiv & group)

• State Funded Policy

Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, Community Living and Supports.When school is not in session, up to 84 hours per week may be Authrorizationorized. Adult beneficiary who lives in private homes: No more than 84 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports. 

• Clinical Coverage Policy

Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, Community Living and Supports.When school is not in session, up to 84 hours per week may be Authrorizationorized. Adult beneficiary who lives in private homes: No more than 84 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports. 

• Clinical Coverage Policy

Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, Community Living and Supports.When school is not in session, up to 84 hours per week may be Authrorizationorized. Adult beneficiary who lives in private homes: No more than 84 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports. 

• Clinical Coverage Policy

Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, Community Living and Supports.When school is not in session, up to 84 hours per week may be Authrorizationorized. Adult beneficiary who lives in private homes: No more than 84 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports. 

• Clinical Coverage Policy

Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, Community Living and Supports.When school is not in session, up to 84 hours per week may be Authrorizationorized. Adult beneficiary who lives in private homes: No more than 84 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports. 

• Clinical Coverage Policy

Prior authorization is required. Reauthorization every 6 months to ensure level of care eligibility

• Policy

Prior authorization is required. Reauthorization every 6 months to ensure level of care eligibility

• Policy

Prior authorization is required. Reauthorization every 6 months to ensure level of care eligibility

• Policy

Prior authorization is required. Reauthorization every 6 months to ensure level of care eligibility

• Policy

Prior authorization is required. Reauthorization every 6 months to ensure level of care eligibility

• Policy

• Clinical Coverage Policy

• Clinical Coverage Policy

• Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week can be authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized.
• Adult beneficiary who lives in private homes: No more than 84 hours per week is authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.   
• Community Network Classes and Conference- Payment for attendance at classes and conferences cannot exceed $1,000/ per beneficiary plan year. 
• Community Network Transportation does not cover transportation to/from school settings. (Transportation to/from beneficiary’s home or any community location where the beneficiary may be receiving services before/after school is covered for this service.)

• Clinical Coverage Policy

• Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week can be authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized.
• Adult beneficiary who lives in private homes: No more than 84 hours per week is authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.   
• Community Network Classes and Conference- Payment for attendance at classes and conferences cannot exceed $1,000/ per beneficiary plan year. 
• Community Network Transportation does not cover transportation to/from school settings. (Transportation to/from beneficiary’s home or any community location where the beneficiary may be receiving services before/after school is covered for this service.)

• Clinical Policy Coverage

• Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week can be authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized.
• Adult beneficiary who lives in private homes: No more than 84 hours per week is authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.   
• Community Network Classes and Conference- Payment for attendance at classes and conferences cannot exceed $1,000/ per beneficiary plan year. 
• Community Network Transportation does not cover transportation to/from school settings. (Transportation to/from beneficiary’s home or any community location where the beneficiary may be receiving services before/after school is covered for this service.)

• Clinical Coverage Policy

• Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week can be authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized.
• Adult beneficiary who lives in private homes: No more than 84 hours per week is authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.   
• Community Network Classes and Conference- Payment for attendance at classes and conferences cannot exceed $1,000/ per beneficiary plan year. 
• Community Network Transportation does not cover transportation to/from school settings. (Transportation to/from beneficiary’s home or any community location where the beneficiary may be receiving services before/after school is covered for this service.)

• Clinical Coverage Policy

Brief Service Description: Provides direct support to adults with a dx of MH, SU, or comorbid disorder and who have complex and extensive tx needs. This is an intensive community-based rehab team service that provides direct tx and restorative interventions as well as case management.  This service consists of community-based MH and SU services, and structured rehabilitative interventions intended to increase and restore a individuals ability to live successfully in the community. The team approach involves assistance in re-est. the individuals community roles related to the following life domains: emotional, behavioral, social, safety, housing, medical and health, educational, vocational, and legal.

Auth Submission Requirements
Initial Requests:
1. TAR: Prior authorization is required
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable.
3. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of applicable records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the individual’s progress with the service to include all required signatures and the 3-page crisis plan.
3. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status. 
4. Submission of applicable records that support the individual has met the medical necessity criteria.

Authorization Parameters
Length of Stay: 
1. Up to a 60-day auth period per request.
2. No more than 3 months in a rolling year will be authorized.

Units:
1. One unit = 15 minutes
2. Up to 128 units for 60 calendar days. For those searching for stable housing and requiring permanent supportive housing interventions, up to 420 units for the initial authorization period. These additional units have a 3-month max limit per rolling year.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. CST must not be provided in conjunction with ACT; during the same auth period as any other service that contains duplicative service components (to include TMS or PSS); to individuals residing in Institutions for Mental Disease (IMD), and; Family individuals or LRPs of the individual may not provide this service.  
2. To help w/ transition, CST services may be provided for a max of 8 units for the first and last 30-day period for individuals who transitioning to or from: ACTT, SAIOP or SACOT.

• State-Funded Community Support Team Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a MH, SU, or co-morbid disorder and who have complex and extensive treatment needs. Consists of community-based MH and SU services, and structured rehab interventions intended to increase and restore a member’s ability to live successfully in the community. The team approach involves structured, face-to-face therapeutic interventions that assist in reestablishing the members community roles related to life domains.

Auth Submission Requirements
Pass-Through Period: Up to 36 unmanaged units for an initial 30 calendar days.  Unmanaged units are available only once per FY.

Initial Requests (after pass-through):
1. TAR: Prior authorization is required beyond the unmanaged limit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable
3. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Transition/ Stepdown Plan: Encouraged
6. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the member’s progress with the service.
3. CCA: For services lasting more than six months, a new CCA or an addendum must be submitted.
4. Service Order: Service must be ordered at least annually.
5. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units and Length of Stay: 
1. One unit = 15 minutes
2. Initial Request: 128 units for 60 calendar days. Up to 420 units for 60 calendar days available to members searching for stable housing and requiring permanent supportive housing interventions.
3. Reauth Request: up to 192 units for 90 calendar days. Up to 630 units for 90 calendar days for members searching for stable housing and requiring permanent supportive housing interventions.
4. It is expected that service intensity titrates down as the member demonstrates improvement.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. When helping a member transition to and from a service, CST services may be provided for a max of eight units for the first and last 30-day period for members auth’d for: ACTT, SAIOP, SACOT.
2. May not be provided in conjunction with ACTT or during the same auth period as any other State Plan service that contains duplicative service components. This includes PSS, as CCP 8G states that PSS must not be provided during the same auth period as CST, as a member who needs CST and peer support will be offered by peer support by the CST providers.

