Prior Authorization Services

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3 Way Contract - 100

Authorization Guidelines:

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

Service Code
100
Diagnosis Group
Mental Health
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Ambulatory Detox - H0014

Authorization Guidelines:

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

Service Code
H0014
Diagnosis Group
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Assertive Community Treatment (ACT) Program - H0040 - Case Rate

Authorization Guidelines:

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.


 

Service Code
H0040 - Case Rate
Diagnosis Group
Substance Abuse
Mental Health
Age Group
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Assertive Community Treatment (ACT) Program - H0040 - Case Rate

Authorization Guidelines:

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.

Service Code
H0040 - Case Rate
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Assertive Community Treatment (ACT) Program - H0040 U1 Shadow Claim

Authorization Guidelines:

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.

Service Code
H0040 U1 Shadow Claim
Diagnosis Group
Substance Abuse
Mental Health
Age Group
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Assertive Community Treatment (ACT) Program - H0040 U1 Shadow Claim

Authorization Guidelines:

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.

Service Code
H0040 U1 Shadow Claim
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
No

Assistive Technology Equipment and Supplies - T2029

Authorization Guidelines:

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

Service Code
T2029
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

B3 Respite Group - H0045HQ

Authorization Guidelines:

Maximum of 64 units (16 hrs/day) in 24 hr period. Maximum 1536 units (384 hrs or 24 days) per calendar year.

Service Code
H0045HQ
Diagnosis Group
Intellectual Development Disability
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
B3
Prior Authorization Required
Yes

B3 Respite Individual - H0045

Authorization Guidelines:

Maximum of 64 units (16 hrs/day) in 24 hr period. Maximum 1536 units (384 hrs or 24 days) per calendar year.

Service Code
H0045
Diagnosis Group
Intellectual Development Disability
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
B3
Prior Authorization Required
Yes

Behavioral Health Crisis Assessment and Intervention (BH-CAI) - T2016 U5 Tier III

Authorization Guidelines:

No Prior Authorization

Service Code
T2016 U5 Tier III
Diagnosis Group
Substance Abuse
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
No

Behavioral Health Crisis Assessment and Intervention (BH-CAI) - T2016-U6 Tier IV

Authorization Guidelines:

No Prior Authorization

Service Code
T2016-U6 Tier IV
Diagnosis Group
Substance Abuse
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
No

Child First - H2022 HE

Authorization Guidelines:

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

Service Code
H2022 HE
Diagnosis Group
Intellectual Development Disability
Mental Health
Age Group
Child
Benefit Plan
Medicaid
Prior Authorization Required
No

Child First - H2022 HE U1 (enounters)

Authorization Guidelines:

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

Service Code
H2022 HE U1
Diagnosis Group
Intellectual Development Disability
Mental Health
Age Group
Child
Benefit Plan
Medicaid
Prior Authorization Required
No

Community Living and Supports - YM 851 - Individual

Authorization Guidelines:

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

Service Code
YM 851 - Individual
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Community Living and Supports - YM852 - Group

Authorization Guidelines:

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

Service Code
YM852 - Group
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Community Living and Supports- Innovations - T2012 GC HQ Community Living and Supports Group- Live In Caregiver

Authorization Guidelines:

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. 

Service Code
T2012 CG HQ Community Living and Supports Group- Live In Caregiver
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Community Living and Supports- Innovations - T2012 GC- Community Living and Supports-Live In Caregiver

Authorization Guidelines:

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. 

Service Code
T2012 CG - Community Living and Supports-Live In Caregiver
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Community Living and Supports- Innovations - T2012 – Community Living and Supports Community

Authorization Guidelines:

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. 

Service Code
T2012 – Community Living and Supports Community
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Community Living and Supports- Innovations - T2013 TF HQ- Group- EVV Required

Authorization Guidelines:

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. 

Service Code
T2013 TF HQ - Group - EVV Required
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Community Living and Supports- Innovations - T2013 TF Individual- In Home EVV required

Authorization Guidelines:

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. 

Service Code
T2013 TF Individual - In Home EVV required
Diagnosis Group
Intellectual Development Disability
Age Group
Child
Adult
18-20
Benefit Plan
Innovations
Prior Authorization Required
Yes

Community Living Facilities and Support

Authorization Guidelines:

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

Service Code
T2016 U5 U6-Level5
Diagnosis Group
Intellectual Development Disability
Age Group
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Community Living Facilities and Support - T2016 U5 U2-Level 2

Authorization Guidelines:

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

Service Code
T2016 U5 U2-Level 2
Diagnosis Group
Intellectual Development Disability
Age Group
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Community Living Facilities and Support - T2016 U5 U3-Level 3

Authorization Guidelines:

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

Service Code
T2016 U5 U3-Level 3
Diagnosis Group
Intellectual Development Disability
Age Group
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Community Living Facilities and Support - T2016 U5 U4-Level 4

Authorization Guidelines:

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

Service Code
T2016 U5 U4-Level 4
Diagnosis Group
Intellectual Development Disability
Age Group
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Community Living Facilities and Support -T2016 U5 U1-Level 1

Authorization Guidelines:

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

Service Code
T2016 U5 U1-Level 1
Diagnosis Group
Intellectual Development Disability
Age Group
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Community Navigator - T2041 U1- Community Navigator Training (Periodic)

Authorization Guidelines:
Service Code
T2041 U1 - Community Navigator Training (Periodic)
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Community Navigator - T2041- Community Navigator

Authorization Guidelines:
Service Code
T2041 - Community Navigator
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Community Networking - Group - H2015 HQ- Community Networking Group

Authorization Guidelines:
  • 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.)
Service Code
H2015 HQ - Community Networking Group
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Community Networking - Individual - H2015 U1- Community Networking Classes and Conference

Authorization Guidelines:
  • 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.)
Service Code
H2015 U1 - Community Networking Classes and Conference
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Community Networking - Individual - H2015 U2- Community Networking Transportation

Authorization Guidelines:
  • 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.)
Service Code
H2015 U2 - Community Networking Transportation
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Community Networking - Individual - H2015- Community Networking Individual

Authorization Guidelines:
  • 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.)
Service Code
H2015 - Community Networking Individual
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Community Support Team (CST) - H2015 HT HF (LCAS, LCAS-A, CCS, CSAC )

Authorization Guidelines:

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.

Service Code
H2015HT HF - CST LCAS, other SA
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Community Support Team (CST) - H2015 HT HM (Paraprofessional)

Authorization Guidelines:

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.

Service Code
H2015 HT HM - CST Paraprofessional
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Community Support Team (CST) - H2015 HT HM (Paraprofessional)

Authorization Guidelines:

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.

Service Code
H2015 HT HM - CST Paraprofessional
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Community Support Team (CST) - H2015 HT HN (QP, AP)

Authorization Guidelines:

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.

Service Code
H2015 HT HN - CST QP/AP
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Community Support Team (CST) - H2015 HT HN (QP, AP)

Authorization Guidelines:

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.

Service Code
H2015 HT HN - CST QP/AP
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Community Support Team (CST) - H2015 HT HO (Licensed Team Lead)

Authorization Guidelines:

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.
 

Service Code
H2015 HT HO - CST Team Lead
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Community Support Team (CST) - H2015 HT HO (Licensed Team Lead)

Authorization Guidelines:

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.

Service Code
H2015 HT HO - CST Team Lead
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Community Support Team (CST) - H2015 HT U1 (NC Peer Support Specialist)

Authorization Guidelines:

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.

Service Code
H2015 HT U1 - CST NC Peer Support Specialist
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Community Support Team (CST) - H2015 HT U1 (NC Peer Support Specialist)

Authorization Guidelines:

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.

Service Code
H2015 HT U1 - CST NC Peer Support Specialist
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Community Support Team (CST) - H2015HT HF (LCAS, LCAS-A, CCS, CSAC)

Authorization Guidelines:

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.

Service Code
H2015HT HF - CST LCAS, other SA
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Community Transition - Innovations - T2038

Authorization Guidelines:

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.

Service Code
T2038
Diagnosis Group
Intellectual Development Disability
Age Group
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Crisis Consultation - T2025 U3

Authorization Guidelines:

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.

Service Code
T2025 U3
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Crisis Intervention and Stabilization Supports - H2011 U1

Authorization Guidelines:

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.

Service Code
H2011 U1
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Criterion 5

Authorization Guidelines:

Utilization review up to 7 days

Required Documentation

  • Hospital discharge plan
Service Code
Y2343
Diagnosis Group
Mental Health
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Day Supports - Innovations - T2021 HQ – Days Supports Group

Authorization Guidelines:
  • 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. 
Service Code
T2021 HQ – Days Supports Group
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Day Supports - Innovations - T2021- Day Supports Individual

Authorization Guidelines:
  • 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. 
Service Code
T2021 - Day Supports Individual
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Day Supports - Innovations - T2027- Day Supports Developmental Day

Authorization Guidelines:
  • 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. 
Service Code
T2027 - Day Supports Developmental Day
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Day Supports - YM590

Authorization Guidelines:

30 hours/week

Service Code
YM590
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Day Treatment - H2012HA

Authorization Guidelines:

No Prior Authorization

Service Code
H2012HA
Diagnosis Group
Mental Health
Age Group
Child
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Employer Supplies - T2025 U2

Authorization Guidelines:

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.

Service Code
T2025 U2
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Evaluation and Management - 99202 - E & M Expanded, New Patient

Authorization Guidelines:
Service Code
99202 - E & M Expanded, New Patient
Diagnosis Group
Substance Abuse
Intellectual Development Disability
Mental Health
Age Group
Child
Adult
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99203 - E & M Detailed, New Patient

Authorization Guidelines:
Service Code
99203 - E & M Detailed, New Patient
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99204 - E & M Moderate, New Patient

Authorization Guidelines:
Service Code
99204 - E & M Moderate, New Patient
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99205 - E & M High, New Patient

Authorization Guidelines:
Service Code
99205 - E & M High, New Patient
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99211 - E&M Minimum, Estab Patient

Authorization Guidelines:
Service Code
99211 - E&M Minimum, Estab Patient
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
Adult
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99212 - E & M Expanded, Estab Patient

Authorization Guidelines:
Service Code
99212 - E & M Expanded, Estab Patient
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
Adult
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99213 - E & M Detailed, Estab Patient

Authorization Guidelines:
Service Code
99213 - E & M Detailed, Estab Patient
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
Adult
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99214 - E & M Moderate, Estab Patient

Authorization Guidelines:
Service Code
99214 - E & M Moderate, Estab Patient
Diagnosis Group
Substance Abuse
Intellectual Development Disability
Mental Health
Age Group
Child
Adult
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99215 - E & M High Estab Patient

Authorization Guidelines:
Service Code
99215 - E & M High Estab Patient
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99305 - initial nursing facility care, per day, for the evaluation and management of

Authorization Guidelines:
Service Code
99305 - initial nursing facility care, per day, for the evaluation and management of
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99306 - initial nursing facility care, per day, for the evaluation and management of a

Authorization Guidelines:
Service Code
99306 - initial nursing facility care, per day, for the evaluation and management of a
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99307 - subsequent nursing facility care, per day, for the evaluation and management of

Authorization Guidelines:
Service Code
99307 - subsequent nursing facility care, per day, for the evaluation and management of
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99308 - subsequent nursing facility care, per day, for the evaluation and management of

Authorization Guidelines:
Service Code
99308 - subsequent nursing facility care, per day, for the evaluation and management of
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Adult
18-20
Child
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99309 - subsequent nursing facility care, per day, for the evaluation and management of

Authorization Guidelines:
Service Code
99309 - subsequent nursing facility care, per day, for the evaluation and management of
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
Adult
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99310 - subsequent nursing facility care, per day, for the evaluation and management of

Authorization Guidelines:
Service Code
99310 - subsequent nursing facility care, per day, for the evaluation and management of
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
Adult
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99315 - nursing facility discharge day management; 30 minutes or less

Authorization Guidelines:
Service Code
99315 - nursing facility discharge day management; 30 minutes or less
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99316 - nursing facility discharge day management; 30 minutes or less more than 30

