Behavioral Health Covered Services & Authorization Guidelines Florida Managed Medical Assistance (MMA) & Child Welfare (CW)

Transcription

1 Behavioral Health Covered Services & Authorization Guidelines Florida Managed Medical Assistance (MMA) & Child Welfare (CW) Please refer to your Agreement with Cenpatico to identify additional services you are contracted and eligible to provide. All n-par services require prior auth unless specifically stated otherwise below. Limits are Fiscal Year July 1 through June 30 Unlimited benefit based on medical necessity or as specified below. Inpatient Hospital Services Maximum of 1 unit per day Service (REV or CPT) Inpatient Services (MH) Hospital 124, 114, 134, 144, 154, 204 Inpatient Eating Disorders (diagnosis: , ) Inpatient Services (Detox SA Treatment Hospital 120, 130, 140, 150 Hospital 126, 116, 136, 146, 156 Statewide Inpatient Psychiatric Program (SIPP) Hospital 101 Under age 21 Crisis Stabilization Hospital 100 Residential Treatment (MH & SA) Hospital 1001, 1002 Observation Hospital 760, 761, 762, 769 Page 1 of 18

2 Outpatient Hospital Services Maximum of 1 unit per day Service Partial Hospitalization (PHP) MH Intensive Outpatient Program (IOP) SA Intensive Outpatient Program (IOP) Outpatient Electroconvulsive Therapy - MH Hospital 912, 913 Hospital 905 Hospital 906 Hospital 901 Auth Required 22, 51, 52, 53, 55, 56, 57 22, 52, 53, 55, 56, 57 22, 52, 53, 55, 56, 57 21, 22, 51, 52, 53, 55, 56, 57 Outpatient Treatment - MH/SA Hospital 900, 915, , 52, 53,57 Discharge Consultation Hospital , 22, 51,52 Professional Behavioral Health Services Telemedicine services can only be billed by participating network providers whose contract allows for this service. Service Add-on Auth Required Psychiatric Diagnostic Evaluation, inpatient PsyD, EDD ML, PA Blank, GT Blank, GT 21, 22, 51, 52, 55, 56, 57 - Included in IP auth Psychiatric Diagnostic/Eval, interactive PsyD, EDD 90791, Interactive complexity 21, 22, 51, 52, 55, 56, 57 - Included in IP auth Page 2 of 18

3 Service Psychiatric Diagnostic Evaluation Maximum of 1 unit per rolling 6 months without authorization. PsyD, EDD, ML, PA Add-on Blank, GT 03, 04, 11, 12, 20, 23, 49, 50, 53, 71, 72, 99 Auth Required if more than 1 within 6 rolling months Interactive Psychiatric Diagnostic Interview Maximum of 1 unit per rolling 6 months without authorization. PsyD, EDD Blank, GT 03, 04, 11, 12, 20, 23, 49, 50, 53, 71, 72, 99 if more than 1 within 6 rolling months Individual Psychotherapy, inpatient MD, DO 90832, 90834, Blank, GT Interactive complexity 21, 22, 51, 52,55, 56, 57 Individual Psychotherapy APNP, NP, CNS, LMFT, LMHC 90832, 90834, Blank, GT Interactive complexity 03, 04, 11, 12, 20, 23, 49, 50, 53, 71, 72, 99 Individual Psychotherapy w/ Art therapy Psychoanalysis APNP, NP, CNS, LMFT, LMHC with Art Therapy Certification APNP, NP, CNS, LMFT, LMHC 90832, 90834, TF 03, 11, 12, 03, 04, 11, 12, 20, 21, 22, 23, 49, 50, 51, 52, 53, 55, 56, 57, 71, 72, 99 Based on medical necessity Page 3 of 18

4 Service Psychoanalysis w/ Art therapy Family Psychotherapy, without patient APNP, NP, CNS, LMFT, LMHC with Art Therapy Certification APNP, NP, CNS, LMFT, LMHC Add-on TF Blank, GT 03, 11, 12, 03, 04, 11, 12, 21, 22, 49, 50, 51, 52, 53, 55, 56, 57, 71, 72, 99 Auth Required Based on medical necessity Family Psychotherapy, with patient Family Psychotherapy, with patient w/ Art Therapy Group Psychotherapy APNP, NP, CNS, LMFT, LMHC APNP, NP, CNS, LMFT, LMHC with Art Therapy Certification APNP, NP, CNS, LMFT, LMHC Blank, GT TF , 04, 11, 12, 21, 22, 49, 50, 51, 52, 53, 55, 56, 57, 71, 72, 99 03, 11, 12, 03, 04, 11, 12, 21, 22, 49, 50, 51, 52, 53, 55, 56, 57, 71, 72, 99 Based on medical necessity Group Psychotherapy w/ Art Therapy APNP, NP, CNS, LMFT, LMHC with Art Therapy Certification TF 03, 11, 12, Based on medical necessity Page 4 of 18