• Clinical Coverage Policy No 8A-6: Community Support Team
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a dx of MH, SU, or comorbid disorder and who have complex and extensive tx needs. This is an intensive community-based rehab team service that provides direct tx and restorative interventions as well as case management.  This service consists of community-based MH and SU services, and structured rehabilitative interventions intended to increase and restore a individuals ability to live successfully in the community. The team approach involves assistance in re-est. the individuals community roles related to the following life domains: emotional, behavioral, social, safety, housing, medical and health, educational, vocational, and legal.

Auth Submission Requirements
Initial Requests:
1. TAR: Prior authorization is required
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable.
3. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of applicable records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the individual’s progress with the service to include all required signatures and the 3-page crisis plan.
3. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status. 
4. Submission of applicable records that support the individual has met the medical necessity criteria.

Authorization Parameters
Length of Stay: 
1. Up to a 60-day auth period per request.
2. No more than 3 months in a rolling year will be authorized.

Units:
1. One unit = 15 minutes
2. Up to 128 units for 60 calendar days. For those searching for stable housing and requiring permanent supportive housing interventions, up to 420 units for the initial authorization period. These additional units have a 3-month max limit per rolling year.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. CST must not be provided in conjunction with ACT; during the same auth period as any other service that contains duplicative service components (to include TMS or PSS); to individuals residing in Institutions for Mental Disease (IMD), and; Family individuals or LRPs of the individual may not provide this service.  
2. To help w/ transition, CST services may be provided for a max of 8 units for the first and last 30-day period for individuals who transitioning to or from: ACTT, SAIOP or SACOT.

• State-Funded Community Support Team Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a MH, SU, or co-morbid disorder and who have complex and extensive treatment needs. Consists of community-based MH and SU services, and structured rehab interventions intended to increase and restore a member’s ability to live successfully in the community. The team approach involves structured, face-to-face therapeutic interventions that assist in reestablishing the members community roles related to life domains.

Auth Submission Requirements
Pass-Through Period: Up to 36 unmanaged units for an initial 30 calendar days.  Unmanaged units are available only once per FY.

Initial Requests (after pass-through):
1. TAR: Prior authorization is required beyond the unmanaged limit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable
3. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Transition/ Stepdown Plan: Encouraged
6. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the member’s progress with the service.
3. CCA: For services lasting more than six months, a new CCA or an addendum must be submitted.
4. Service Order: Service must be ordered at least annually.
5. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units and Length of Stay: 
1. One unit = 15 minutes
2. Initial Request: 128 units for 60 calendar days. Up to 420 units for 60 calendar days available to members searching for stable housing and requiring permanent supportive housing interventions.
3. Reauth Request: up to 192 units for 90 calendar days. Up to 630 units for 90 calendar days for members searching for stable housing and requiring permanent supportive housing interventions.
4. It is expected that service intensity titrates down as the member demonstrates improvement.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. When helping a member transition to and from a service, CST services may be provided for a max of eight units for the first and last 30-day period for members auth’d for: ACTT, SAIOP, SACOT.
2. May not be provided in conjunction with ACTT or during the same auth period as any other State Plan service that contains duplicative service components. This includes PSS, as CCP 8G states that PSS must not be provided during the same auth period as CST, as a member who needs CST and peer support will be offered by peer support by the CST providers.

• Clinical Coverage Policy No 8A-6: Community Support Team
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a dx of MH, SU, or comorbid disorder and who have complex and extensive tx needs. This is an intensive community-based rehab team service that provides direct tx and restorative interventions as well as case management.  This service consists of community-based MH and SU services, and structured rehabilitative interventions intended to increase and restore a individuals ability to live successfully in the community. The team approach involves assistance in re-est. the individuals community roles related to the following life domains: emotional, behavioral, social, safety, housing, medical and health, educational, vocational, and legal.

Auth Submission Requirements
Initial Requests:
1. TAR: Prior authorization is required
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable.
3. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of applicable records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the individual’s progress with the service to include all required signatures and the 3-page crisis plan.
3. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status. 
4. Submission of applicable records that support the individual has met the medical necessity criteria.

Authorization Parameters
Length of Stay: 
1. Up to a 60-day auth period per request.
2. No more than 3 months in a rolling year will be authorized.

Units:
1. One unit = 15 minutes
2. Up to 128 units for 60 calendar days. For those searching for stable housing and requiring permanent supportive housing interventions, up to 420 units for the initial authorization period. These additional units have a 3-month max limit per rolling year.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. CST must not be provided in conjunction with ACT; during the same auth period as any other service that contains duplicative service components (to include TMS or PSS); to individuals residing in Institutions for Mental Disease (IMD), and; Family individuals or LRPs of the individual may not provide this service.  
2. To help w/ transition, CST services may be provided for a max of 8 units for the first and last 30-day period for individuals who transitioning to or from: ACTT, SAIOP or SACOT.

• State-Funded Community Support Team Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a MH, SU, or co-morbid disorder and who have complex and extensive treatment needs. Consists of community-based MH and SU services, and structured rehab interventions intended to increase and restore a member’s ability to live successfully in the community. The team approach involves structured, face-to-face therapeutic interventions that assist in reestablishing the members community roles related to life domains.

Auth Submission Requirements
Pass-Through Period: Up to 36 unmanaged units for an initial 30 calendar days.  Unmanaged units are available only once per FY.

Initial Requests (after pass-through):
1. TAR: Prior authorization is required beyond the unmanaged limit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable
3. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Transition/ Stepdown Plan: Encouraged
6. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the member’s progress with the service.
3. CCA: For services lasting more than six months, a new CCA or an addendum must be submitted.
4. Service Order: Service must be ordered at least annually.
5. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units and Length of Stay: 
1. One unit = 15 minutes
2. Initial Request: 128 units for 60 calendar days. Up to 420 units for 60 calendar days available to members searching for stable housing and requiring permanent supportive housing interventions.
3. Reauth Request: up to 192 units for 90 calendar days. Up to 630 units for 90 calendar days for members searching for stable housing and requiring permanent supportive housing interventions.
4. It is expected that service intensity titrates down as the member demonstrates improvement.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. When helping a member transition to and from a service, CST services may be provided for a max of eight units for the first and last 30-day period for members auth’d for: ACTT, SAIOP, SACOT.
2. May not be provided in conjunction with ACTT or during the same auth period as any other State Plan service that contains duplicative service components. This includes PSS, as CCP 8G states that PSS must not be provided during the same auth period as CST, as a member who needs CST and peer support will be offered by peer support by the CST providers.
 