Authorization Guidelines:
Service Code
99316 - nursing facility discharge day management; 30 minutes or less more than 30
Diagnosis Group
Substance Abuse
Mental Health
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99341 - home visit for the evaluation and management of a new patient, which requires

Authorization Guidelines:
Service Code
99341 - home visit for the evaluation and management of a new patient, which requires
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99342 - home visit for the evaluation and management of a new patient, which requires

Authorization Guidelines:
Service Code
99342 - home visit for the evaluation and management of a new patient, which requires
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
Adult
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99344 - home visit for the evaluation and management of a new patient, which requires

Authorization Guidelines:
Service Code
99344 - home visit for the evaluation and management of a new patient, which requires
Diagnosis Group
Substance Abuse
Mental Health
Intellectual Development Disability
Age Group
Adult
Child
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99345 - home visit for the evaluation and management of a new patient, which requires

Authorization Guidelines:
Service Code
99345 - home visit for the evaluation and management of a new patient, which requires
Diagnosis Group
Substance Abuse
Intellectual Development Disability
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99347 - home visit for the evaluation and management of an established patient, which

Authorization Guidelines:
Service Code
99347 - home visit for the evaluation and management of an established patient, which
Diagnosis Group
Intellectual Development Disability
Substance Abuse
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99348 - home visit for the evaluation and management of an established patient, which

Authorization Guidelines:
Service Code
99348 - home visit for the evaluation and management of an established patient, which
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99349 - home visit for the evaluation and management of an established patient, which

Authorization Guidelines:
Service Code
99349 - home visit for the evaluation and management of an established patient, which
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Evaluation and Management - 99350 - home visit for the evaluation and management of an established patient, which

Authorization Guidelines:
Service Code
99350 - home visit for the evaluation and management of an established patient, which
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Facility Based Crisis - S9484

Authorization Guidelines:

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

Service Code
S9484
Diagnosis Group
Substance Abuse
Mental Health
Age Group
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Facility Based Crisis Child - S9484 HA

Authorization Guidelines:

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. 

 

Service Code
S9484 HA
Diagnosis Group
Substance Abuse
Mental Health
Age Group
Child
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Family Centered Treatment - H2022 U5 U1 FCT- Case Rate

Authorization Guidelines:
  • 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
Service Code
H2022 U5 U1 FCT- Case Rate
Diagnosis Group
Mental Health
Age Group
Child
Benefit Plan
Medicaid
Prior Authorization Required
No

Family Centered Treatment - H2022 U5 U2 FCT - 3 month outcome

Authorization Guidelines:
  • 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
Service Code
H2022 U5 U2 FCT
Diagnosis Group
Mental Health
Age Group
Child
Benefit Plan
Medicaid
Prior Authorization Required
No

Family Centered Treatment - H2022 U5 U3 FCT - 6 month outcome

Authorization Guidelines:
  • 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
Service Code
H2022 U5 U1 FCT
Diagnosis Group
Mental Health
Age Group
Child
Benefit Plan
Medicaid
Prior Authorization Required
No

Family Living - YP740 (Low Intensity)

Authorization Guidelines:

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.  

Service Code
YP740 Low Intensity
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Family Living - YP740 (Moderate Intensity)

Authorization Guidelines:

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.  

Service Code
YP750 - Family Living - Moderate Intensity
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Family Navigator - T2041 U5

Authorization Guidelines:

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.

Service Code
T2041 U5
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Financial Supports Services - T2025 U1

Authorization Guidelines:

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.

Service Code
T2025 U1
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Group Living - YP760 (Low Intensity)

Authorization Guidelines:

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.

Service Code
YP760 - Group Living - Low Intensity
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Group Living - YP770 (Moderate Intensity)

Authorization Guidelines:

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.

Service Code
YP770
Diagnosis Group
Substance Abuse
Mental Health
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Group Living - YP780 (High Intensity)

Authorization Guidelines:

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.

Service Code
YP780 - Group Living - High Intensity
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Halfway House - H2034

Authorization Guidelines:

State - no prior authorization               

Reauth after 90 days  (contract variations) 

State funded must apply for Medicaid   

Service Code
H2034
Diagnosis Group
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
No

High Fidelity Wrap Around - H0032 U5

Authorization Guidelines:

Due to the complex nature and urgency of admission, a Comprehensive Clinical Assessment or addendum with documentation of meeting the entrance criteria is acceptable for initiation of services with the submission of the PCP within 30 days of initial authorization. Before any service can be billed to Medicaid a written CCA and service order for medical necessity must be in place

Service Code
H0032 U5
Diagnosis Group
Substance Abuse
Mental Health
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

High Fidelity Wrap Around - H0032 U5

Authorization Guidelines:

Due to the complex nature and urgency of admission, a Comprehensive Clinical Assessment or addendum with documentation of meeting the entrance criteria is acceptable for initiation of services with the submission of the PCP within 30 days of initial authorization. Before any service can be billed to Medicaid a written CCA and service order for medical necessity must be in place

Service Code
H0032 U5
Diagnosis Group
Mental Health
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Home Modification - Innovations - S5165

Authorization Guidelines:

The service is limited to expenditures of $50,000 of supports (ATES, Home Modifications) over the duration of the waiver. HM covers purchases, installation, maintenance, and as necessary, the repair of home modifications required to enable individuals to increase, maintain or improve their functional capacity to perform daily life tasks. Medical necessity must be documented by the physician, physician assistant, or nurse practitioner, for every item provided/billed regardless of any requirements for approval.

Service Code
S5165
Diagnosis Group
Intellectual Development Disability
Age Group
Child
Adult
18-20
Benefit Plan
Innovations
Prior Authorization Required
Yes

IDD Long-Term Vocational Support Services (Extended Services) - YA389

Authorization Guidelines:

40 hours/plan year

Service Code
YA389
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Individual Goods and Services - Innovations - T1999

Authorization Guidelines:

The cost of individual directed goods and services for each beneficiary cannot exceed $2,000.00 per beneficiary plan year annually.

Service Code
T1999
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Individual Placement and Support (IPS) for Adult Mental Health/Adult Substance Use - H2023 Z1 (Milestone 1)

Authorization Guidelines:

Brief Service Description: A behavioral health service with a focus on employment that provides assistance in choosing, acquiring, and maintaining competitive paid employment in the community for individuals 16 years and older for whom employment has not been achieved or employment has been interrupted or intermittent. This service is co-located with an agency’s behavioral health treatment services to ensure consistent behavioral health integration. If a provider of IPS does not also provide behavioral health services, the provider must partner with one or two behavioral health agencies. The IPS model requires ongoing behavioral health Integration.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA: Required, to include current diagnosis, level of functioning, and an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
2. Career Profile or Complete PCP: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.
3. Service Order: Required
4. VR Documentation: Evidence of on-going Voc Rehab collaboration.  IPS providers must refer individuals to DVRS for eligibility determination of employment services when initiating services. If determined eligible for VR services, the provider and DVRS will collaborate on employment services.
5.  Updated PCP, Service Plan or Career Profile: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.

Authorization Parameters
Length of Stay: The duration and frequency at which IPS is provided must be based on MN and progress made by the individual toward goals outlined in the Career Profile

Units: One unit= 15 minutes

Age Group: Adults & Adolescents (age 16 years and older) with: 
1. A serious mental illness (SMI) that includes severe and persistent mental illness (SPMI); OR
2. A serious emotional disturbance (SED); OR
3. A severe substance use disorder (SUD)

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. IPS services shall not be provided during the same auth period as ACT.
2. Individuals may not be disqualified from engaging in employment because of perceived readiness factors, such as active substance use, criminal background issues, active MH symptoms, or personal presentation. The individual’s assessment and the Career Profile must be submitted within the first 30 calendar days of service initiation.
3. State funds will not cover:
a. Services provided to teach academics, to include special education provided under the Individuals with Disabilities Education Act (IDEA)
b. Pre-vocational classes and/or group employment searches or classes
c. Supports or services to help with volunteering
d. Set-aside jobs for people with disabilities, such as enclaves, and will not cover group employment/work crews.  
e. Services to acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in community settings, to include time spent attending or participating in recreational activities
f. Childcare services
g. Service provided under the Rehabilitation Act of 1973
h. IPS services can only be billed when providing employment services and support directly to the individual or on behalf of the beneficiary and cannot be billed for meetings, paperwork, documentation, or travel time.
4. State funds will only reimburse for services not covered in a DVR milestone. IPS providers will bill DVRS for milestone payments for services provided by the Employment Support Professional (ESP). A individual may receive peer services and benefits counseling during the vocational rehabilitation milestones. IPS providers should bill H2023U4 for services provided by the Employment Peer Mentor (EPM) and the Benefits Counselor (BC).

Service Code
H2023 Z1 – IPS for AMH/ASU - Milestone 1
Diagnosis Group
Mental Health
Substance Abuse
Age Group
16 and Older
Benefit Plan
State
Prior Authorization Required
No

Individual Placement and Support (IPS) for Adult Mental Health/Adult Substance Use - H2023 Z2 (Milestone 2)

Authorization Guidelines:

Brief Service Description: A behavioral health service with a focus on employment that provides assistance in choosing, acquiring, and maintaining competitive paid employment in the community for individuals 16 years and older for whom employment has not been achieved or employment has been interrupted or intermittent. This service is co-located with an agency’s behavioral health treatment services to ensure consistent behavioral health integration. If a provider of IPS does not also provide behavioral health services, the provider must partner with one or two behavioral health agencies. The IPS model requires ongoing behavioral health Integration.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA: Required, to include current diagnosis, level of functioning, and an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
2. Career Profile or Complete PCP: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.
3. Service Order: Required
4. VR Documentation: Evidence of on-going Voc Rehab collaboration.  IPS providers must refer individuals to DVRS for eligibility determination of employment services when initiating services. If determined eligible for VR services, the provider and DVRS will collaborate on employment services.
5.  Updated PCP, Service Plan or Career Profile: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.

Authorization Parameters
Length of Stay: The duration and frequency at which IPS is provided must be based on MN and progress made by the individual toward goals outlined in the Career Profile

Units: One unit= 15 minutes

Age Group: Adults & Adolescents (age 16 years and older) with: 
1. A serious mental illness (SMI) that includes severe and persistent mental illness (SPMI); OR
2. A serious emotional disturbance (SED); OR
3. A severe substance use disorder (SUD)

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. IPS services shall not be provided during the same auth period as ACT.
2. Individuals may not be disqualified from engaging in employment because of perceived readiness factors, such as active substance use, criminal background issues, active MH symptoms, or personal presentation. The individual’s assessment and the Career Profile must be submitted within the first 30 calendar days of service initiation.
3. State funds will not cover:
a. Services provided to teach academics, to include special education provided under the Individuals with Disabilities Education Act (IDEA)
b. Pre-vocational classes and/or group employment searches or classes
c. Supports or services to help with volunteering
d. Set-aside jobs for people with disabilities, such as enclaves, and will not cover group employment/work crews.  
e. Services to acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in community settings, to include time spent attending or participating in recreational activities
f. Childcare services
g. Service provided under the Rehabilitation Act of 1973
h. IPS services can only be billed when providing employment services and support directly to the individual or on behalf of the beneficiary and cannot be billed for meetings, paperwork, documentation, or travel time.
4. State funds will only reimburse for services not covered in a DVR milestone. IPS providers will bill DVRS for milestone payments for services provided by the Employment Support Professional (ESP). A individual may receive peer services and benefits counseling during the vocational rehabilitation milestones. IPS providers should bill H2023U4 for services provided by the Employment Peer Mentor (EPM) and the Benefits Counselor (BC).