5 Service Add-on Auth Required Electroconvulsive Therapy (ECT) Psychiatric Therapy with Biofeedback, interactive complexity Maximum of 1 unit of can be billed in conjunction with 1 unit of , , , or Psychological Testing MD, DO PsyD, EDD ML, PA PsyD, EDD , 96102, , 22, 51, 52, 55, 56, 57 11, 22, 49, 50, 52, 53, 55, 57, 99 04, 11, 12, 20, 21, 22, 23, 52, 53, 55, 71, 72 Assessment of Aphasia 1 Unit = 1 hour PsyD, EDD , 11, 12, 20, 21, 22, 23, 52, 53, 55, 71, 72 Neuro- Psychological Testing PsyD, EDD 96116, , , 11, 12, 20, 21, 22, 23, 32, 51, 52, 53, 55, 71, 72 Individual Psychotherapy with Medication Management, inpatient Individual Psychotherapy with Medication Management MD, DO PA, Blank, GT With or without: Blank, GT With or without: , 22, 51, 52, 55, 56, 57 04, 11, 12, 20, 21, 22, 23, 52, 53, 55, 71, 72, 99 Initial Hospital Care PA, , 51, 55, 56 Page 5 of 18

6 Service Add-on Auth Required Subsequent Hospital Care PA, , 51, 55, 56 Initial Inpatient Consultation Hospital Discharge Management Initial Observation Care PA, PA, PA, 99251, 99252, 99253, 99254, , , 51, 55, 56 21, 51, 55, 56 22, 23, 52, 57 Community Mental Health Center (CMHC) Services Please note that Community Mental Health Centers must submit a roster of clinicians rendering services in order to avoid claim pends. s rendering services on behalf of the CMHC, who s NPI will be included in box 24-J of the claim form, must be loaded in Cenpatico s claim system under their corresponding CMHC in order to avoid claim errors including pends or denials. Telemedicine services can only be billed by participating network providers whose contract allows for this service. Service Psychiatric Evaluation By Physician 2 Per Member Per with H2000HO Psychiatric Evaluation By n-physician MD, DO H2000 HP, HP-GT 2 Per Member Per with H2000HP, H2000HPGT PhD, ARNP, PA H2000 HO Page 6 of 18

7 Service Brief Behavioral Health Status Exam 1 Unit = 15 minutes Max of 2 units per day 10 Units Per Member Per Fiscal Year Psychiatric Review of Records H2010 HO, HO-GT H0001HN, H0001HNGT, H0001HO, H0001HOGT, H001TS, H001TSGT H0031HN, H0031HNGT, H0031HO, H0031HOGT, H0031TS, H0031TSGT, H2000HP, H2000HPGT, H2000HO 2 Per Member Per Fiscal Year This service may not be billed for review of lab work (see medication management). PA, ARNP H2000 Blank In-depth Assessment, New Patient, MH 1 Per Member Per Fiscal Year limit applies to all in-depth assessment codes H0031 HO, HO-GT H0001HN, H0001HNGT, H0031HN, H0031HNGT In-depth Assessment, Established Patient, MH 1 Per Member Per Fiscal Year limit applies to all in-depth assessment codes H0031 TS, TS-GT H0001HN, H0001HNGT, H0031HN, H0031HNGT Page 7 of 18

8 Service In-depth Assessment, New Patient, Substance Abuse** 1 Per Member Per Fiscal Year limit applies to all in-depth assessment codes In-depth Assessment, Established Patient, Substance Abuse** 1 Per Member Per Fiscal Year limit applies to all in-depth assessment codes H0001 H0001 HO, HO-GT TS, TS-GT H0001HN, H0001HNGT, H0031HN, H0031HNGT H0001HN, H0001HNGT, H0031HN, H0031HNGT Bio-Psychosocial Evaluation, MH 1 Per Member Per Fiscal Year limit applies to all bio-psych evaluation codes H0031 HN, HN-GT H0001HO, H0001HOGT, H001TS, H001TSGT H0031HN, H0031HNGT, H0031HO, H0031HOGT, H0031TS, H0031TSGT Bio-Psychosocial Evaluation, Substance Abuse** 1 Per Member Per Fiscal Year limit applies to all bio-psych evaluation codes Psychological Testing H0001 HN, HN-GT H0001HO, H0001HOGT, H001TS, H001TSGT H0031HN, H0031HNGT, H0031HO, H0031HOGT, H0031TS, H0031TSGT I unit = 15 minutes 40 Units Per Member Per Fiscal Year PsyD, EDD H2019 Blank Page 8 of 18