• Clinical Coverage Policy No 8A-6: Community Support Team
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a dx of MH, SU, or comorbid disorder and who have complex and extensive tx needs. This is an intensive community-based rehab team service that provides direct tx and restorative interventions as well as case management.  This service consists of community-based MH and SU services, and structured rehabilitative interventions intended to increase and restore a individuals ability to live successfully in the community. The team approach involves assistance in re-est. the individuals community roles related to the following life domains: emotional, behavioral, social, safety, housing, medical and health, educational, vocational, and legal.

Auth Submission Requirements
Initial Requests:
1. TAR: Prior authorization is required
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable.
3. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of applicable records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the individual’s progress with the service to include all required signatures and the 3-page crisis plan.
3. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status. 
4. Submission of applicable records that support the individual has met the medical necessity criteria.

Authorization Parameters
Length of Stay: 
1. Up to a 60-day auth period per request.
2. No more than 3 months in a rolling year will be authorized.

Units:
1. One unit = 15 minutes
2. Up to 128 units for 60 calendar days. For those searching for stable housing and requiring permanent supportive housing interventions, up to 420 units for the initial authorization period. These additional units have a 3-month max limit per rolling year.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. CST must not be provided in conjunction with ACT; during the same auth period as any other service that contains duplicative service components (to include TMS or PSS); to individuals residing in Institutions for Mental Disease (IMD), and; Family individuals or LRPs of the individual may not provide this service.  
2. To help w/ transition, CST services may be provided for a max of 8 units for the first and last 30-day period for individuals who transitioning to or from: ACTT, SAIOP or SACOT.

• State-Funded Community Support Team Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a MH, SU, or co-morbid disorder and who have complex and extensive treatment needs. Consists of community-based MH and SU services, and structured rehab interventions intended to increase and restore a member’s ability to live successfully in the community. The team approach involves structured, face-to-face therapeutic interventions that assist in reestablishing the members community roles related to life domains.

Auth Submission Requirements
Pass-Through Period: Up to 36 unmanaged units for an initial 30 calendar days.  Unmanaged units are available only once per FY.

Initial Requests (after pass-through):
1. TAR: Prior authorization is required beyond the unmanaged limit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable
3. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Transition/ Stepdown Plan: Encouraged
6. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the member’s progress with the service.
3. CCA: For services lasting more than six months, a new CCA or an addendum must be submitted.
4. Service Order: Service must be ordered at least annually.
5. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units and Length of Stay: 
1. One unit = 15 minutes
2. Initial Request: 128 units for 60 calendar days. Up to 420 units for 60 calendar days available to members searching for stable housing and requiring permanent supportive housing interventions.
3. Reauth Request: up to 192 units for 90 calendar days. Up to 630 units for 90 calendar days for members searching for stable housing and requiring permanent supportive housing interventions.
4. It is expected that service intensity titrates down as the member demonstrates improvement.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. When helping a member transition to and from a service, CST services may be provided for a max of eight units for the first and last 30-day period for members auth’d for: ACTT, SAIOP, SACOT.
2. May not be provided in conjunction with ACTT or during the same auth period as any other State Plan service that contains duplicative service components. This includes PSS, as CCP 8G states that PSS must not be provided during the same auth period as CST, as a member who needs CST and peer support will be offered by peer support by the CST providers.

• Clinical Coverage Policy No 8A-6: Community Support Team
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a dx of MH, SU, or comorbid disorder and who have complex and extensive tx needs. This is an intensive community-based rehab team service that provides direct tx and restorative interventions as well as case management.  This service consists of community-based MH and SU services, and structured rehabilitative interventions intended to increase and restore a individuals ability to live successfully in the community. The team approach involves assistance in re-est. the individuals community roles related to the following life domains: emotional, behavioral, social, safety, housing, medical and health, educational, vocational, and legal.

Auth Submission Requirements
Initial Requests:
1. TAR: Prior authorization is required
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable.
3. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of applicable records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the individual’s progress with the service to include all required signatures and the 3-page crisis plan.
3. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status. 
4. Submission of applicable records that support the individual has met the medical necessity criteria.

Authorization Parameters
Length of Stay: 
1. Up to a 60-day auth period per request.
2. No more than 3 months in a rolling year will be authorized.

Units:
1. One unit = 15 minutes
2. Up to 128 units for 60 calendar days. For those searching for stable housing and requiring permanent supportive housing interventions, up to 420 units for the initial authorization period. These additional units have a 3-month max limit per rolling year.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. CST must not be provided in conjunction with ACT; during the same auth period as any other service that contains duplicative service components (to include TMS or PSS); to individuals residing in Institutions for Mental Disease (IMD), and; Family individuals or LRPs of the individual may not provide this service.  
2. To help w/ transition, CST services may be provided for a max of 8 units for the first and last 30-day period for individuals who transitioning to or from: ACTT, SAIOP or SACOT.

• State-Funded Community Support Team Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a MH, SU, or co-morbid disorder and who have complex and extensive treatment needs. Consists of community-based MH and SU services, and structured rehab interventions intended to increase and restore a member’s ability to live successfully in the community. The team approach involves structured, face-to-face therapeutic interventions that assist in reestablishing the members community roles related to life domains.

Auth Submission Requirements
Pass-Through Period: Up to 36 unmanaged units for an initial 30 calendar days.  Unmanaged units are available only once per FY.