Service Code
H2023 Z2 – IPS for AMH/ASU - Milestone 2
Diagnosis Group
Mental Health
Substance Abuse
Age Group
16 and Older
Benefit Plan
State
Prior Authorization Required
No

Individual Placement and Support (IPS) for Adult Mental Health/Adult Substance Use - H2023 Z3 (Milestone 3)

Authorization Guidelines:

Brief Service Description: A behavioral health service with a focus on employment that provides assistance in choosing, acquiring, and maintaining competitive paid employment in the community for individuals 16 years and older for whom employment has not been achieved or employment has been interrupted or intermittent. This service is co-located with an agency’s behavioral health treatment services to ensure consistent behavioral health integration. If a provider of IPS does not also provide behavioral health services, the provider must partner with one or two behavioral health agencies. The IPS model requires ongoing behavioral health Integration.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA: Required, to include current diagnosis, level of functioning, and an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
2. Career Profile or Complete PCP: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.
3. Service Order: Required
4. VR Documentation: Evidence of on-going Voc Rehab collaboration.  IPS providers must refer individuals to DVRS for eligibility determination of employment services when initiating services. If determined eligible for VR services, the provider and DVRS will collaborate on employment services.
5.  Updated PCP, Service Plan or Career Profile: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.

Authorization Parameters
Length of Stay: The duration and frequency at which IPS is provided must be based on MN and progress made by the individual toward goals outlined in the Career Profile

Units: One unit= 15 minutes

Age Group: Adults & Adolescents (age 16 years and older) with: 
1. A serious mental illness (SMI) that includes severe and persistent mental illness (SPMI); OR
2. A serious emotional disturbance (SED); OR
3. A severe substance use disorder (SUD)

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. IPS services shall not be provided during the same auth period as ACT.
2. Individuals may not be disqualified from engaging in employment because of perceived readiness factors, such as active substance use, criminal background issues, active MH symptoms, or personal presentation. The individual’s assessment and the Career Profile must be submitted within the first 30 calendar days of service initiation.
3. State funds will not cover:
a. Services provided to teach academics, to include special education provided under the Individuals with Disabilities Education Act (IDEA)
b. Pre-vocational classes and/or group employment searches or classes
c. Supports or services to help with volunteering
d. Set-aside jobs for people with disabilities, such as enclaves, and will not cover group employment/work crews.  
e. Services to acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in community settings, to include time spent attending or participating in recreational activities
f. Childcare services
g. Service provided under the Rehabilitation Act of 1973
h. IPS services can only be billed when providing employment services and support directly to the individual or on behalf of the beneficiary and cannot be billed for meetings, paperwork, documentation, or travel time.
4. State funds will only reimburse for services not covered in a DVR milestone. IPS providers will bill DVRS for milestone payments for services provided by the Employment Support Professional (ESP). A individual may receive peer services and benefits counseling during the vocational rehabilitation milestones. IPS providers should bill H2023U4 for services provided by the Employment Peer Mentor (EPM) and the Benefits Counselor (BC).

Service Code
H2023 Z3 – IPS for AMH/ASU - Milestone 3
Diagnosis Group
Mental Health
Substance Abuse
Age Group
16 and Older
Benefit Plan
State
Prior Authorization Required
No

Individual Placement and Support (IPS) for Adult Mental Health/Adult Substance Use - H2023 Z4 (Milestone 4)

Authorization Guidelines:

Brief Service Description: A behavioral health service with a focus on employment that provides assistance in choosing, acquiring, and maintaining competitive paid employment in the community for individuals 16 years and older for whom employment has not been achieved or employment has been interrupted or intermittent. This service is co-located with an agency’s behavioral health treatment services to ensure consistent behavioral health integration. If a provider of IPS does not also provide behavioral health services, the provider must partner with one or two behavioral health agencies. The IPS model requires ongoing behavioral health Integration.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA: Required, to include current diagnosis, level of functioning, and an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
2. Career Profile or Complete PCP: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.
3. Service Order: Required
4. VR Documentation: Evidence of on-going Voc Rehab collaboration.  IPS providers must refer individuals to DVRS for eligibility determination of employment services when initiating services. If determined eligible for VR services, the provider and DVRS will collaborate on employment services.
5.  Updated PCP, Service Plan or Career Profile: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.

Authorization Parameters
Length of Stay: The duration and frequency at which IPS is provided must be based on MN and progress made by the individual toward goals outlined in the Career Profile

Units: One unit= 15 minutes

Age Group: Adults & Adolescents (age 16 years and older) with: 
1. A serious mental illness (SMI) that includes severe and persistent mental illness (SPMI); OR
2. A serious emotional disturbance (SED); OR
3. A severe substance use disorder (SUD)

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. IPS services shall not be provided during the same auth period as ACT.
2. Individuals may not be disqualified from engaging in employment because of perceived readiness factors, such as active substance use, criminal background issues, active MH symptoms, or personal presentation. The individual’s assessment and the Career Profile must be submitted within the first 30 calendar days of service initiation.
3. State funds will not cover:
a. Services provided to teach academics, to include special education provided under the Individuals with Disabilities Education Act (IDEA)
b. Pre-vocational classes and/or group employment searches or classes
c. Supports or services to help with volunteering
d. Set-aside jobs for people with disabilities, such as enclaves, and will not cover group employment/work crews.  
e. Services to acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in community settings, to include time spent attending or participating in recreational activities
f. Childcare services
g. Service provided under the Rehabilitation Act of 1973
h. IPS services can only be billed when providing employment services and support directly to the individual or on behalf of the beneficiary and cannot be billed for meetings, paperwork, documentation, or travel time.
4. State funds will only reimburse for services not covered in a DVR milestone. IPS providers will bill DVRS for milestone payments for services provided by the Employment Support Professional (ESP). A individual may receive peer services and benefits counseling during the vocational rehabilitation milestones. IPS providers should bill H2023U4 for services provided by the Employment Peer Mentor (EPM) and the Benefits Counselor (BC).

Service Code
H2023 Z4 – IPS for AMH/ASU - Milestone 4
Diagnosis Group
Mental Health
Substance Abuse
Age Group
16 and Older
Benefit Plan
State
Prior Authorization Required
No

Individual Placement and Support (IPS) for Adult Mental Health/Adult Substance Use - H2023 Z5 (Successful IPS)

Authorization Guidelines:

Brief Service Description: A behavioral health service with a focus on employment that provides assistance in choosing, acquiring, and maintaining competitive paid employment in the community for individuals 16 years and older for whom employment has not been achieved or employment has been interrupted or intermittent. This service is co-located with an agency’s behavioral health treatment services to ensure consistent behavioral health integration. If a provider of IPS does not also provide behavioral health services, the provider must partner with one or two behavioral health agencies. The IPS model requires ongoing behavioral health Integration.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA: Required, to include current diagnosis, level of functioning, and an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
2. Career Profile or Complete PCP: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.
3. Service Order: Required
4. VR Documentation: Evidence of on-going Voc Rehab collaboration.  IPS providers must refer individuals to DVRS for eligibility determination of employment services when initiating services. If determined eligible for VR services, the provider and DVRS will collaborate on employment services.
5.  Updated PCP, Service Plan or Career Profile: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.

Authorization Parameters
Length of Stay: The duration and frequency at which IPS is provided must be based on MN and progress made by the individual toward goals outlined in the Career Profile

Units: One unit= 15 minutes

Age Group: Adults & Adolescents (age 16 years and older) with: 
1. A serious mental illness (SMI) that includes severe and persistent mental illness (SPMI); OR
2. A serious emotional disturbance (SED); OR
3. A severe substance use disorder (SUD)

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. IPS services shall not be provided during the same auth period as ACT.
2. Individuals may not be disqualified from engaging in employment because of perceived readiness factors, such as active substance use, criminal background issues, active MH symptoms, or personal presentation. The individual’s assessment and the Career Profile must be submitted within the first 30 calendar days of service initiation.
3. State funds will not cover:
a. Services provided to teach academics, to include special education provided under the Individuals with Disabilities Education Act (IDEA)
b. Pre-vocational classes and/or group employment searches or classes
c. Supports or services to help with volunteering
d. Set-aside jobs for people with disabilities, such as enclaves, and will not cover group employment/work crews.  
e. Services to acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in community settings, to include time spent attending or participating in recreational activities
f. Childcare services
g. Service provided under the Rehabilitation Act of 1973
h. IPS services can only be billed when providing employment services and support directly to the individual or on behalf of the beneficiary and cannot be billed for meetings, paperwork, documentation, or travel time.
4. State funds will only reimburse for services not covered in a DVR milestone. IPS providers will bill DVRS for milestone payments for services provided by the Employment Support Professional (ESP). A individual may receive peer services and benefits counseling during the vocational rehabilitation milestones. IPS providers should bill H2023U4 for services provided by the Employment Peer Mentor (EPM) and the Benefits Counselor (BC).

Service Code
H2023 Z5 – IPS for AMH/ASU - Successful IPS
Diagnosis Group
Mental Health
Substance Abuse
Age Group
16 and Older
Benefit Plan
State
Prior Authorization Required
No

Individual Placement and Support (IPS) for Adult Mental Health/Adult Substance Use - H2023 Z6 (Milestone 5)

Authorization Guidelines:

Brief Service Description: A behavioral health service with a focus on employment that provides assistance in choosing, acquiring, and maintaining competitive paid employment in the community for individuals 16 years and older for whom employment has not been achieved or employment has been interrupted or intermittent. This service is co-located with an agency’s behavioral health treatment services to ensure consistent behavioral health integration. If a provider of IPS does not also provide behavioral health services, the provider must partner with one or two behavioral health agencies. The IPS model requires ongoing behavioral health Integration.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA: Required, to include current diagnosis, level of functioning, and an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
2. Career Profile or Complete PCP: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.
3. Service Order: Required
4. VR Documentation: Evidence of on-going Voc Rehab collaboration.  IPS providers must refer individuals to DVRS for eligibility determination of employment services when initiating services. If determined eligible for VR services, the provider and DVRS will collaborate on employment services.
5.  Updated PCP, Service Plan or Career Profile: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.

Authorization Parameters
Length of Stay: The duration and frequency at which IPS is provided must be based on MN and progress made by the individual toward goals outlined in the Career Profile

Units: One unit= 15 minutes

Age Group: Adults & Adolescents (age 16 years and older) with: 
1. A serious mental illness (SMI) that includes severe and persistent mental illness (SPMI); OR
2. A serious emotional disturbance (SED); OR
3. A severe substance use disorder (SUD)

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. IPS services shall not be provided during the same auth period as ACT.
2. Individuals may not be disqualified from engaging in employment because of perceived readiness factors, such as active substance use, criminal background issues, active MH symptoms, or personal presentation. The individual’s assessment and the Career Profile must be submitted within the first 30 calendar days of service initiation.
3. State funds will not cover:
a. Services provided to teach academics, to include special education provided under the Individuals with Disabilities Education Act (IDEA)
b. Pre-vocational classes and/or group employment searches or classes
c. Supports or services to help with volunteering
d. Set-aside jobs for people with disabilities, such as enclaves, and will not cover group employment/work crews.  
e. Services to acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in community settings, to include time spent attending or participating in recreational activities
f. Childcare services
g. Service provided under the Rehabilitation Act of 1973
h. IPS services can only be billed when providing employment services and support directly to the individual or on behalf of the beneficiary and cannot be billed for meetings, paperwork, documentation, or travel time.
4. State funds will only reimburse for services not covered in a DVR milestone. IPS providers will bill DVRS for milestone payments for services provided by the Employment Support Professional (ESP). A individual may receive peer services and benefits counseling during the vocational rehabilitation milestones. IPS providers should bill H2023U4 for services provided by the Employment Peer Mentor (EPM) and the Benefits Counselor (BC).

Service Code
H2023 Z6 – IPS for AMH/ASU - Milestone 5
Diagnosis Group
Mental Health
Substance Abuse
Age Group
16 and Older
Benefit Plan
State
Prior Authorization Required
No

Individual Placement and Support (IPS) for Adult Mental Health/Adult Substance Use - H2023 Z7 (Milestone 6)

Authorization Guidelines:

Brief Service Description: A behavioral health service with a focus on employment that provides assistance in choosing, acquiring, and maintaining competitive paid employment in the community for individuals 16 years and older for whom employment has not been achieved or employment has been interrupted or intermittent. This service is co-located with an agency’s behavioral health treatment services to ensure consistent behavioral health integration. If a provider of IPS does not also provide behavioral health services, the provider must partner with one or two behavioral health agencies. The IPS model requires ongoing behavioral health Integration.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA: Required, to include current diagnosis, level of functioning, and an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
2. Career Profile or Complete PCP: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.
3. Service Order: Required
4. VR Documentation: Evidence of on-going Voc Rehab collaboration.  IPS providers must refer individuals to DVRS for eligibility determination of employment services when initiating services. If determined eligible for VR services, the provider and DVRS will collaborate on employment services.
5.  Updated PCP, Service Plan or Career Profile: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.