9 Service Limited Functional Assessment, MH 3 Per Member Per with H0001 & H0001GT Limited Functional Assessment, Substance Abuse** 3 Per Member Per with H0031 & H0031GT Treatment Plan Development, New and Established patient, MH 1 Per Per Member Per Fiscal Year, 2 Per Member Per Fiscal Yearcombined with T1007 Treatment Plan Development, New and Established Patient, Substance Abuse** 1 Per Per Member Per Fiscal Year, 2 Per Member Per Fiscal Yearcombined with H0032 Treatment Plan Review, MH 4 Per Member Per Fiscal Year - combined with T1007TS Treatment Plan Review, Substance Abuse** 4 Per Member Per Fiscal Year - combined with H0032TS H0031 H0001 H0032 T1007 H0032 T1007 Blank, GT Blank, GT Blank Blank TS TS Page 9 of 18

10 Service Medication Management Unlimited based on medical necessity Brief Individual Medical Psychotherapy, MH 1 Unit = 15 minutes Max of 2 units per day 16 Units Per Fiscal Year combined with H2010HF & H2010HFGT Brief Individual Medical Psychotherapy, Substance Abuse** PA, ARNP PA, ARNP T1015 H2010 Blank, GT HE, HE-GT H2010HE, H2010HEGT, H2010HF, H2010GT, H2010HQ H2010HQ, T1015, T1015GT 1 Unit = 15 minutes Max of 2 units per day 16 Units Per Fiscal Year combined with H2010HE & H2010HEGT Group Medical Therapy 1 Unit = 15 minutes Max of 2 units per day 18 Units Per Member Per Fiscal Year PA, ARNP H2010 HF, HF-GT PA, ARNP H2010 HQ H2010HQ, T1015, T1015GT H0046, H0046GT, H0047, H0047GT, H2010HE, H2010HEGT, H2010HF, H2010GT, T1015, T1015GT Behavioral Health Screening, MH 2 Per Member Per with T1023HF PA, ARNP T1023 HE H0046, H0046GT, H0047, H0047GT, T1015, T1015GT Page 10 of 18

11 Service Behavioral Health Screening, Substance Abuse** 2 Per Member Per with T1023HE Behavioral Health Services: Verbal Interaction MH 1 unit = 1 event 52 Per Member Per with H0047, H0047GT, T1015HE, T1015HF, H0048, H0020 Behavioral Health Services: Verbal Interaction, Substance Abuse** 52 Per Member Per with H0046, H0046GT, T1015HE, T1015HF, H0048, H0020 Behavioral Health Services, Medical Procedures, MH PA, ARNP T1023 HF PA, ARNP H0046 Blank, GT PA, ARNP H0047 Blank, GT H0046, H0046GT, H0047, H0047GT, T1015, T1015GT T1023HE, T1023HF T1023HE, T1023HF 52 Per Member Per with H0046, H0046GT, H0047, H0047GT, T1015HF, H0048, H0020 Behavioral Health Services: Medical Procedures, Substance Abuse** 52 Per Member Per with H0046, H0046GT, H0047, H0047GT, T1015HE, H0048, H0020 PA, ARNP PA, ARNP T1015 T1015 HE HF Page 11 of 18

12 Service Behavioral Health Services: Specimen Collection, Substance Abuse** 52 Per Member Per with H0046, H0046GT, H0047, H0047GT, T1015HE, T1015HF, H0020 Individual and Family Therapy 1 Unit = 15 minutes 4 Units per day max 104 Units Per Member Per Fiscal Year Group Therapy 1 Unit = 15 minutes 4 Units per day max 156 Units Per Member Per Fiscal Year Behavioral Health Day Services, MH, age 6 and older 1 unit = 1 hour 190 Units Per Member Per Fiscal Year - combined with H2012 HF H0048 H2019 H2019 H2012 HF HR, HR-GT HQ Cannot bill same day as H2017 Page 12 of 18