Initial Requests (after pass-through):
1. TAR: Prior authorization is required beyond the unmanaged limit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable
3. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Transition/ Stepdown Plan: Encouraged
6. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the member’s progress with the service.
3. CCA: For services lasting more than six months, a new CCA or an addendum must be submitted.
4. Service Order: Service must be ordered at least annually.
5. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units and Length of Stay: 
1. One unit = 15 minutes
2. Initial Request: 128 units for 60 calendar days. Up to 420 units for 60 calendar days available to members searching for stable housing and requiring permanent supportive housing interventions.
3. Reauth Request: up to 192 units for 90 calendar days. Up to 630 units for 90 calendar days for members searching for stable housing and requiring permanent supportive housing interventions.
4. It is expected that service intensity titrates down as the member demonstrates improvement.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. When helping a member transition to and from a service, CST services may be provided for a max of eight units for the first and last 30-day period for members auth’d for: ACTT, SAIOP, SACOT.
2. May not be provided in conjunction with ACTT or during the same auth period as any other State Plan service that contains duplicative service components. This includes PSS, as CCP 8G states that PSS must not be provided during the same auth period as CST, as a member who needs CST and peer support will be offered by peer support by the CST providers.

• Clinical Coverage Policy No 8A-6: Community Support Team
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service provides funding for an individual to move from an institutional setting into his/her own private residence in the community or to divert an enrollee from entering an adult care home. Institutional settings include adult care homes, Institutions for Mental Diseases (IMDs), State Psychiatric Hospitals, ICF-IIDs, nursing facilities, PRTFs, or alternative family living arrangements. This service may only be provided in a private home or apartment with a lease in the beneficiary’s / legal guardian’s / representative’s name or a home owned by the beneficiary.

Auth Submission Requirements
Initial Requests:
1. TAR: prior authorization required
2. Community Transition Checklist
3. Meets ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22 or TBI

Reauthorization Requests:
None - may be provided only once during the five-year waiver period

Authorization Parameters
Length of Stay: May be provided only once per waiver period and has a lifetime limit of $5,000 per individual

Age Group: Adults with I/DD or SPMI

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Expenses are covered only to the extent that the member is unable to meet such an expense or when other support cannot be obtained.
2. Service does not include: Monthly rental or mortgage expenses; regular utility bills; Rec items such as televisions, CD/DVD players and components; service and maintenance contracts and extended warranties. 
3. Service cannot duplicate services currently being provided by educational institutions or VR.
4. Individuals on the Innovations waiver are not eligible for (b)(3) funded services.
5. Community Transition may not be provided by family members.

• Trillium CCB #37: 1915(i) waiver services and new B3 codes
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual
• Clinical Coverage Policy 8E: Intermediate Care Facilities for Individuals with …

The cost of Community Transition has a life of the waiver limit of $5,000.00 per beneficiary. Community Transition includes the actual cost of services and does not cover provider overhead charges. Authorization per plan year.

• Clinical Coverage Policy

Per Plan Year, Crisis Supports are an immediate intervention available 24 hours per day, 7 days per week, to support the individual. Following Authorization any modification to the ISP and budget must occur within 5 working days of the verbal service Authorization. Crisis Intervention & Stabilization Supports may be Authrorizationorized for periods of up to 14 calendar day increments per event.

• Clinical Coverage Policy

Per Plan Year, Crisis Supports are an immediate intervention available 24 hours per day, 7 days per week, to support the individual. Following Authrorization any modification to the ISP and budget must occur within 5 working days of the verbal service Authorization. Crisis Intervention & Stabilization Supports may be Authorization for periods of up to 14 calendar day increments per event.

• Clinical Coverage Policy
• Clinical Coverage Policy

Utilization review up to 7 days

Required Documentation

• Hospital discharge plan

• Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized  for any combination of community networking, day supports, supported employment, Community Living and Supports.
• When school is not in session, up to 84 hours per week may be authorized.
• Adult beneficiary who lives in private homes: No more than 84 hours per week is authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.    
• Developmental Day: For school-aged or younger children. Developmental Day provides individual habilitative programming in a licensed childcare center. Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized. 

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized  for any combination of community networking, day supports, supported employment, Community Living and Supports.
• When school is not in session, up to 84 hours per week may be authorized.
• Adult beneficiary who lives in private homes: No more than 84 hours per week is authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.    
• Developmental Day: For school-aged or younger children. Developmental Day provides individual habilitative programming in a licensed childcare center. Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized. 

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized  for any combination of community networking, day supports, supported employment, Community Living and Supports.
• When school is not in session, up to 84 hours per week may be authorized.
• Adult beneficiary who lives in private homes: No more than 84 hours per week is authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.    
• Developmental Day: For school-aged or younger children. Developmental Day provides individual habilitative programming in a licensed childcare center. Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized. 

• Clinical Coverage Policy
• Clinical Coverage Policy

30 hours/week

• State Funded Policy

No Prior Authorization

• Medicaid Policy
• State Funded Policy

Brief Service Description: An in-depth look at a member’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the member, give the member a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements
All Requests: TAR: required if the unmanaged units have been exhausted.  Providers may seek prior authorization if they are unsure the member has reached their unmanaged visit limit.  To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.

Authorization Parameters
Units: 
1. The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  
2. Up to 9 unmanaged units of 96110: Developmental Testing - Limited.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: An in-depth look at a member’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the member, give the member a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements
All Requests: TAR: required if the unmanaged units have been exhausted.  Providers may seek prior authorization if they are unsure the member has reached their unmanaged visit limit.  To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.

Authorization Parameters
Units: 
1. The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  
2. Up to 9 unmanaged units of 96110: Developmental Testing - Limited.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: An in-depth look at a recipient’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the recipient, give the recipient a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements
All Requests: TAR: required if the unmanaged units have been exhausted.  Providers may seek prior authorization if they are unsure the recipient has reached their unmanaged visit limit.  To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.

Authorization Parameters
Units: 
1. The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  
2. Up to 9 unmanaged units of 96110: Developmental Testing - Limited.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Funding will not cover Outpatient Behavioral Health Services when the service duplicates another service approved with another provider.
2. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
3. The provider shall communicate and coordinate care with others providing care. When the recipient is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: An in-depth look at a recipient’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the recipient, give the recipient a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements
All Requests: TAR: required if the unmanaged units have been exhausted.  Providers may seek prior authorization if they are unsure the recipient has reached their unmanaged visit limit.  To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.