Authorization Parameters
Length of Stay: The duration and frequency at which IPS is provided must be based on MN and progress made by the individual toward goals outlined in the Career Profile

Units: One unit= 15 minutes

Age Group: Adults & Adolescents (age 16 years and older) with: 
1. A serious mental illness (SMI) that includes severe and persistent mental illness (SPMI); OR
2. A serious emotional disturbance (SED); OR
3. A severe substance use disorder (SUD)

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. IPS services shall not be provided during the same auth period as ACT.
2. Individuals may not be disqualified from engaging in employment because of perceived readiness factors, such as active substance use, criminal background issues, active MH symptoms, or personal presentation. The individual’s assessment and the Career Profile must be submitted within the first 30 calendar days of service initiation.
3. State funds will not cover:
a. Services provided to teach academics, to include special education provided under the Individuals with Disabilities Education Act (IDEA)
b. Pre-vocational classes and/or group employment searches or classes
c. Supports or services to help with volunteering
d. Set-aside jobs for people with disabilities, such as enclaves, and will not cover group employment/work crews.  
e. Services to acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in community settings, to include time spent attending or participating in recreational activities
f. Childcare services
g. Service provided under the Rehabilitation Act of 1973
h. IPS services can only be billed when providing employment services and support directly to the individual or on behalf of the beneficiary and cannot be billed for meetings, paperwork, documentation, or travel time.
4. State funds will only reimburse for services not covered in a DVR milestone. IPS providers will bill DVRS for milestone payments for services provided by the Employment Support Professional (ESP). A individual may receive peer services and benefits counseling during the vocational rehabilitation milestones. IPS providers should bill H2023U4 for services provided by the Employment Peer Mentor (EPM) and the Benefits Counselor (BC).

Service Code
H2023 Z7 – IPS for AMH/ASU - Milestone 6
Diagnosis Group
Mental Health
Substance Abuse
Age Group
16 and Older
Benefit Plan
State
Prior Authorization Required
No

Individual Placement and Support (IPS) for Adult Mental Health/Adult Substance Use - H2023 Z8 (Milestone 7a)

Authorization Guidelines:

Brief Service Description: A behavioral health service with a focus on employment that provides assistance in choosing, acquiring, and maintaining competitive paid employment in the community for individuals 16 years and older for whom employment has not been achieved or employment has been interrupted or intermittent. This service is co-located with an agency’s behavioral health treatment services to ensure consistent behavioral health integration. If a provider of IPS does not also provide behavioral health services, the provider must partner with one or two behavioral health agencies. The IPS model requires ongoing behavioral health Integration.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA: Required, to include current diagnosis, level of functioning, and an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
2. Career Profile or Complete PCP: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.
3. Service Order: Required
4. VR Documentation: Evidence of on-going Voc Rehab collaboration.  IPS providers must refer individuals to DVRS for eligibility determination of employment services when initiating services. If determined eligible for VR services, the provider and DVRS will collaborate on employment services.
5.  Updated PCP, Service Plan or Career Profile: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.

Authorization Parameters
Length of Stay: The duration and frequency at which IPS is provided must be based on MN and progress made by the individual toward goals outlined in the Career Profile

Units: One unit= 15 minutes

Age Group: Adults & Adolescents (age 16 years and older) with: 
1. A serious mental illness (SMI) that includes severe and persistent mental illness (SPMI); OR
2. A serious emotional disturbance (SED); OR
3. A severe substance use disorder (SUD)

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. IPS services shall not be provided during the same auth period as ACT.
2. Individuals may not be disqualified from engaging in employment because of perceived readiness factors, such as active substance use, criminal background issues, active MH symptoms, or personal presentation. The individual’s assessment and the Career Profile must be submitted within the first 30 calendar days of service initiation.
3. State funds will not cover:
a. Services provided to teach academics, to include special education provided under the Individuals with Disabilities Education Act (IDEA)
b. Pre-vocational classes and/or group employment searches or classes
c. Supports or services to help with volunteering
d. Set-aside jobs for people with disabilities, such as enclaves, and will not cover group employment/work crews.  
e. Services to acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in community settings, to include time spent attending or participating in recreational activities
f. Childcare services
g. Service provided under the Rehabilitation Act of 1973
h. IPS services can only be billed when providing employment services and support directly to the individual or on behalf of the beneficiary and cannot be billed for meetings, paperwork, documentation, or travel time.
4. State funds will only reimburse for services not covered in a DVR milestone. IPS providers will bill DVRS for milestone payments for services provided by the Employment Support Professional (ESP). A individual may receive peer services and benefits counseling during the vocational rehabilitation milestones. IPS providers should bill H2023U4 for services provided by the Employment Peer Mentor (EPM) and the Benefits Counselor (BC).

Service Code
H2023 Z8 – IPS for AMH/ASU - Milestone 7a
Diagnosis Group
Mental Health
Substance Abuse
Age Group
16 and Older
Benefit Plan
State
Prior Authorization Required
No

Individual Placement and Support (IPS) for Adult Mental Health/Adult Substance Use - H2023 Z9 (Milestone 7b)

Authorization Guidelines:

Brief Service Description: A behavioral health service with a focus on employment that provides assistance in choosing, acquiring, and maintaining competitive paid employment in the community for individuals 16 years and older for whom employment has not been achieved or employment has been interrupted or intermittent. This service is co-located with an agency’s behavioral health treatment services to ensure consistent behavioral health integration. If a provider of IPS does not also provide behavioral health services, the provider must partner with one or two behavioral health agencies. The IPS model requires ongoing behavioral health Integration.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA: Required, to include current diagnosis, level of functioning, and an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
2. Career Profile or Complete PCP: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.
3. Service Order: Required
4. VR Documentation: Evidence of on-going Voc Rehab collaboration.  IPS providers must refer individuals to DVRS for eligibility determination of employment services when initiating services. If determined eligible for VR services, the provider and DVRS will collaborate on employment services.
5.  Updated PCP, Service Plan or Career Profile: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.

Authorization Parameters
Length of Stay: The duration and frequency at which IPS is provided must be based on MN and progress made by the individual toward goals outlined in the Career Profile

Units: One unit= 15 minutes

Age Group: Adults & Adolescents (age 16 years and older) with: 
1. A serious mental illness (SMI) that includes severe and persistent mental illness (SPMI); OR
2. A serious emotional disturbance (SED); OR
3. A severe substance use disorder (SUD)

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. IPS services shall not be provided during the same auth period as ACT.
2. Individuals may not be disqualified from engaging in employment because of perceived readiness factors, such as active substance use, criminal background issues, active MH symptoms, or personal presentation. The individual’s assessment and the Career Profile must be submitted within the first 30 calendar days of service initiation.
3. State funds will not cover:
a. Services provided to teach academics, to include special education provided under the Individuals with Disabilities Education Act (IDEA)
b. Pre-vocational classes and/or group employment searches or classes
c. Supports or services to help with volunteering
d. Set-aside jobs for people with disabilities, such as enclaves, and will not cover group employment/work crews.  
e. Services to acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in community settings, to include time spent attending or participating in recreational activities
f. Childcare services
g. Service provided under the Rehabilitation Act of 1973
h. IPS services can only be billed when providing employment services and support directly to the individual or on behalf of the beneficiary and cannot be billed for meetings, paperwork, documentation, or travel time.
4. State funds will only reimburse for services not covered in a DVR milestone. IPS providers will bill DVRS for milestone payments for services provided by the Employment Support Professional (ESP). A individual may receive peer services and benefits counseling during the vocational rehabilitation milestones. IPS providers should bill H2023U4 for services provided by the Employment Peer Mentor (EPM) and the Benefits Counselor (BC).

Service Code
H2023 Z9 – IPS for AMH/ASU - Milestone 7b
Diagnosis Group
Mental Health
Substance Abuse
Age Group
16 and Older
Benefit Plan
State
Prior Authorization Required
No

Individual Placement and Support (IPS) for Adult Mental Health/Adult Substance Use - YP630 (For Non-Milestone Providers)

Authorization Guidelines:

Brief Service Description: A behavioral health service with a focus on employment that provides assistance in choosing, acquiring, and maintaining competitive paid employment in the community for individuals 16 years and older for whom employment has not been achieved or employment has been interrupted or intermittent. This service is co-located with an agency’s behavioral health treatment services to ensure consistent behavioral health integration. If a provider of IPS does not also provide behavioral health services, the provider must partner with one or two behavioral health agencies. The IPS model requires ongoing behavioral health Integration.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA: Required, to include current diagnosis, level of functioning, and an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
2. Career Profile or Complete PCP: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.
3. Service Order: Required
4. VR Documentation: Evidence of on-going Voc Rehab collaboration.  IPS providers must refer individuals to DVRS for eligibility determination of employment services when initiating services. If determined eligible for VR services, the provider and DVRS will collaborate on employment services.
5.  Updated PCP, Service Plan or Career Profile: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.

Authorization Parameters
Length of Stay: The duration and frequency at which IPS is provided must be based on MN and progress made by the individual toward goals outlined in the Career Profile

Units: One unit= 15 minutes

Age Group: Adults & Adolescents (age 16 years and older) with: 
1. A serious mental illness (SMI) that includes severe and persistent mental illness (SPMI); OR
2. A serious emotional disturbance (SED); OR
3. A severe substance use disorder (SUD)

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. IPS services shall not be provided during the same auth period as ACT.
2. Individuals may not be disqualified from engaging in employment because of perceived readiness factors, such as active substance use, criminal background issues, active MH symptoms, or personal presentation. The individual’s assessment and the Career Profile must be submitted within the first 30 calendar days of service initiation.
3. State funds will not cover:
a. Services provided to teach academics, to include special education provided under the Individuals with Disabilities Education Act (IDEA)
b. Pre-vocational classes and/or group employment searches or classes
c. Supports or services to help with volunteering
d. Set-aside jobs for people with disabilities, such as enclaves, and will not cover group employment/work crews.  
e. Services to acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in community settings, to include time spent attending or participating in recreational activities
f. Childcare services
g. Service provided under the Rehabilitation Act of 1973
h. IPS services can only be billed when providing employment services and support directly to the individual or on behalf of the beneficiary and cannot be billed for meetings, paperwork, documentation, or travel time.
4. State funds will only reimburse for services not covered in a DVR milestone. IPS providers will bill DVRS for milestone payments for services provided by the Employment Support Professional (ESP). A individual may receive peer services and benefits counseling during the vocational rehabilitation milestones. IPS providers should bill H2023U4 for services provided by the Employment Peer Mentor (EPM) and the Benefits Counselor (BC).

Service Code
YP630 – IPS for AMH/ASU - Non-Milestone Providers
Diagnosis Group
Mental Health
Substance Abuse
Age Group
16 and Older
Benefit Plan
State
Prior Authorization Required
No

Individual Placement and Support (IPS) for Adult Mental Health/Adult Substance Use - YP630 U6 (For Transition to Community Living (TCL))

Authorization Guidelines:

Brief Service Description: A behavioral health service with a focus on employment that provides assistance in choosing, acquiring, and maintaining competitive paid employment in the community for individuals 16 years and older for whom employment has not been achieved or employment has been interrupted or intermittent. This service is co-located with an agency’s behavioral health treatment services to ensure consistent behavioral health integration. If a provider of IPS does not also provide behavioral health services, the provider must partner with one or two behavioral health agencies. The IPS model requires ongoing behavioral health Integration.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA: Required, to include current diagnosis, level of functioning, and an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
2. Career Profile or Complete PCP: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.
3. Service Order: Required
4. VR Documentation: Evidence of on-going Voc Rehab collaboration.  IPS providers must refer individuals to DVRS for eligibility determination of employment services when initiating services. If determined eligible for VR services, the provider and DVRS will collaborate on employment services.
5.  Updated PCP, Service Plan or Career Profile: Required. If the individual receives an enhanced service, employment and other services must be identified on an integrated PCP with an attached in-depth Career Profile. Frequency and intensity of services must be documented in the Career Profile and must be individualized.