13 Service Behavioral Health Day Services, MH (for children ages 24 months through 5 years) 1 unit = 1 hour Must provide a minimum of 2 hours to a max of 4 hours per day. Same day hours do not have to be consistent. 190 Units Per Member Per Fiscal Year combined with H2012HF Behavioral Health Day Services, Substance Abuse** 1 Unit = 1 hour 190 Units Per Member Per Fiscal Year combined with H2012 H2012 H2012 HF Cannot bill the same day as: H2017, H2019 HM H2019 HN H2019 HO H2020 HA H2020 HK S5145 S5145 HE S5145 HK Cannot bill same day as H2017 Psychosocial Rehabilitation Services 1,920 Units Per Member Per Fiscal Year Therapeutic Behavioral On-Site Services, Therapy (Child/Adolescent) Services limited to recipients under age Units per Member Per Month combined with H2019HN H2017 H2019 HO Cannot bill same day as H2012. Page 13 of 18

14 Service Therapeutic Behavioral On-Site Services, Therapeutic Support (Child/Adolescent) Services limited to recipients under age Units per Member Per Month combined with H2019HO H2019 HM Behavior Management (Child/Adolescent) Services limited to recipients under age 21 Maximum of 128 units per month. H2019 HN Telemedicine Origination Charge (spoke site) CMHC Q3014 GT 53 Federally Qualified Health Center Services & Rural Health Clinics Telemedicine services can only be billed by participating network providers whose contract allows for this service Service Individual and/or Group Therapy 1 visit per day, per member per provider FQHC, RHC H0004 Blank, GT 50, visits per member per fiscal year Telemedicine Origination Charge FQHC, RHC Q3014 GT 50, 72 Page 14 of 18

15 Targeted Case Management Service Targeted Case Management for Children Birth through age 17 Masters, some at Bachelor's with Masters Supervision T1017 HA 03, 04, 11, 12, 21, Max 344 units per month Targeted Case Management for Adults 18 years or older Most Masters, some at Bachelor's with Masters Supervision T , 04, 11, 12, Max 344 units per month Intensive Team Targeted Case Management for Adults 18 years or older Most Masters, some at Bachelor's with Masters Supervision T1017 HK 03,04, 11, 12, Max 48 units per day Long Term Care Service Behavioral Management, Intervention All BH Specialties, exclude SPHH H2019 Blank, HM, U9 11,12,32, 31, 53, 54, 56, Units Per Member w/o Authorization Per Calendar Year Behavioral Management Assessment, Per Diem All BH Specialties, exclude SPHH H2020 Blank, HM 11,12,32, 31, 53, 54, 56, 99 Page 15 of 18

16 1 Unit in 365 Days Covered Services Effective 5/1/2014 Service Behavioral Health Overlay Services, Child Welfare Setting 1 Unit = 1 day Max 1 unit per day- 365 days max, CNS, LPC, LCSW, LMFT, LMHC, H2020 HA 03, 11, 12, a) May bill the same day as the following but only if the following are performed in location 03: H2017 b) Cannot bill same day as H2019 HR H2017, H2012 H2012 HF H2019 HO H2019 HM H2019 HN, H0019 S5145, S5145 HE S5145 HK Service Therapeutic Group Care Services, CNS, LPC, LCSW, LMFT, LMHC, H , 11, 12, May bill the same day as the following but only if the following are performed in location 03: H2012, H2012 HF H2017, H2019 HO H2019 HM H2019 HN Medicationassisted treatment PA, H , 11, Page 16 of 18

17 services: Methadone Administration using ANY other procedure code 1 service per 7 days. 52 per Member Per Fiscal Year - combined with H0046, H0046GT, H0047, H0047GT, T1015HE, T1015HF, H0048 Specialized Therapeutic Foster Care Services, 1, CNS, LPC, LCSW, LMFT, LMHC, S , 11, 12, a) May bill the same day as the following but only if the following are performed in location 03: H2012, H2012 HF H2019 HM H2019 HN H2019 HO b) Cannot bill same day as H2017 Service Specialized Therapeutic Foster Care Services, 2 and Crisis Intervention, CNS, LPC, LCSW, LMFT, LMHC, S5145 HE, HK 03, 11, 12, a) May bill the same day as the following but only if the following are performed in location 03: H2012, H2012 HF H2019 HM H2019 HN H2019 HO Comprehensive Behavioral Health Assessment Clin Psych, PA,, H0031 HA 03, 11, 12, b) Cannot bill same day as H2017 If more than 15 hours Page 17 of 18

18 0-20 years of age 1 Per Member Per Fiscal Year CNS, LPC, LCSW, LMFT, LMHC Max of 20 hours (80 units) Per Member Per Fiscal Year Self-help/Peer Services Certified Peer Support Specialist H ** Diagnosis: , , 302.7, and , 315.3, , 315.5, 315.8, and Page 18 of 18