Authorization Parameters
Units: 
1. The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  
2. Up to 9 unmanaged units of 96110: Developmental Testing - Limited.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Funding will not cover Outpatient Behavioral Health Services when the service duplicates another service approved with another provider.
2. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
3. The provider shall communicate and coordinate care with others providing care. When the recipient is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: An in-depth look at a member’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the member, give the member a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements
All Requests: TAR: required if the unmanaged units have been exhausted.  Providers may seek prior authorization if they are unsure the member has reached their unmanaged visit limit.  To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.

Authorization Parameters
Units: 
1. The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  
2. Up to 9 unmanaged units of 96110: Developmental Testing - Limited.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: An in-depth look at a member’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the member, give the member a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements
All Requests: TAR: required if the unmanaged units have been exhausted.  Providers may seek prior authorization if they are unsure the member has reached their unmanaged visit limit.  To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.

Authorization Parameters
Units: 
1. The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  
2. Up to 9 unmanaged units of 96110: Developmental Testing - Limited.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: An in-depth look at a recipient’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the recipient, give the recipient a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements
All Requests: TAR: required if the unmanaged units have been exhausted.  Providers may seek prior authorization if they are unsure the recipient has reached their unmanaged visit limit.  To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.

Authorization Parameters
Units: 
1. The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  
2. Up to 9 unmanaged units of 96110: Developmental Testing - Limited.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Funding will not cover Outpatient Behavioral Health Services when the service duplicates another service approved with another provider.
2. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
3. The provider shall communicate and coordinate care with others providing care. When the recipient is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: An in-depth look at a recipient’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the recipient, give the recipient a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements
All Requests: TAR: required if the unmanaged units have been exhausted.  Providers may seek prior authorization if they are unsure the recipient has reached their unmanaged visit limit.  To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.

Authorization Parameters
Units: 
1. The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  
2. Up to 9 unmanaged units of 96110: Developmental Testing - Limited.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Funding will not cover Outpatient Behavioral Health Services when the service duplicates another service approved with another provider.
2. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
3. The provider shall communicate and coordinate care with others providing care. When the recipient is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Per Plan Year, A beneficiary who chooses to self-direct via the Employer of Record model may require equipment necessary to carry out duties of Employer of Record and may access Employer Supplies.

• Clinical Coverage Policy
• Clinical Coverage Policy

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition
• State-Funded Telehealth and Virtual Services Service Definition

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Brief Service Description: Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Auth Submission Requirements
1. Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior approval.
2. Medicaid Application: Individuals must apply for Medicaid.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

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

• State-Funded Outpatient Behavioral Health Services Service Definition

Currently No Prior Auth (NPA) Level of care criteria for member 
May not exceed 45 days in a 12 month period

• Medicaid Policy
• State Funded Policy

Prior authorization required
Initial and concurrent: Up to 7 days
Billing limits of up to 24 units/day
Age 6-17 years
Within 24-hrs of admission, provider must contact the MCO to determine if the member is enrolled with another service provider or if the member is receiving care coordination. If the member is not already linked with a care coordinator, a referral must be made. 

• Medicaid Policy
• State Funded Policy

• No Prior Authorization is required for the initial length of stay is six months. 
• Any service delivered beyond six months requires authorization. 
• Eligibility for Outcome Payments dependent on the following criteria: 
  • Enrolled in Family Centered Treatment for at least 60 days 
  • No inpatient admissions 
  • No residential Level II or higher from discharge(planned or unplanned discharge) 
  • No return to Family Centered Treatment, admission to Intensive In-Home or Multisystemic Therapy

• Policy

• No Prior Authorization is required for the initial length of stay is six months. 
• Any service delivered beyond six months requires authorization. 
• Eligibility for Outcome Payments dependent on the following criteria: 
  • Enrolled in Family Centered Treatment for at least 60 days 
  • No inpatient admissions 
  • No residential Level II or higher from discharge(planned or unplanned discharge) 
  • No return to Family Centered Treatment, admission to Intensive In-Home or Multisystemic Therapy

• Policy

• No Prior Authorization is required for the initial length of stay is six months. 
• Any service delivered beyond six months requires authorization. 
• Eligibility for Outcome Payments dependent on the following criteria: 
  • Enrolled in Family Centered Treatment for at least 60 days 
  • No inpatient admissions 
  • No residential Level II or higher from discharge(planned or unplanned discharge) 
  • No return to Family Centered Treatment, admission to Intensive In-Home or Multisystemic Therapy

• Policy

Brief Service Description: A residential service which includes room and board and provides "family style" supervision and monitoring of daily activities. Individuals live with a family who act as providers of supportive services. The service providers are supported by the professional staff of the area program or the contract agency with ongoing consultation and education to the service providers in their own homes.

Auth Submission Requirements
Initial Requests:
1. TAR: Prior authorization is required
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable..
3. NC SNAP or SIS: Required, if applicable
4. Service/ Tx Plan: Required

Reauthorization Requests:
1. TAR: prior approval required
2. Service/ Tx Plan: recently reviewed detailing the recipient’s progress with the service.
3. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status.

Authorization Parameters
Length of Stay: Request length of stay can be for up to one fiscal year or the end of the PCP (whichever comes first).

Units: One unit = 1 day

Age Group: Adults (age 18 and older)

Level of Care: While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. No new admissions effective 10/5/2023.  

• State Funded MH/DD/SA Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: A 24-hour service (including room and board) which provides professionally trained parent-substitutes who work intensively with individuals in providing for their basic living, socialization, therapeutic, and skill-learning needs. The parent-substitutes receive substantial training and receive close supervision and support from the area program or its contract agencies. Recipients receiving this service may utilize periodic or day program services from the area program; but such services should be accounted for and reported separately.

Auth Submission Requirements
Initial Requests:
1. TAR: Prior authorization is required
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable..
3. NC SNAP or SIS: Required, if applicable
4. Service/ Tx Plan: Required

Reauthorization Requests:
1. TAR: prior approval required
2. Service/ Tx Plan: recently reviewed detailing the recipient’s progress with the service.
3. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status.

Authorization Parameters
Length of Stay: Request length of stay can be for up to one fiscal year or the end of the PCP (whichever comes first).

Units: One unit = 1 day

Age Group: Adults (age 18 and older)

Level of Care: While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. No new admissions effective 10/5/2023.  

• State Funded MH/DD/SA Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Prior Authorization is required. Medicaid funded services may cover up to 60 days for the initial authorization. This service is limited to 40 units per month.