Authorization Parameters
Length of Stay: The duration and frequency at which IPS is provided must be based on MN and progress made by the individual toward goals outlined in the Career Profile

Units: One unit= 15 minutes

Age Group: Adults & Adolescents (age 16 years and older) with: 
1. A serious mental illness (SMI) that includes severe and persistent mental illness (SPMI); OR
2. A serious emotional disturbance (SED); OR
3. A severe substance use disorder (SUD)

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. IPS services shall not be provided during the same auth period as ACT.
2. Individuals may not be disqualified from engaging in employment because of perceived readiness factors, such as active substance use, criminal background issues, active MH symptoms, or personal presentation. The individual’s assessment and the Career Profile must be submitted within the first 30 calendar days of service initiation.
3. State funds will not cover:
a. Services provided to teach academics, to include special education provided under the Individuals with Disabilities Education Act (IDEA)
b. Pre-vocational classes and/or group employment searches or classes
c. Supports or services to help with volunteering
d. Set-aside jobs for people with disabilities, such as enclaves, and will not cover group employment/work crews.  
e. Services to acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in community settings, to include time spent attending or participating in recreational activities
f. Childcare services
g. Service provided under the Rehabilitation Act of 1973
h. IPS services can only be billed when providing employment services and support directly to the individual or on behalf of the beneficiary and cannot be billed for meetings, paperwork, documentation, or travel time.
4. State funds will only reimburse for services not covered in a DVR milestone. IPS providers will bill DVRS for milestone payments for services provided by the Employment Support Professional (ESP). A individual may receive peer services and benefits counseling during the vocational rehabilitation milestones. IPS providers should bill H2023U4 for services provided by the Employment Peer Mentor (EPM) and the Benefits Counselor (BC).

Service Code
YP630 U6 – IPS for AMH/ASU - TCL
Diagnosis Group
Mental Health
Substance Abuse
Age Group
16 and Older
Benefit Plan
State
Prior Authorization Required
No

Inpatient - 100

Authorization Guidelines:

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

Service Code
100
Diagnosis Group
Substance Abuse
Intellectual Development Disability
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Intensive In Home - H2022

Authorization Guidelines:

Initial: 60 days; Concurrent: 60 days State Funded Limited to 6 months per calendar year

Service Code
H2022
Diagnosis Group
Mental Health
Age Group
Child
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Intermediate Care Facility (ICF) - 100

Authorization Guidelines:

Authrorization may be up to one year. LOC must be submitted every 180 days

Service Code
100
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Mobile Crisis - H2011

Authorization Guidelines:

Authorization required within 48 hours after 32 unmanaged units have been exhausted. Clinical documents required if TAR is for more than 8 additional units.

Service Code
H2011
Diagnosis Group
Intellectual Development Disability
Substance Abuse
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Multisystemic Therapy (MST) - H2033 HA Case Rate

Authorization Guidelines:

Initial: 5 months; NPA for Mediciad. 

State Funded limited to 1 treatment episode per lifetime. 

Service Code
H2033 HA Case Rate
Diagnosis Group
Mental Health
Age Group
Child
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Multisystemic Therapy (MST) - H2033 HA U1 Shadow Claim

Authorization Guidelines:

Initial: 5 months; Currently NPA for Mediciad. State Funded limited to 1 treatment episode per lifetime. 

Service Code
H2033 HA U1 Shadow Claim
Diagnosis Group
Mental Health
Age Group
Child
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Natural Supports Education - Innovations - S5110- Natural Supports Education

Authorization Guidelines:
  • Natural Supports Education provides education and training which must have outcomes directly related to the needs of the beneficiary or the natural support network’s ability to provide care and support to the beneficiary.
  • Training and education, including reimbursement for conferences, are excluded for family members and natural support networks when those members are employed to provide supervision and care to the beneficiary.
  • Reimbursement for conference and class attendance will be limited to $1,000 per year.
Service Code
S5110 - Natural Supports Education
Diagnosis Group
Intellectual Development Disability
Age Group
Child
Adult
18-20
Benefit Plan
Innovations
Prior Authorization Required
Yes

Natural Supports Education - Innovations - S5111- Natural Supports Education-Conference

Authorization Guidelines:
  • Natural Supports Education provides education and training which must have outcomes directly related to the needs of the beneficiary or the natural support network’s ability to provide care and support to the beneficiary.
  • Training and education, including reimbursement for conferences, are excluded for family members and natural support networks when those members are employed to provide supervision and care to the beneficiary.
  • Reimbursement for conference and class attendance will be limited to $1,000 per year.
Service Code
S5111 - Natural Supports Education-Conference
Diagnosis Group
Intellectual Development Disability
Age Group
Child
Adult
18-20
Benefit Plan
Innovations
Prior Authorization Required
Yes

Opioid Treatment - H0020

Authorization Guidelines:

No Prior Authorization.

Service Code
H0020
Diagnosis Group
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Out of Home Crisis - T2034

Authorization Guidelines:

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 30 calendar day increments per event.

Service Code
T2034
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Outpatient Therapy - 90791 - Psychiatric Diagnostic Evaluation (No Medical Services)

Authorization Guidelines:

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

Service Code
90791 - Psychiatric Diagnostic Evaluation (No Medical Services)
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Outpatient Therapy - 90792 - Psychiatric Diagnostic Evaluation With Medical Services

Authorization Guidelines:

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

Service Code
90792 - Psychiatric Diagnostic Evaluation With Medical Services
Diagnosis Group
Intellectual Development Disability
Substance Abuse
Mental Health
Age Group
Child
Adult
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Outpatient Therapy - 90832 - Psychotherapy - 30 Minutes

Authorization Guidelines:

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

Service Code
90832 - Psychotherapy - 30 Minutes
Diagnosis Group
Intellectual Development Disability
Substance Abuse
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Outpatient Therapy - 90833 - Psychotherapy - 30 Minutes with E/M service

Authorization Guidelines:

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

Service Code
90833 - Psychotherapy - 30 Minutes with E/M service
Diagnosis Group
Intellectual Development Disability
Substance Abuse
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Outpatient Therapy - 90834 - Psychotherapy - 45 Minutes

Authorization Guidelines:

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

Service Code
90834 - Psychotherapy - 45 Minutes
Diagnosis Group
Intellectual Development Disability
Substance Abuse
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Outpatient Therapy - 90836 - Psychotherapy – 45 Minutes with E/M Service

Authorization Guidelines:

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

Service Code
90836- Psychotherapy – 45 Minutes with E/M Service
Diagnosis Group
Intellectual Development Disability
Substance Abuse
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Outpatient Therapy - 90837 - Psychotherapy - 60 Minutes

Authorization Guidelines:

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

Service Code
90837 - Psychotherapy - 60 Minutes
Diagnosis Group
Intellectual Development Disability
Substance Abuse
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Outpatient Therapy - 90838- Psychotherapy – 60 Minutes with E/M Service

Authorization Guidelines:

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

Service Code
90838- Psychotherapy – 60 Minutes with E/M Service
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Outpatient Therapy - 90846 - Family Therapy w/o client

Authorization Guidelines:

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

Service Code
90846 - Family Therapy w/o client
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Outpatient Therapy - 90847 - Family Therapy w/ client

Authorization Guidelines:

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

Service Code
90847 - Family Therapy w/ client
Diagnosis Group
Intellectual Development Disability
Intellectual Development Disability
Mental Health
Age Group
Child
Adult
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Outpatient Therapy - 90853 - Group Therapy

Authorization Guidelines:

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

Service Code
90853 - Group Therapy
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Outpatient Therapy- Crisis Services - 90839 - Psychotherapy for Crisis First 60 Minutes

Authorization Guidelines:
Service Code
90839 - Psychotherapy for Crisis First 60 Minutes
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
Adult
18-20
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Outpatient Therapy- Crisis Services - 90840 - Psychotherapy for Crisis each additional 30 minutes

Authorization Guidelines:
Service Code
90840 - Psychotherapy for Crisis each additional 30 minutes
Diagnosis Group
Intellectual Development Disability
Substance Abuse
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
No

Partial Hospitalization - H0035

Authorization Guidelines:

Brief Service Description: A short-term service for acutely mentally ill children or adults, which provides a broad range of intensive therapeutic approaches which may include: group activities or therapy, individual therapy, recreational therapy, community living skills or training, increases the individual’s ability to relate to others and to function appropriately, coping skills, medical services. This service is designed to prevent hospitalization or to serve as an interim step for those leaving an inpatient facility.
 

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for the first 7 days (7 units)

Initial Requests (after pass-through):
1. TAR: Prior authorization is required.  
2. CCA: Required
3. Complete PCP: Required, to include all necessary signatures and the 3-page crisis plan. The amount, duration, and frequency of services must be included.  If limited information is available at admission, staff shall document on the PCP whatever is known and update it when additional information becomes available.
4. Service Order: Required, signed by a MD/DO, doctoral level licensed psychologist, psychiatric NP, psychiatric clinical nurse specialist.
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: 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:  Initial (after pass-through) and Reauthorization requests shall not exceed 7 calendar days.

Units:
1. One unit = 1 event  
2. This is day or night service provided a minimum of 4 hrs/day, 5 days/week, and 12 months/year (excluding transportation time).  Excludes legal or governing body designated holidays.

Age Group: Children, Adolescents & Adults

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 Code
H0035
Diagnosis Group
Substance Abuse
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Partial Hospitalization - H0035

Authorization Guidelines:

Brief Service Description: A short-term service for acutely mentally ill children or adults, which provides a broad range of intensive therapeutic approaches which may include: group activities or therapy, individual therapy, recreational therapy, community living skills or training, increases the individual’s ability to relate to others and to function appropriately, coping skills, medical services. This service is designed to prevent hospitalization or to serve as an interim step for those leaving an inpatient facility. A physician shall participate in diagnosis, tx planning, and admission or discharge decisions. Physician involvement shall be one factor that distinguishes Partial Hospitalization from Day Treatment services.
 

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for the first 7 days (7 units)

Initial Requests (after pass-through):
1. TAR: Prior authorization is required.  
2. CCA: Required
3. Complete PCP: Required, to include all required signatures and the 3-page crisis plan. The amount, duration, and frequency of services must be included.  If limited information is available at admission, staff shall document on the PCP whatever is known and update it when additional information becomes available.
4. Service Order: Required
5. Medicaid Application: Evidence of individual applying for Medicaid or update on application status.
6. 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: 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. Initial (after pass-through) and Reauthorization requests shall not exceed 7 calendar days.
2. Maximum length of stay is 30 days in a 12-month period.

Units:
1. One unit = 1 event  
2. This is day or night service provided a minimum of 4 hrs/day, 5 days/week, and 12 months/year (excluding transportation time).  Excludes legal or governing body designated holidays.

Age Group: Children, Adolescents & Adults

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): Individuals may be ineligible for a state-funded service due to coverage by other payors that would make them ineligible for the same or similar service funded by the state (e.g. individual is eligible for the same service covered by Medicaid or other third party payor)

Service Code
H0035
Diagnosis Group
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Peer Support - H0038 (Individual)

Authorization Guidelines:

Brief Service Description: An evidenced-based mental health model of care that provides community-based recovery services directly to a Medicaid-eligible adult member diagnosed with an MH or SU disorder. PSS provides structured, scheduled services that promote recovery, self-determination, self-advocacy, engagement in self-care and wellness and enhancement of community living skills of beneficiaries.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for the first 6 hours (24 units) of service initiation. 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 necessary signatures and the 3-page crisis plan.
4. Service Order: Required, signed by physician or other licensed clinician (DO, NP, PA, PhD)
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: 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: 
1. Up to a 90-day auth period per request.
2. Providers shall seek prior authorization if they are uncertain that the member has reached the unmanaged unit limit.

