Behavioral Health Providers Frequently Asked Questions

Transcription

1 Behavioral Health Providers Frequently Asked Questions Q. What has changed as far as Behavioral Health services? A1. Effective April 1, 2012, the professional and outpatient facility charges for Licensed Independent Practitioners (LIPS) associated with Medicaid covered behavioral health services became part of the managed care organizations (MCO) covered responsibilities. A2. Effective Feb. 1, 2013 the services provided by the South Carolina Department of Alcohol and Other Drug Services became part of the MCO covered responsibilities. A3. Effective July, 2014 Select Health of SC (SHSC) will no longer require for certain behavioral health outpatient therapy and medication management services for in-network/participating LIPS, psychiatrists, psychologists, and nurse practitioners. This no requirement will be retro-active to January 1, Q. Will some services still be covered by Medicaid fee-for-service? A.. Medicaid fee-for-service will still cover all services provided by the state agencies listed below. Medicaid fee-for-service will also cover all services that the below agencies refer for, even if the treating provider is participating with an MCO. Department of Mental Health (DMH) Private residential treatment facilities (PRTF) Developmental evaluation centers (DEC) Adolescent treatment facilities (ATF) Referrals from state entities, such as schools and DHHS Q. Which providers will be affected by this change? A. Licensed Independent Practitioners (LIPs): Psychologists Marriage and family therapists Professional counselors Independent social workers Medical professionals: Psychiatrists Physicians Nurse practitioners Federally qualified health centers (FQHC) Rural health clinics (RHC) Acute care hospitals Department of Alcohol and Other Drug Abuse Service Authorities

2 Q. Which services will be included in this benefit? FOR LICENSED INDEPENDENT PRACTITIONERS: CPT Code Description Time Frequency Modifiers Individual OP therapy, Individual OP therapy, Individual OP therapy, Family therapy client Family therapy with client 1 encounter 1 per date of service 1 encounter 1 per date of service 1 encounter 1 per date of service 1 encounter 4 per month 1 encounter 4 per month Group therapy 1 30-minute encounter H0002 Behavioral health screening -minute unit H2011 Crisis intervention -minute unit Service plan development with client Service plan development client Psychiatric diagnostic evaluation H2000 H0031 Diagnostic Assessment- Initial Comprehensive Assessment Diagnostic Assessment- Follow up comprehensive ax Psychological Testing 60 minute units Prior Auth Rules for Par Providers AH, HO PAR providers do not require AH, HO PAR providers do not require AH, HO PAR providers do not require AH, HO PAR providers do not require AH, HO PAR providers do not require 8 per AH, HO PAR providers do not month require 2 per day AH, HO PAR providers do not require 16 per day AH, HO PAR providers do not require 1 encounter PAR providers do not require 1 encounter PAR providers do not require 1 encounter 1 every 6 months 1 encounter 1 every 6 months AH, HO AH, HO PAR providers do not require PAR providers do not require 1 encounter 12 per year AH, HO PAR providers do not require tes complexity complexity complexity complexity complexity complexity Authorization requests have to be submitted within 2 business days of service Requires Psychological Advisor Review

3 FOR MEDICAL PROFESSIONALS MD (including specialists), Physician Assistant, Advance Practice Registered Nurse (APRN) Providers, Nurse Practitioners CPT Codes E/M Code + add on Description Psychiatric Diagnostic Eval (no medical services) OR Psychiatric Diagnostic Eval with medical services Individual OP therapy, 30 E/M + 30-minute psychotherapy Prior Auth Rules for Par Providers tes Must bill in conjunction with E/M ; cannot be billed alone Individual OP therapy, 45 E/M Code + add E/M + 45-minute on psychotherapy Individual OP therapy, 60 E/M + add E/M + 60-minute on psychotherapy Must bill in conjunction with E/M ; cannot be billed alone Must bill in conjunction with E/M ; cannot be billed alone E/M + add on Individual OP therapy, 30 + Interactive complexity E/M + 30-minute psychotherapy + Interactive complexity Must bill in conjunction with E/M ; cannot be billed alone Individual OP therapy, 45 + Interactive complexity E/M + add on E/M + 45 minute psychotherapy + Interactive complexity Must bill in conjunction with E/M ; cannot be billed alone Individual OP therapy, 60 + Interactive complexity

4 MD (including specialists), Physician Assistant, Advance Practice Registered Nurse (APRN) Providers, Nurse Practitioners CPT Codes E/M + add on Description E/M + 60-minute psychotherapy + Interactive complexity Prior Auth Rules for Par Providers tes Must bill in conjunction with E/M ; cannot be billed alone Group therapy +Interactive complexity E/M Code E/M Code-(99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 992) required for PAR providers only- any non-par providers require auth for all services ECT Environmental Intervention Med Management (30-minute units) Interpretation or Explanation of results (event) Unlisted psychiatric service or procedure (event) Psychological Testing (60-minute units) Neuro Psychological Testing by MD (60-minute units) Prior is based on medical necessity and requires an MD approval Prior auth determination by a Physician Advisor Requires Psychological Advisor Review Requires Psychological Advisor Review

5 DAODAS PROVIDERS Service Type Bundles Bundle 1 Bundle 2 Bundle 3 Bundle 4 Description Social Detox / IP Medical Detox / IP Residential Rehab Residential Rehab Service Code ASAM Level H0010 III.2-D 1 day H0011 III.7-D 1 day H0019 III.5-R 1 day H0018 H0018HA III.7-R III.7-RA Unit Prior Auth Rule Review Type 1 day Bundle 5 PHP H2035 II.5 1 hour Telephonic Telephonic Telephonic Telephonic Telephonic Bundle 6 IOP H00 II.1 1 hour Discrete OP Multiple I Varies See Discrete Services Tab Written Written Proc Code Description Unit Diag Eval w/ medical Psychological testing, includes face-to-face time administering tests, time interpreting results, and preparing report 1 hour Frequency Limits / Benefit Structure 1 per 6 months Prior Auth Req Mnc Cluster Comments ASAM *This is outside InterQua l *This is outside.