• Policy

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains.  The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 24 unmanaged visits each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after the 22nd pass-through visit.
2. CCA: Required
3. Tx/ Service Plan: Required.  Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C.
4. Service Order: Required
5. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the member’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
3. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis. 
2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
3. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
4. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
5. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
6. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains.  The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 24 unmanaged visits each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after the 22nd pass-through visit.
2. CCA: Required
3. Tx/ Service Plan: Required.  Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C.
4. Service Order: Required
5. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the member’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
3. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis. 
2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
3. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
4. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
5. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
6. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

TELEPHONIC SERVICES (KX) ARE RESERVED FOR WHEN PHYSICAL OR BH STATUS OR ACCESS ISSUES (TRANSPORTATION, TELEHEALTH TECHNOLOGY) PREVENT THE MEMBER FROM PARTICIPATING IN-PERSON OR TELEHEALTH SERVICES

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains.  The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 24 unmanaged visits each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after the 22nd pass-through visit.
2. CCA: Required
3. Tx/ Service Plan: Required.  Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C.
4. Service Order: Required
5. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the member’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
3. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis. 
2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
3. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
4. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
5. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
6. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains.  The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 12 unmanaged visits for adults & 24 unmanaged visits for children/ adolescents each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after pass-through visit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
3. Tx/ Service Plan: Required, consistent with and supportive of the service provided and within professional standards of practice. When the individual is receiving multiple BH services in addition to this service, a PCP must be developed with the individual, and outpatient BH services are to be incorporated into the individual’s PCP.
4. Service Order: Required
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 applicable records that support the recipient has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the recipient’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the state-funded enhanced MH/SU service definition.
3. Submission of applicable records that support the recipient has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Family therapy must be billed once per date of service for the identified family recipient only. No separate billing for participating recipient(s) of the therapy session is permissible.
2. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
3. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
4. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
5. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
7. The provider will communicate and coordinate care with other professionals providing care to the recipient.
8. Provider must verify individual’s eligibility each time a service is rendered
9. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
10. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains.  The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 12 unmanaged visits for adults & 24 unmanaged visits for children/ adolescents each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after pass-through visit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
3. Tx/ Service Plan: Required, consistent with and supportive of the service provided and within professional standards of practice. When the individual is receiving multiple BH services in addition to this service, a PCP must be developed with the individual, and outpatient BH services are to be incorporated into the individual’s PCP.
4. Service Order: Required
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 applicable records that support the recipient has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the recipient’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the state-funded enhanced MH/SU service definition.
3. Submission of applicable records that support the recipient has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Family therapy must be billed once per date of service for the identified family recipient only. No separate billing for participating recipient(s) of the therapy session is permissible.
2. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
3. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
4. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
5. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
7. The provider will communicate and coordinate care with other professionals providing care to the recipient.
8. Provider must verify individual’s eligibility each time a service is rendered
9. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
10. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains.  The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 12 unmanaged visits for adults & 24 unmanaged visits for children/ adolescents each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after pass-through visit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
3. Tx/ Service Plan: Required, consistent with and supportive of the service provided and within professional standards of practice. When the individual is receiving multiple BH services in addition to this service, a PCP must be developed with the individual, and outpatient BH services are to be incorporated into the individual’s PCP.
4. Service Order: Required
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 applicable records that support the recipient has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the recipient’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the state-funded enhanced MH/SU service definition.
3. Submission of applicable records that support the recipient has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Family therapy must be billed once per date of service for the identified family recipient only. No separate billing for participating recipient(s) of the therapy session is permissible.
2. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
3. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
4. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
5. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
7. The provider will communicate and coordinate care with other professionals providing care to the recipient.
8. Provider must verify individual’s eligibility each time a service is rendered
9. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
10. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains.  The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 24 unmanaged visits each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after the 22nd pass-through visit.
2. CCA: Required
3. Tx/ Service Plan: Required.  Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C.
4. Service Order: Required
5. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the member’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
3. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis. 
2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
3. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
4. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
5. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
6. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains.  The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 24 unmanaged visits each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after the 22nd pass-through visit.
2. CCA: Required
3. Tx/ Service Plan: Required.  Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C.
4. Service Order: Required
5. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the member’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
3. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis. 
2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
3. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
4. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
5. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
6. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

TELEPHONIC SERVICES (KX) ARE RESERVED FOR WHEN PHYSICAL OR BH STATUS OR ACCESS ISSUES (TRANSPORTATION, TELEHEALTH TECHNOLOGY) PREVENT THE MEMBER FROM PARTICIPATING IN-PERSON OR TELEHEALTH SERVICES

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains.  The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 24 unmanaged visits each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after the 22nd pass-through visit.
2. CCA: Required
3. Tx/ Service Plan: Required.  Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C.
4. Service Order: Required
5. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the member’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
3. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis. 
2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
3. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
4. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
5. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
6. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains.  The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 12 unmanaged visits for adults & 24 unmanaged visits for children/ adolescents each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after pass-through visit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
3. Tx/ Service Plan: Required, consistent with and supportive of the service provided and within professional standards of practice. When the individual is receiving multiple BH services in addition to this service, a PCP must be developed with the individual, and outpatient BH services are to be incorporated into the individual’s PCP.
4. Service Order: Required
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 applicable records that support the recipient has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the recipient’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the state-funded enhanced MH/SU service definition.
3. Submission of applicable records that support the recipient has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Family therapy must be billed once per date of service for the identified family recipient only. No separate billing for participating recipient(s) of the therapy session is permissible.
2. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
3. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
4. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
5. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
7. The provider will communicate and coordinate care with other professionals providing care to the recipient.
8. Provider must verify individual’s eligibility each time a service is rendered
9. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
10. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains.  The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 12 unmanaged visits for adults & 24 unmanaged visits for children/ adolescents each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after pass-through visit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
3. Tx/ Service Plan: Required, consistent with and supportive of the service provided and within professional standards of practice. When the individual is receiving multiple BH services in addition to this service, a PCP must be developed with the individual, and outpatient BH services are to be incorporated into the individual’s PCP.
4. Service Order: Required
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 applicable records that support the recipient has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the recipient’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the state-funded enhanced MH/SU service definition.
3. Submission of applicable records that support the recipient has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Family therapy must be billed once per date of service for the identified family recipient only. No separate billing for participating recipient(s) of the therapy session is permissible.
2. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
3. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
4. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
5. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
7. The provider will communicate and coordinate care with other professionals providing care to the recipient.
8. Provider must verify individual’s eligibility each time a service is rendered
9. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
10. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains.  The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 12 unmanaged visits for adults & 24 unmanaged visits for children/ adolescents each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after pass-through visit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
3. Tx/ Service Plan: Required, consistent with and supportive of the service provided and within professional standards of practice. When the individual is receiving multiple BH services in addition to this service, a PCP must be developed with the individual, and outpatient BH services are to be incorporated into the individual’s PCP.
4. Service Order: Required
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 applicable records that support the recipient has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the recipient’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the state-funded enhanced MH/SU service definition.
3. Submission of applicable records that support the recipient has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Family therapy must be billed once per date of service for the identified family recipient only. No separate billing for participating recipient(s) of the therapy session is permissible.
2. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
3. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
4. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
5. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
7. The provider will communicate and coordinate care with other professionals providing care to the recipient.
8. Provider must verify individual’s eligibility each time a service is rendered
9. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
10. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Per Plan Year, Financial Support Services (FSS) is the umbrella service for the continuum of supports offered to NC Innovations individuals who elect the Individual and Family Directed Services Option, Employer of Record Model. A financial supports agency may be an Agency with Choice and provide Community Navigator.