Units:
1. One unit = 15 minutes
2. Up to 270 units (individual and group combined) for 90 days for the initial auth period (after pass-through).  Up to 270 units for 90 days for reauth periods, if medically necessary.

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. Telehealth or telephonically, audio-only communication is limited to 20% or less of total service time provided per fiscal year.
2. May not be provided during the same auth period as ACTT or CST.  Member with a sole diagnosis of IDD is not eligible this service.

Service Code
H0038 - Peer Support Individual
Diagnosis Group
Substance Abuse
Mental Health
Age Group
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Peer Support - H0038 (Individual)

Authorization Guidelines:

Brief Service Description: Service is an evidenced-based MH model of care that provides community-based recovery services directly to an adult diagnosed with a MH or SU disorder. PSS provides structured, scheduled services that promote recovery, self-determination, self-advocacy, engagement in self-care and wellness and enhancement of community living skills of individuals. PSS services are directly provided by Certified Peer Support Specialists (CPSS) who have self-identified as a person(s) in recovery from a mental health or substance use disorder.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for the first 6 hours (24 units) of service initiation. 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 physician or other licensed clinician (DO, PA, NP, PhD)
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 90-day auth period per request.
2. Providers shall seek prior authorization if they are uncertain that the individual has reached the unmanaged unit limit.

Units: 
1. One unit = 15 minutes 
2. Up to 270 units (individual and group combined) for 90 days for all authorization periods (after pass-through). 

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. Must not be provided during the same authorization period as ACT, CST.  PSS must not be provided during the same time of day when an individual is receiving SAIOP, SACOT, Partial Hospitalization, PSR, Respite, or Individual Support services. 
2. Individuals with a sole diagnosis of IDD is not eligible for this service.
3. Telehealth or telephonically, audio-only communication is limited to 20% or less of total service time provided per fiscal year.
4. If MN dictates the need for increased service duration and frequency, clinical consideration must be given to interventions with a more intense clinical component.

Service Code
H0038 - SF Peer Support - Individual
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
No

Peer Support - H0038 GT (Individual Telehealth)

Authorization Guidelines:

Brief Service Description: An evidenced-based mental health model of care that provides community-based recovery services directly to a Medicaid-eligible adult member diagnosed with an MH or SU disorder. PSS provides structured, scheduled services that promote recovery, self-determination, self-advocacy, engagement in self-care and wellness and enhancement of community living skills of beneficiaries.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for the first 6 hours (24 units) of service initiation. 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 necessary signatures and the 3-page crisis plan.
4. Service Order: Required, signed by physician or other licensed clinician (DO, NP, PA, PhD)
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: 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: 
1. Up to a 90-day auth period per request.
2. Providers shall seek prior authorization if they are uncertain that the member has reached the unmanaged unit limit.

Units:
1. One unit = 15 minutes
2. Up to 270 units (individual and group combined) for 90 days for the initial auth period (after pass-through).  Up to 270 units for 90 days for reauth periods, if medically necessary.

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. Telehealth or telephonically, audio-only communication is limited to 20% or less of total service time provided per fiscal year.
2. May not be provided during the same auth period as ACTT or CST.  Member with a sole diagnosis of IDD is not eligible this service.

Service Code
H0038 GT - Peer Support - Individual Telehealth
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Peer Support - H0038 GT (Individual Telehealth)

Authorization Guidelines:

Brief Service Description: Service is an evidenced-based MH model of care that provides community-based recovery services directly to an adult diagnosed with a MH or SU disorder. PSS provides structured, scheduled services that promote recovery, self-determination, self-advocacy, engagement in self-care and wellness and enhancement of community living skills of individuals. PSS services are directly provided by Certified Peer Support Specialists (CPSS) who have self-identified as a person(s) in recovery from a mental health or substance use disorder.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for the first 6 hours (24 units) of service initiation. 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 physician or other licensed clinician (DO, PA, NP, PhD)
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 90-day auth period per request.
2. Providers shall seek prior authorization if they are uncertain that the individual has reached the unmanaged unit limit.

Units: 
1. One unit = 15 minutes 
2. Up to 270 units (individual and group combined) for 90 days for all authorization periods (after pass-through). 

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. Must not be provided during the same authorization period as ACT, CST.  PSS must not be provided during the same time of day when an individual is receiving SAIOP, SACOT, Partial Hospitalization, PSR, Respite, or Individual Support services. 
2. Individuals with a sole diagnosis of IDD is not eligible for this service.
3. Telehealth or telephonically, audio-only communication is limited to 20% or less of total service time provided per fiscal year.
4. If MN dictates the need for increased service duration and frequency, clinical consideration must be given to interventions with a more intense clinical component.

Service Code
H0038– SF Peer Support – Individual Telehealth
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Peer Support - H0038 HQ (Group)

Authorization Guidelines:

Brief Service Description: An evidenced-based mental health model of care that provides community-based recovery services directly to a Medicaid-eligible adult member diagnosed with an MH or SU disorder. PSS provides structured, scheduled services that promote recovery, self-determination, self-advocacy, engagement in self-care and wellness and enhancement of community living skills of beneficiaries.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for the first 6 hours (24 units) of service initiation. 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 necessary signatures and the 3-page crisis plan.
4. Service Order: Required, signed by physician or other licensed clinician (DO, NP, PA, PhD)
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: 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: 
1. Up to a 90-day auth period per request.
2. Providers shall seek prior authorization if they are uncertain that the member has reached the unmanaged unit limit.

Units:
1. One unit = 15 minutes
2. Up to 270 units (individual and group combined) for 90 days for the initial auth period (after pass-through).  Up to 270 units for 90 days for reauth periods, if medically necessary.

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. Telehealth or telephonically, audio-only communication is limited to 20% or less of total service time provided per fiscal year.
2. May not be provided during the same auth period as ACTT or CST.  Member with a sole diagnosis of IDD is not eligible this service.

Service Code
H0038 HQ - Peer Support Group
Diagnosis Group
Substance Abuse
Mental Health
Age Group
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Peer Support - H0038 HQ (Group)

Authorization Guidelines:

Brief Service Description: Service is an evidenced-based MH model of care that provides community-based recovery services directly to an adult diagnosed with a MH or SU disorder. PSS provides structured, scheduled services that promote recovery, self-determination, self-advocacy, engagement in self-care and wellness and enhancement of community living skills of individuals. PSS services are directly provided by Certified Peer Support Specialists (CPSS) who have self-identified as a person(s) in recovery from a mental health or substance use disorder.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for the first 6 hours (24 units) of service initiation. 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 physician or other licensed clinician (DO, PA, NP, PhD)
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 90-day auth period per request.
2. Providers shall seek prior authorization if they are uncertain that the individual has reached the unmanaged unit limit.

Units: 
1. One unit = 15 minutes 
2. Up to 270 units (individual and group combined) for 90 days for all authorization periods (after pass-through). 

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 Code
H0038 HQ – SF Peer Support – Group
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Peer Support - H0038 KX (Individual Telephonic)

Authorization Guidelines:

Brief Service Description: An evidenced-based mental health model of care that provides community-based recovery services directly to a Medicaid-eligible adult member diagnosed with an MH or SU disorder. PSS provides structured, scheduled services that promote recovery, self-determination, self-advocacy, engagement in self-care and wellness and enhancement of community living skills of beneficiaries.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for the first 6 hours (24 units) of service initiation. 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 necessary signatures and the 3-page crisis plan.
4. Service Order: Required, signed by physician or other licensed clinician (DO, NP, PA, PhD)
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: 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: 
1. Up to a 90-day auth period per request.
2. Providers shall seek prior authorization if they are uncertain that the member has reached the unmanaged unit limit.

Units:
1. One unit = 15 minutes
2. Up to 270 units (individual and group combined) for 90 days for the initial auth period (after pass-through).  Up to 270 units for 90 days for reauth periods, if medically necessary.

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. Telehealth or telephonically, audio-only communication is limited to 20% or less of total service time provided per fiscal year.
2. May not be provided during the same auth period as ACTT or CST.  Member with a sole diagnosis of IDD is not eligible this service.

Service Code
H0038 KX - Peer Support - Individual Telephonic
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Peer Support - H0038 KX (Individual Telephonic)

Authorization Guidelines:

Brief Service Description: Service is an evidenced-based MH model of care that provides community-based recovery services directly to an adult diagnosed with a MH or SU disorder. PSS provides structured, scheduled services that promote recovery, self-determination, self-advocacy, engagement in self-care and wellness and enhancement of community living skills of individuals. PSS services are directly provided by Certified Peer Support Specialists (CPSS) who have self-identified as a person(s) in recovery from a mental health or substance use disorder.

Auth Submission Requirements
Pass-Through Period: Prior authorization is not required for the first 6 hours (24 units) of service initiation. 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 physician or other licensed clinician (DO, PA, NP, PhD)
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 90-day auth period per request.
2. Providers shall seek prior authorization if they are uncertain that the individual has reached the unmanaged unit limit.

Units: 
1. One unit = 15 minutes 
2. Up to 270 units (individual and group combined) for 90 days for all authorization periods (after pass-through). 

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. Must not be provided during the same authorization period as ACT, CST.  PSS must not be provided during the same time of day when an individual is receiving SAIOP, SACOT, Partial Hospitalization, PSR, Respite, or Individual Support services. 
2. Individuals with a sole diagnosis of IDD is not eligible for this service.
3. Telehealth or telephonically, audio-only communication is limited to 20% or less of total service time provided per fiscal year.
4. If MN dictates the need for increased service duration and frequency, clinical consideration must be given to interventions with a more intense clinical component.

Service Code
H0038 KX – SF Peer Support – Individual Telephonic
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

PPP Contract Inpatient (Brynn Marr, Holly Hill) - 100

Authorization Guidelines:

Intial 5 days. Concurrent: 3 days Maximum  8 days 

Service Code
100
Diagnosis Group
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

PRTF - 911

Authorization Guidelines:

Initial: 30 days; Concurrent: 30 days

Service Code
911
Diagnosis Group
Mental Health
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Psychological Testing - 94616- ADMINISTRATION OF PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST BY SINGLE STANDARDIZED INSTRUMENT VIA ELECTRONIC PLATFORM WITH AUTOMATED RESULT

Authorization Guidelines:

Authorization required after 9 hours

Service Code
94616 - Administration of Psychological or Neuropsychological Test by Single Standardized Instrument via Electronic Platform With Automated Result
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Psychological Testing - 96110- DEVELOPMENTAL SCREENING

Authorization Guidelines:

Authorization required after 9 hours

Service Code
96110 - Developmental Screening
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Psychological Testing - 96112- ADMINISTRATION OF DEVELOPMENTAL TEST, FIRST HOUR

Authorization Guidelines:

Authorization required after 9 hours

Service Code
96112 - Administration of Developmental Test, First Hour
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Psychological Testing - 96113 -ADMINISTRATION OF DEVELOPMENTAL TEST, EACH ADDITIONAL 30 MINUTES

Authorization Guidelines:

Authorization required after 9 hours

Service Code
96113 - Administration of Developmental Test, Each Additional 30 Minutes
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Psychological Testing - 96116 EXAM OF NEUROBEHAVIORAL STATUS, FIRST HOUR

Authorization Guidelines:

Authorization required after 9 hours

Service Code
96116 - Exam of Neurobehavioral Status, First Hour
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Psychological Testing - 96121 EXAM OF NEUROBEHAVIORAL STATUS, EACH ADDITIONAL HOUR

Authorization Guidelines:

Authorization required after 9 hours

Service Code
96121 - Exam of Neurobehavioral Status, Each Additional Hour
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Psychological Testing - 96130- EVALUATION OF PSYCHOLOGICAL TEST, FIRST HOUR

Authorization Guidelines:

Authorization required after 9 hours

Service Code
96130 - Evaluation of Psychological Test, First Hour
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Psychological Testing - 96131 -EVALUATION OF PSYCHOLOGICAL TEST, EACH ADDITIONAL HOUR

Authorization Guidelines:

Authorization required after 9 hours

Service Code
96131 - Evaluation of Psychological Test, Each Additional Hour
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Psychological Testing - 96132 -EVALUATION OF NEUROPSYCHOLOGICAL TEST, FIRST HOUR

Authorization Guidelines:

Authorization required after 9 hours

Service Code
96132 - Evaluation of Neuropsychological Test, First Hour
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Psychological Testing - 96133- EVALUATION OF NEUROPSYCHOLOGICAL TEST, EACH ADDITIONAL HOUR

Authorization Guidelines:

Authorization required after 9 hours

Service Code
96133 - Evaluation of Neuropsychological Test, Each Additional Hour
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Psychological Testing - 96136 -ADMINISTRATION OF PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST, FIRST 30 MINUTES

Authorization Guidelines:

Authorization required after 9 hours

Service Code
96136 - Administration of Psychological or Neuropsychological Test, First 30 Minutes
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Psychological Testing - 96137- ADMINISTRATION OF PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST, EACH ADDITIONAL 30 MINUTES

Authorization Guidelines:

Authorization required after 9 hours

Service Code
96137 - Administration of Psychological or Neuropsychological Test, Each Additional 30 Minutes
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Psychological Testing - 96138- ADMINISTRATION OF PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST BY TECHNICIAN, FIRST 30 MINUTES

Authorization Guidelines:

Authorization required after 9 hours

Service Code
96138 - Administration of Psychological or Neuropsychological Test by Technician, First 30 Minutes
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Psychological Testing - 96139 -ADMINISTRATION OF PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST BY TECHNICIAN, EACH ADDITONAL 30 MINUTES

Authorization Guidelines:

Authorization required after 9 hours

Service Code
96139 - Administration of Psychological or Neuropsychological Test by Technician, Each Additional 30 Minutes
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Psychosocial Rehabilitation (PSR) - H2017

Authorization Guidelines:

Brief Service Description: Service is designed to help adults with psychiatric disabilities increase their functioning so that they can be successful and satisfied in the environments of their choice with the least amount of ongoing professional intervention. PSR focuses on skill and resource development related to life in the community and to increasing the participant’s ability to live as independently as possible, to manage their illness and their lives with as little professional intervention as possible, and to participate in community opportunities related to functional, social, educational, and vocational goals.

Auth Submission Requirements
Initial Requests:
1. TAR: Prior authorization is required.  
2. CCA: Required
3. Complete PCP: Required, to include all necessary signatures and the 3-page crisis plan.  The amount, duration, and frequency of services must be included.  
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. For PSR, the PCP shall be reviewed at least every 6 months.  The amount, duration, and frequency of services must be included in a member’s PCP.  
3. Transition/ Stepdown Plan: Required.
4. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Length of Stay: 
1. Initial authorization for services must not exceed 90 days. 
2. Reauthorization must not exceed 180 days.  

Units:
1. One unit = 15 minutes
2. The number of hours that a member receives PSR services are to be specified in his or her PCP.

Age Group: Adults

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. PSR cannot be provided during the same authorization period as Partial Hospitalization, 1915i Individual and Transitional Support, and ACTT. 
2. This service is to be available for a period of five or more hours per day at least five days per week and it may be provided on weekends or in the evening.

Service Code
H2017
Diagnosis Group
Substance Abuse
Mental Health
Age Group
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Psychosocial Rehabilitation (PSR) - H2017

Authorization Guidelines:

Brief Service Description: Service is designed to help adults with psychiatric disabilities increase their functioning so that they can be successful and satisfied in the environments of their choice with the least amount of ongoing professional intervention. PSR focuses on skill and resource development related to life in the community and to increasing the participant’s ability to live as independently as possible, to manage their illness and their lives with as little professional intervention as possible, and to participate in community opportunities related to functional, social, educational and vocational goals.

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. The amount, duration, and frequency of services must be included.  
4. Service Order: Required
5. Transition/ Stepdown Plan: Encouraged
6. Submission of applicable records that support the recipient has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the recipient’s progress with the service, to include all required signatures and the 3-page crisis plan. For PSR, the PCP shall be reviewed at least every 6 months.  The amount, duration, and frequency of services must be included in a recipient’s PCP.  
3. Transition/ Stepdown Plan:  Encouraged
4. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status.
5. Submission of applicable records that support the recipient has met the medical necessity criteria.

Authorization Parameters
Length of Stay: 
1. Initial and Reauthorization Requests: Up to 90 days
2. Maximum length of service is 6 months in a rolling 12-mointh period.
3. This service is to be available for a period of five or more hours per day, at least five days per week, and it may be provided on weekends or in the evening.

Units: 
1. One unit = 15 minutes
2. Up to 30 hours (120 units) per week for 90-day auth period (up to 1542 units).

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. PSR may not be provided during the same auth period as Partial Hospitalization and ACT.

Service Code
H2017 – SF Psychosocial Rehabilitation
Diagnosis Group
Mental Health
Substance Abuse
Age Group
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

RB-BHT (Research Based Behavioral Health Treatment) - 97151

Authorization Guidelines:

Initial: 180 days; Concurrent: 180 days

Service Code
97151
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

RB-BHT (Research Based Behavioral Health Treatment) - 97151GT

Authorization Guidelines:

Initial: 180 days; Concurrent: 180 days

Service Code
97151GT
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

RB-BHT (Research Based Behavioral Health Treatment) - 97152

Authorization Guidelines:

Initial: 180 days; Concurrent: 180 days

Service Code
97152
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

RB-BHT (Research Based Behavioral Health Treatment) - 97152GT

Authorization Guidelines:

Initial: 180 days; Concurrent: 180 days

Service Code
97152GT
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

RB-BHT (Research Based Behavioral Health Treatment) - 97153

Authorization Guidelines:

Initial: 180 days; Concurrent: 180 days

Service Code
97153
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

RB-BHT (Research Based Behavioral Health Treatment) - 97153GT

Authorization Guidelines:

Initial: 180 days; Concurrent: 180 days

Service Code
97153GT
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

RB-BHT (Research Based Behavioral Health Treatment) - 97154

Authorization Guidelines:

Initial: 180 days; Concurrent: 180 days

Service Code
97154
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

RB-BHT (Research Based Behavioral Health Treatment) - 97154GT

Authorization Guidelines:

Initial: 180 days; Concurrent: 180 days

Service Code
97154GT
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

RB-BHT (Research Based Behavioral Health Treatment) - 97155

Authorization Guidelines:

Initial: 180 days; Concurrent: 180 days

Service Code
97155
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

RB-BHT (Research Based Behavioral Health Treatment) - 97155GT

Authorization Guidelines:

Initial: 180 days; Concurrent: 180 days

Service Code
97155GT
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

RB-BHT (Research Based Behavioral Health Treatment) - 97156

Authorization Guidelines:

Initial: 180 days; Concurrent: 180 days

Service Code
97156
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

RB-BHT (Research Based Behavioral Health Treatment) - 97156GT

Authorization Guidelines:

Initial: 180 days; Concurrent: 180 days

Service Code
97156GT
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

RB-BHT (Research Based Behavioral Health Treatment) - 97157

Authorization Guidelines:

Initial: 180 days; Concurrent: 180 days

Service Code
97157
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

RB-BHT (Research Based Behavioral Health Treatment) - 97157GT

Authorization Guidelines:

Initial: 180 days; Concurrent: 180 days

Service Code
97157GT
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
No

Residential Level II Family - S5145

Authorization Guidelines:

Initial: 60 days; Concurrent: 60 days

Service Code
S5145
Diagnosis Group
Mental Health
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Residential Level II-H2020 Family Type

Authorization Guidelines:

Initial Authorization: 60 days

Concurrent 60 days

Service Code
Residential Level II-H2020 Family Type
Diagnosis Group
Mental Health
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Residential Level III - H0019 HQ - Res Level III, 4 beds or less

Authorization Guidelines:

Initial: 60 days; Concurrent: 60 days

Service Code
H0019 HQ - Res Level III, 4 beds or less
Diagnosis Group
Mental Health
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Residential Level III - H0019 TJ - Res Level III, 5 beds or more

Authorization Guidelines:

Initial: 60 days; Concurrent: 60 days

Service Code
H0019 TJ - Res Level III, 5 beds or more
Diagnosis Group
Mental Health
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Residential Level IV - H0019 HK - Res Level IV 4 beds or less

Authorization Guidelines:

Initial: 60 days; Concurrent: 60 days

Service Code
H0019 HK - Res Level IV 4 beds or less
Diagnosis Group
Mental Health
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Residential Level IV - H0019 UR - Res Level IV, 5 beds or more

Authorization Guidelines:

Initial: 60 days; Concurrent: 30 days

Service Code
H0019 UR - Res Level IV, 5 beds or more
Diagnosis Group
Mental Health
Age Group
Child
18-20
Benefit Plan
Medicaid
Prior Authorization Required
Yes

Residential Supports - Innovations - H2016 CG - Residential Supports Level 1 AFL

Authorization Guidelines:
  • Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized. 
  • Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.
Service Code
H2016 CG - Residential Supports Level 1 AFL
Diagnosis Group
Intellectual Development Disability
Age Group
Child
Adult
18-20
Benefit Plan
Innovations
Prior Authorization Required
Yes

Residential Supports - Innovations - H2016 HI CG- Residential Supports Level 4 AFL

Authorization Guidelines:
  • Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized. 
  • Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.
Service Code
H2016 HI CG - Residential Supports Level 4 AFL
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Residential Supports - Innovations - H2016 HI- Residential Supports Level 4

Authorization Guidelines:
  • Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized. 
  • Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.
Service Code
H2016 HI - Residential Supports Level 4
Diagnosis Group
Intellectual Development Disability
Age Group
Adult
Child
18-20
Benefit Plan
Innovations
Prior Authorization Required
Yes

Residential Supports - Innovations - T2014 - Residential Supports Level 2

Authorization Guidelines:
  • Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized.
  • Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.
Service Code
T2014 - Residential Supports Level 2
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Residential Supports - Innovations - T2014 CG - Residential Supports Level 2 AFL

Authorization Guidelines:
  • Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized.
  • Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.
Service Code
T2014 CG - Residential Supports Level 2 AFL
Diagnosis Group
Intellectual Development Disability
Age Group
Child
Adult
18-20
Benefit Plan
Innovations
Prior Authorization Required
Yes

Residential Supports - Innovations - T2020 - Residential Supports Level 3

Authorization Guidelines:
  • Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized. 
  • Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.
Service Code
T2020 - Residential Supports Level 3
Diagnosis Group
Intellectual Development Disability
Age Group
Child
Adult
18-20
Benefit Plan
Innovations
Prior Authorization Required
Yes

Residential Supports - Innovations - T2020 CG- Residential Supports Level 3 AFL

Authorization Guidelines:
  • Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized.
  • Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.
Service Code
T2020 CG - Residential Supports Level 3 AFL
Diagnosis Group
Intellectual Development Disability
Age Group
Child
Adult
18-20
Benefit Plan
Innovations
Prior Authorization Required
Yes

Residential Supports - Innovations H2016 - Residential Supports Level 1

Authorization Guidelines:
  • Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized.
  • Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.
Service Code
H2016 - Residential Supports Level 1
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Respite - Innovations - S5150 - Respite - Individual

Authorization Guidelines:
  • Per Plan Year, Respite is periodic or scheduled support and relief to the primary caregiver(s); temporary relief to a beneficiary who resides in Licensed or Unlicensed AFL.                                                                                                                                             Respite is not available to beneficiaries who reside in licensed facilities that are licensed as 5600B or 5600C.  
  • The cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID Facility.                                                  
  • Respite may not be used  for a beneficiary who is living alone or with a roommate and not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.
Service Code
S5150 - Respite - Individual
Diagnosis Group
Intellectual Development Disability
Age Group
Child
Adult
18-20
Benefit Plan
Innovations
Prior Authorization Required
Yes