6 96102 Psychological testing, includes face-to-face time administering tests, and preparing report H0001 Alcohol and Drug Assessment w/o Physical (initial) Alcohol and Drug Assessment w/o Physical (follow-up) A&D Nursing Services Alcohol and/or substance abuse structured screening and brief intervention services Service plan development with patient present Service plan development the patient present Psychotherapy 30 1 hour 1 per 6 months 1 per 6 months 22 units per rolling 12- months 12 per rolling 12-months 6 units per rolling 12- month period, combined total of Cluster 2 s 6 units per rolling 12- month period, combined total of Cluster 2 s auth InterQua l *This is outside. ASAM *This is outside ASAM *This is outside ASAM *This is outside ASAM H0001 and cannot be billed on the same DOS. Billable screenings must be conducted face-toface. *This is outside ASAM Cluster 2 *This is outside ASAM Cluster 2 *This is outside ASAM Cluster 3 Modifiers in red require PA review

7 99203 Medical evaluation and management for new patient Medical evaluation and management for established patient Psychotherapy 45 mins If the prescriber also does therapy, the use s (30 ) or (45 ) If the prescriber also does therapy, the use s (30 ) or (45 ) ASAM Cluster 3 Modifiers in red require PA review Family Psychotherapy (W/O patient present) Family Psychotherapy( with patient present) Group Psychotherapy other than a multiple family group H0004 Substance Abuse Counseling - Individual H0005 Substance Abuse Counseling - group H0038 Peer support Services H2011 H2017 Crisis Intervention Services (face-toface and telephonic) Rehabilitative Psychosocial Services 16 per day ASAM Cluster 3 Modifiers in red require PA review ASAM Cluster 3 Modifiers in red require PA review ASAM Cluster 3 Modifiers in red require PA review ASAM ASAM DHHS Svc Desc DHHS Svc Desc DHHS Svc Desc PA not required as this is a crisis service. Instead, service may be reviewed retrospectively to ensure compliance. *This is outside.

8 S9482 Family Support H0034 Medication Training and Support (face-toface) J23 Injection Vivitrol Medication Administration 1 per month is the manufacturer's recommended limit DHHS Svc Desc DHHS Svc Desc Cannot be billed on same DOS as med check (E/M ) ASAM Reimburses at the same rate as the physician's fee schedule. *This is outside. ASAM Must be billed in conjunction with J23. Code will reject if not billed along with J23. *This is outside. Q. What is the turnaround time for s? A. Please allow 14 calendar days for decisions (BH OP, BH IP, DAODAS IOP and Discrete). Q. What do I need to submit when trying to obtain for additional/extension of services for behavioral health outpatient treatment? A. If the service does not require, obtaining for additional/extension of services is not required. Q. What is the reimbursement rate? A. 100 percent Medicaid fee schedule Q. Will s be required for any outpatient services? A., some outpatient services require : For PAR MDs: 90870, 90882, 90887, 90889, and require For PAR LIPS: requires For DAODAS providers: check your service spreadsheet for guidance.

9 FOR ALL NON-PAR PROVIDERS - is required for any and all services. Contact Select Health Behavioral Health at for information on requirements. Q. Are services for private residential treatment facilities (PRTF), developmental evaluation centers (DEC) services or adolescent treatment facilities (ATF) covered? A.. Services in these facilities are not eligible for Select Health or other managed care plans and must be billed to fee-for-service. Q. Are any Departments of Juvenile Justice (DJJ) services covered? A.. If the DJJ (or any state agency) refers a non-incarcerated member for behavioral health services, those services are not covered by Select Health and remain fee-for-service. Q. Are services for a primary diagnosis of autism covered? A.. Per the South Carolina Department of Health and Human Services, autism services are a non-covered benefit under Medicaid managed care. Q. Are mental health or substance abuse services provided by the MUSC Institute of Psychiatry (IOP) covered? A. Department of Mental Health (DMH) services through MUSC IOP will continue to be handled by Medicaid s fee-for-service program. However, non-dmh services through MUSC are covered by Select Health. Q. Are mental health or substance abuse services provided by the following programs covered? Lighthouse Care Center of Conway Acute Palmetto LowCountry BH Three Rivers BHS Carolina Center for BH Springbrook BH System A.. Services through these providers will continue to be handled by Medicaid s fee-for-service program. Q. If a provider is part of a practice and the practice does not wish to participate with Select Health, can the individual provider still participate? A., the individual provider can be credentialed, but it would have to be under his or her individual tax ID, and the provider would bill separately from the group. Q. Do co-pays apply to these services? A., there are no co-pays or deductibles for persons receiving behavioral health care.

10 Q. Where are claims submitted? A. Submit claims to: Select Health of South Carolina Claims Processing Department P.O. Box 7120 London, KY Q. Is a LPC-I able to provide services and bill under an LPC-S? A., the LPC-I can provide the services but the LPC will be responsible for signing off on all notes and submitting the claims. Q. Whom do I contact if I am interested in becoming a participating provider? A. If you are interested in becoming a participating provider, contact Network Management at , ext , or (Charleston).