• Clinical Coverage Policy
• Clinical Coverage Policy

NO NEW ADMISSIONS EFFECTIVE 10/5/23

Brief Service Description: The determining factor as to whether a particular group living arrangement is to be considered low-moderate-high is the intensity of the individual tx/ habilitation provided and the integration between day and 24-hour tx/ habilitation programming.  This is care (room & board included) provided in a home-like environment to 5 or more individuals. Supervision and therapeutic intervention are limited to sleeping time, home living skills and leisure time activities. Primary tx and rehab services are provided off-site and are accounted for where appropriate (i.e., Outpatient Treatment/ Habilitation, ADVP). Group Living-Low Intensity must be provided in a licensed facility.

Auth Submission Requirements
Pass-Through: No prior authorization is required for those admitted to PORT’s Adolescent SU Tx Program or those admitted to the Robeson Village Perinatal Program. (some contract variations).

Initial Requests:
1. TAR: Prior authorization required
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable.
3. Service/ Tx Plan: Required
4. NC SNAP/ SIS: Required, if applicable

Reauthorization Requests:
1. TAR: Prior authorization required
2. Service/ Tx Plan: recently reviewed detailing the individual’s progress with the service
3. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status.

Authorization Parameters
Length of Stay: Up to a 6-month auth period per request.

Units: One unit = 1 day, to be counted in a midnight occupied bed count. Allowance will be made for Therapeutic Leave.

Age Group: Adults (age 18 and older)

Level of Care: NC SNAP OR Supports Intensity Scale OR ASAM Level 3.1 (for Low Intensity), ASAM Level 3.5 (for Moderate Intensity, and ASAM Level 3.7 (for High Intensity). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. No new admissions effective 10/5/23
2. When available, new admissions are only open to individuals stepping down from long term care (2 yrs or more) in a state operated facility.

• State Funded MH/DD/SA Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

NO NEW ADMISSIONS EFFECTIVE 10/5/23

Brief Service Description: The determining factor as to whether a particular group living arrangement is to be considered low-moderate-high is the intensity of the individual tx/ habilitation provided and the integration between day and 24-hour tx/ habilitation programming.  This is a 24-Hour service that includes a greater degree of supervision and therapeutic intervention for the residents because of the degree of their dependence or the severity of their disability. The care (including room and board), that is provided, includes individualized therapeutic or rehabilitative programming designed to supplement day tx services which are provided in another setting. This level of group living is often provided because the individual's removal from his/her regular living arrangement is necessary in order to facilitate tx.

Auth Submission Requirements
Pass-Through: No prior authorization is required for those admitted to PORT’s Adolescent SU Tx Program or those admitted to the Robeson Village Perinatal Program. (some contract variations).

Initial Requests:
1. TAR: Prior authorization required
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable.
3. Service/ Tx Plan: Required
4. NC SNAP/ SIS: Required, if applicable

Reauthorization Requests:
1. TAR: Prior authorization required
2. Service/ Tx Plan: recently reviewed detailing the individual’s progress with the service
3. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status.

Authorization Parameters
Length of Stay: Up to a 6-month auth period per request.

Units: One unit = 1 day, to be counted in a midnight occupied bed count. Allowance will be made for Therapeutic Leave.

Age Group: Adults (age 18 and older)

Level of Care: NC SNAP OR Supports Intensity Scale OR ASAM Level 3.1 (for Low Intensity), ASAM Level 3.5 (for Moderate Intensity, and ASAM Level 3.7 (for High Intensity). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. No new admissions effective 10/5/23
2. When available, new admissions are only open to individuals stepping down from long term care (2 yrs or more) in a state operated facility.

• State Funded MH/DD/SA Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

NO NEW ADMISSIONS EFFECTIVE 10/5/23

Brief Service Description: The determining factor as to whether a particular group living arrangement is to be considered low-moderate-high is the intensity of the individual tx/ habilitation provided and the integration between day and 24-hour tx/ habilitation programming.  This is a 24-Hour service (including room and board) that includes a significant amount of individualized therapeutic or rehabilitative programming as a part of the residential placement. The individuals can receive day treatment services either on-site or off-site; but the day and residential programming is highly integrated. The individuals who receive this level of 24-Hour care are significantly disabled and dependent and would need to be served in an institutional setting. Staff are trained and receive regular professional support and supervision. The costs related to day programming are often a part of the day rate for this service. If the day service cost is reported separately, Group Living-Moderate Intensity should be considered as an alternative for this type of service.

Auth Submission Requirements
Pass-Through: No prior authorization is required for those admitted to PORT’s Adolescent SU Tx Program or those admitted to the Robeson Village Perinatal Program. (some contract variations).

Initial Requests:
1. TAR: Prior authorization required
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable.
3. Service/ Tx Plan: Required
4. NC SNAP/ SIS: Required, if applicable

Reauthorization Requests:
1. TAR: Prior authorization required
2. Service/ Tx Plan: recently reviewed detailing the individual’s progress with the service
3. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status.