Respite - Innovations - S5150 HQ - Respite - Group

Authorization Guidelines:
  • Per Plan Year, Respite is periodic or scheduled support and relief to the primary caregiver(s); temporary relief to a beneficiary who resides in Licensed or Unlicensed AFL.                                                                                                                                             Respite is not available to beneficiaries who reside in licensed facilities that are licensed as 5600B or 5600C.  
  • The cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID Facility.                                                  
  • Respite may not be used  for a beneficiary who is living alone or with a roommate and not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.
Service Code
S5150 HQ - Respite - Group
Diagnosis Group
Intellectual Development Disability
Age Group
Child
Adult
18-20
Benefit Plan
Innovations
Prior Authorization Required
Yes

Respite - Innovations - S5150 US- Respite - Facility

Authorization Guidelines:
  • Per Plan Year, Respite is periodic or scheduled support and relief to the primary caregiver(s); temporary relief to a beneficiary who resides in Licensed or Unlicensed AFL.                                                                                                                                             Respite is not available to beneficiaries who reside in licensed facilities that are licensed as 5600B or 5600C.  
  • The cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID Facility.                                                  
  • Respite may not be used  for a beneficiary who is living alone or with a roommate and not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.
Service Code
S5150 US - Respite - Facility
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Respite - Innovations - T1005 TD - Respite – RN

Authorization Guidelines:
  • Per Plan Year, Respite is periodic or scheduled support and relief to the primary caregiver(s); temporary relief to a beneficiary who resides in Licensed or Unlicensed AFL.                                                                                                                                             Respite is not available to beneficiaries who reside in licensed facilities that are licensed as 5600B or 5600C.  
  • The cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID Facility.                                                  
  • Respite may not be used  for a beneficiary who is living alone or with a roommate and not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.
Service Code
T1005 TD - Respite – RN
Diagnosis Group
Intellectual Development Disability
Age Group
Adult
Child
18-20
Benefit Plan
Innovations
Prior Authorization Required
Yes

Respite - Innovations - T1005 TE - Respite - LPN

Authorization Guidelines:
  • Per Plan Year, Respite is periodic or scheduled support and relief to the primary caregiver(s); temporary relief to a beneficiary who resides in Licensed or Unlicensed AFL.                                                                                                                                             Respite is not available to beneficiaries who reside in licensed facilities that are licensed as 5600B or 5600C.  
  • The cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID Facility.                                                  
  • Respite may not be used  for a beneficiary who is living alone or with a roommate and not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.
Service Code
T1005 TE - Respite - LPN
Diagnosis Group
Intellectual Development Disability
Age Group
Child
Adult
18-20
Benefit Plan
Innovations
Prior Authorization Required
Yes

Respite - YP012 - Individual Adult

Authorization Guidelines:

No more than 1,536 units (384 hours) can be provided to a recipient in a plan year. This service is a periodic service.

Service Code
YP012 - Individual Adult
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Respite - YP013 - Group Adult

Authorization Guidelines:

No more than 1,536 units (384 hours) can be provided to a recipient in a plan year. This service is a periodic service.

Service Code
YP013 - Group Adult
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Respite - YP014 Individual Child

Authorization Guidelines:

No more than 1,536 units (384 hours) can be provided to a recipient in a plan year. This service is a periodic service.

Service Code
YP014 Individual Child
Diagnosis Group
Intellectual Development Disability
Substance Abuse
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Respite - YP015 – Group Child

Authorization Guidelines:

No more than 1,536 units (384 hours) can be provided to a recipient in a plan year. This service is a periodic service.

Service Code
YP015 – Group Child
Diagnosis Group
Intellectual Development Disability
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

SA Medically Monitored Community Residential Treatment - H0013

Authorization Guidelines:

Initial authorization shall not exceed 10 days. Reauthorization shall not exceed 10 days. All utilization review activity shall be documented in the Provider’s Service Plan. This is a short-term service that may not exceed more than 45 days in a 12-month period.

Service Code
H0013
Diagnosis Group
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Specialized Consultation Services - T2025 - Specialized Consultative Services

Authorization Guidelines:
Service Code
T2025 - Specialized Consultative Services
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Specialized Consultation Services - T2025 HO - Specialized Consultative Services (BCBA)

Authorization Guidelines:
Service Code
T2025 HO - Specialized Consultative Services (BCBA)
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Substance Abuse Comprehensive Outpatient Treatment (SACOT) - H2035

Authorization Guidelines:

No Prior Authorization for first 60 days (“Pass-through” available once per fiscal year, July 1-June 30); Concurrent for 60 days (contract variations) 

Service Code
H2035
Diagnosis Group
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Substance Abuse Intensive Outpatient Program (SAIOP) - H0015

Authorization Guidelines:

State/Medicaid members: NPA for first 30 days (“Pass-through” available once per fiscal year, July 1-June 30) Concurrent: 60 days (contract variations) 

Service Code
H0015
Diagnosis Group
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Medicaid
Prior Authorization Required
Yes

Supervised Living - YP710 (Low)

Authorization Guidelines:

NO NEW ADMISSIONS EFFECTIVE 10/5/23

Brief Service Description: Service is typically provided in individual apartments, sometimes clustered in small developments that may or may not have an apartment manager on site during regularly scheduled hours. This is the least restrictive residential service which includes room and periodic support care. These apartments are the individual's home, not licensed facilities. No BH services are attached to the apartment. The individual may receive periodic MH services such as outpatient tx, structured day programming, etc., independent of the "supervised living" apartment. Community based MH services such as ACTT may be provided to the individual in the home, but the service is not programmatically linked to the home.

Auth Submission Requirements
Initial Requests:
1. TAR: Prior approval 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 authorization 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: Up to a 6-month per authorization.

Units: One unit = 1 day  

Age Group: Children, Adolescents & Adults

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 10/5/23
2. If an individual is temporarily in a respite or other 24-hour placement, staff are to assure that there is no double billing. 
3. Therapeutic leave does not apply to this service.

Service Code
YP710 - Supervised Living - Low
Diagnosis Group
Substance Abuse
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Supervised Living - YP720 (Moderate)

Authorization Guidelines:

NO NEW ADMISSIONS EFFECTIVE 10/5/23

Brief Service Description: Service is typically in an apartment which includes periodic support care to one or more individuals who do not need 24-hour supervision; or, for whom care in a group setting is considered inappropriate. Supervision includes routine or spontaneous visits, on-call support, and sometimes more intense one-on-one contact for several consecutive hours. It includes assistance in daily living skills, supportive counseling, and monitoring of the client's well-being. It may also include the employment of an individual to live with the client(s) to provide the appropriate level of supervision.

Auth Submission Requirements
Initial Requests:
1. TAR: Prior approval 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 authorization 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: Up to a 6-month per authorization.

Units: One unit = 1 day  

Age Group: Children, Adolescents & Adults

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 10/5/23
2. If an individual is temporarily in a respite or other 24-hour placement, staff are to assure that there is no double billing. 
3. Therapeutic leave does not apply to this service.

Service Code
YP720 - Supervised Living – Moderate
Diagnosis Group
Mental Health
Substance Abuse
Age Group
Child
18-20
Adult
Benefit Plan
State
Prior Authorization Required
Yes

Supported Employment - Innovations - H2025 HQ - Supported Employment Group

Authorization Guidelines:
  • Per Plan Year, Supported Employment is available to any beneficiary ages 16 and older for whom individualized, competitive integrated employment has not been achieved, and/or has been interrupted or intermittent.                                                                                  
  • Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services.  
  • 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 (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.  
Service Code
H2025 HQ - Supported Employment Group
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Supported Employment - Innovations - H2025 TS - Supported Employment Long Term Follow-up

Authorization Guidelines:
  • Per Plan Year, Supported Employment is available to any beneficiary ages 16 and older for whom individualized, competitive integrated employment has not been achieved, and/or has been interrupted or intermittent.                                                                                  
  • Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services.  
  • 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 (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.  
Service Code
H2025 TS - Supported Employment Long Term Follow-up
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Supported Employment - Innovations H2025 - Supported Employment Individual

Authorization Guidelines:
  • Per Plan Year, Supported Employment is available to any beneficiary ages 16 and older for whom individualized, competitive integrated employment has not been achieved, and/or has been interrupted or intermittent.                                                                                  
  • Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services.  
  • 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 (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.  
Service Code
H2025 - Supported Employment Individual
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Supported Employment - YA390 - Supported Employment Individual

Authorization Guidelines:
  • Supported Employment Individual- 30 hours per week 
  • Supported Employment Group- 40 hours per plan year 
Service Code
YA390 - Supported Employment Individual
Diagnosis Group
Intellectual Development Disability
Age Group
Adult
Child
18-20
Benefit Plan
State
Prior Authorization Required
Yes

Supported Employment - YP640 - Supported Employment Group

Authorization Guidelines:
  • Supported Employment Individual- 30 hours per week
  • Supported Employment Group- 40 hours per plan year
Service Code
YP640 - Supported Employment Group
Diagnosis Group
Intellectual Development Disability
Age Group
Child
Adult
18-20
Benefit Plan
State
Prior Authorization Required
Yes

Supported Living - Innovations - T2033 - Supported Living Level 1

Authorization Guidelines:
  • The amount of Supported Living is subject to the Limits on Sets of Services. Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents. 
  • Supported Living Periodic service is available for a beneficiary who uses four or less hours of Supported Living per day. 
  • Supported Living Transition is only available only during the six-month period in advance of the beneficiary’s move to a Supported Living setting.
Service Code
T2033 - Supported Living Level 1
Diagnosis Group
Intellectual Development Disability
Age Group
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Supported Living - Innovations - T2033 HI - Supported Living Level 2

Authorization Guidelines:
  • The amount of Supported Living is subject to the Limits on Sets of Services. Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents. 
  • Supported Living Periodic service is available for a beneficiary who uses four or less hours of Supported Living per day. 
  • Supported Living Transition is only available only during the six-month period in advance of the beneficiary’s move to a Supported Living setting.
Service Code
T2033 HI - Supported Living Level 2
Diagnosis Group
Intellectual Development Disability
Age Group
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Supported Living - Innovations - T2033 TF - Supported Living Level 3

Authorization Guidelines:
  • The amount of Supported Living is subject to the Limits on Sets of Services. Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents. 
  • Supported Living Periodic service is available for a beneficiary who uses four or less hours of Supported Living per day. 
  • Supported Living Transition is only available only during the six-month period in advance of the beneficiary’s move to a Supported Living setting.
Service Code
T2033 TF - Supported Living Level 3
Diagnosis Group
Intellectual Development Disability
Age Group
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Supported Living - Innovations - T2033 U1 - Supported Living Periodic

Authorization Guidelines:
  • The amount of Supported Living is subject to the Limits on Sets of Services. Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents. 
  • Supported Living Periodic service is available for a beneficiary who uses four or less hours of Supported Living per day. 
  • Supported Living Transition is only available only during the six-month period in advance of the beneficiary’s move to a Supported Living setting.
Service Code
T2033 U1 - Supported Living Periodic
Diagnosis Group
Intellectual Development Disability
Age Group
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Supported Living - Innovations - T2033 U2- Supported Living Transition

Authorization Guidelines:
  • The amount of Supported Living is subject to the Limits on Sets of Services. Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents. 
  • Supported Living Periodic service is available for a beneficiary who uses four or less hours of Supported Living per day. 
  • Supported Living Transition is only available only during the six-month period in advance of the beneficiary’s move to a Supported Living setting.
Service Code
T2033 U2 - Supported Living Transition
Diagnosis Group
Intellectual Development Disability
Age Group
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes

Therapeutic Leave (TL) - 183

Authorization Guidelines:
Service Code
183
Diagnosis Group
Intellectual Development Disability
Mental Health
Age Group
Child
18-20
Adult
Benefit Plan
Medicaid
Prior Authorization Required
No

Vehicle Modifications - Innovations - T2039

Authorization Guidelines:

Limited to expenditures of $20,000 over the life of the waiver. Vehicle Modifications can only be used on a vehicle that you already have and the vehicle must be insured. Medical necessity must be documented by the physician, physician assistant, or nurse practitioner, for every item provided/billed regardless of any requirements for approval.

Service Code
T2039
Diagnosis Group
Intellectual Development Disability
Age Group
Child
18-20
Adult
Benefit Plan
Innovations
Prior Authorization Required
Yes