Authorization Parameters
Length of Stay: Up to a 6-month auth period per request.

Units: One unit = 1 day, to be counted in a midnight occupied bed count. Allowance will be made for Therapeutic Leave.

Age Group: Adults (age 18 and older)

Level of Care: NC SNAP OR Supports Intensity Scale OR ASAM Level 3.1 (for Low Intensity), ASAM Level 3.5 (for Moderate Intensity, and ASAM Level 3.7 (for High Intensity). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. No new admissions effective 10/5/23
2. When available, new admissions are only open to individuals stepping down from long term care (2 yrs or more) in a state operated facility.

• State Funded MH/DD/SA Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains.  The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 24 unmanaged visits each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after the 22nd pass-through visit.
2. CCA: Required
3. Tx/ Service Plan: Required.  Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C.
4. Service Order: Required
5. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the member’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
3. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis. 
2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
3. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
4. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
5. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains.  The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 24 unmanaged visits each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after the 22nd pass-through visit.
2. CCA: Required
3. Tx/ Service Plan: Required.  Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C.
4. Service Order: Required
5. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the member’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
3. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis. 
2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
3. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
4. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
5. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Telephonic Services (KX) are reserved for when physical or BH status or access issues (transportation, telehealth technology) prevent the member from participating in-person or telehealth services.

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains.  The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 24 unmanaged visits each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after the 22nd pass-through visit.
2. CCA: Required
3. Tx/ Service Plan: Required.  Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C.
4. Service Order: Required
5. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the member’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
3. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis. 
2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
3. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
4. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
5. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains.  The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 24 unmanaged visits each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after the 22nd pass-through visit.
2. CCA: Required
3. Tx/ Service Plan: Required.  Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C.
4. Service Order: Required
5. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the member’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
3. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis. 
2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
3. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
4. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
5. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains.  The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 24 unmanaged visits each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after the 22nd pass-through visit.
2. CCA: Required
3. Tx/ Service Plan: Required.  Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C.
4. Service Order: Required
5. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the member’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
3. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis. 
2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
3. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
4. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
5. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Telephonic Services (KX) are reserved for when physical or BH status or access issues (transportation, telehealth technology) prevent the member from participating in-person or telehealth services.

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the member’s functioning in familial, social, educational, or occupational life domains.  The member’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 24 unmanaged visits each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after the 22nd pass-through visit.
2. CCA: Required
3. Tx/ Service Plan: Required.  Complete PCP is required when the member is receiving multiple BH services in addition to the
services in Clinical Coverage Policies 8C.
4. Service Order: Required
5. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the member’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the Clinical Coverage Policies 8A, as well as the state-funded enhanced MH/SA.
3. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis. 
2. Individual, Group, or Family Outpatient services cannot be billed while a member is auth’d for: ACT, IIH, MST, Day Treatment, SAIOP, SACOT. Outpatient Med Management and Outpatient Psychiatric Services cannot be billed while a member is auth’d to receive ACT.
3. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, the PCP must be developed, and outpatient behavioral health services are to be incorporated into PCP.
4. Provider must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.
5. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
6. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains.  The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 12 unmanaged visits for adults & 24 unmanaged visits for children/ adolescents each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after pass-through visit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
3. Tx/ Service Plan: Required, consistent with and supportive of the service provided and within professional standards of practice. When the individual is receiving multiple BH services in addition to this service, a PCP must be developed with the individual, and outpatient BH services are to be incorporated into the individual’s PCP.
4. Service Order: Required
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 applicable records that support the recipient has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the recipient’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the state-funded enhanced MH/SU service definition.
3. Submission of applicable records that support the recipient has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
2. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
3. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
4. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
5. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
6. The provider will communicate and coordinate care with other professionals providing care to the recipient.
7. Provider must verify individual’s eligibility each time a service is rendered
8. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
9. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains.  The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 12 unmanaged visits for adults & 24 unmanaged visits for children/ adolescents each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after pass-through visit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
3. Tx/ Service Plan: Required, consistent with and supportive of the service provided and within professional standards of practice. When the individual is receiving multiple BH services in addition to this service, a PCP must be developed with the individual, and outpatient BH services are to be incorporated into the individual’s PCP.
4. Service Order: Required
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 applicable records that support the recipient has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the recipient’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the state-funded enhanced MH/SU service definition.
3. Submission of applicable records that support the recipient has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
2. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
3. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
4. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
5. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
6. The provider will communicate and coordinate care with other professionals providing care to the recipient.
7. Provider must verify individual’s eligibility each time a service is rendered
8. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
9. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains.  The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 12 unmanaged visits for adults & 24 unmanaged visits for children/ adolescents each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after pass-through visit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
3. Tx/ Service Plan: Required, consistent with and supportive of the service provided and within professional standards of practice. When the individual is receiving multiple BH services in addition to this service, a PCP must be developed with the individual, and outpatient BH services are to be incorporated into the individual’s PCP.
4. Service Order: Required
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 applicable records that support the recipient has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the recipient’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the state-funded enhanced MH/SU service definition.
3. Submission of applicable records that support the recipient has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
2. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
3. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
4. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
5. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
6. The provider will communicate and coordinate care with other professionals providing care to the recipient.
7. Provider must verify individual’s eligibility each time a service is rendered
8. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
9. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains.  The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Auth Submission Requirements
Pass-Through Period: Up to 12 unmanaged visits for adults & 24 unmanaged visits for children/ adolescents each fiscal year of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Eval.

Initial Requests (after pass-through):
1. TAR: Submission required after pass-through visit.
2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
3. Tx/ Service Plan: Required, consistent with and supportive of the service provided and within professional standards of practice. When the individual is receiving multiple BH services in addition to this service, a PCP must be developed with the individual, and outpatient BH services are to be incorporated into the individual’s PCP.
4. Service Order: Required
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 applicable records that support the recipient has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Tx/ Service Plan: recently reviewed detailing the recipient’s progress with the service. Updated PCP is required when this service is provided in conjunction with a service found in the state-funded enhanced MH/SU service definition.
3. Submission of applicable records that support the recipient has met the medical necessity criteria.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
2. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
3. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
4. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
5. For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.
6. The provider will communicate and coordinate care with other professionals providing care to the recipient.
7. Provider must verify individual’s eligibility each time a service is rendered
8. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
9. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains.  The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.