Wellcare Health Plan Medicare HIGHER LEVEL OF CARE - BH PRIOR AUTH GRID

Transcription

1 Wellcare Health Plan Medicare HIGHER LEVEL OF CARE - BH PRIOR AUTH GRID MEDICARE BEHAVIORAL HEALTH PRIOR AUTHORIZATION GRID AUTHORIZATION IS NOT A GUARANTEE OF PAYMENT- the is responsible for following all CMS and specific plan liimits when billing for services. AUTHORIZATION REV CODE LEVEL OF CARE REQUIRED Comments 114 ROOM AND BOARD - PRIVATE -PSYCHIATRIC YES 116 ROOM AND BOARD - PRIVATE -DETOXIFICATION YES 124 ROOM AND BOARD - SEMI PRIVATE TWO BED -PSYCHIATRIC YES 126 ROOM AND BOARD - SEMI PRIVATE TWO BED -DETOXIFICATION YES 128 ROOM AND BOARD - SEMI PRIVATE TWO BED -REHABILITATION YES 901 ELECTROSHOCK TREATMENT YES 912 PSYCHIATRIC/PSYCHOLOGICAL SERVICES - PARTIAL HOSPITALIZATION YES 913 PSYCHIATRIC CARE INTENSIVE 4-6 HOURS YES 914 PSYCHIATRIC/PSYCHOLOGICAL SERVICES - INDIVIDUAL THERAPY YES 915 PSYCHIATRIC/PSYCHOLOGICAL SERVICES - GROUP THERAPY YES 915 PSYCHIATRIC/PSYCHOLOGICAL SERVICES - GROUP THERAPY YES 916 PSYCHIATRIC/PSYCHOLOGICAL SERVICES - FAMILY THERAPY YES

2 Medicare Outpatient Behavioral Health Services orization is not a guarantee for payment NOTE : For outpatient services that have yes "auth required" we will enter an authorization for the initial set of services upon submission of a registration form and without the need for MN review, all services requested beyond the initial form submission will require MN (medical necessity) clinical review Code1 Code2 Code3 Code orization Parameters: Psychotherapy, s Psychotherapy, s addon Up to 20 units of any combination of the following s: 90887, 90853,90849,90846, 90847,90832, 90834,90837,90838 of the MN benefit maximum will be approved without speaking to a clinician- MN review and prior authorization services is required beyond the20 units - TO OBTAIN INITIAL SET OF UNITS FAX / INTERNET MEMBER REGISTRATION FORM Psychotherapy, s Psychotherapy, s addon Psychotherapy, s Psychotherapy, s addon Family Psychotherapy, without patient present Family Psychotherapy, Multiple-family group Other YES Other YES Other YES

3 Code1 Code2 Code3 Code Group Group addon Other Other YES YES orization Parameters: Outpatient Collateral, 15 min Electroconvulsive Therapy MD,NP, YES Prior orization FAX INTERNET PRIOR AUTH Biofeedback Training HD YES Prior orization Psychological testing PHD YES Prior orization Psychological testing PHD YES Prior orization Psychological testing PHD YES Prior orization Neuropsychological Testing PHD YES Prior orization Neuropsych Testing Admin by Technician PHD YES Prior orization Neuropsych Testing Admin by Computer PHD YES Prior orization Psychiatric diagnostic evaluation (no medical Services) HD, Other NO Psychiatric diagnostic evaluation (no medical Services) Psychiatric diagnostic evaluation with medical addon HD, Other NO services MD,NP NO Psychiatric diagnostic evaluation with medical addon services MD,NP NO FAX INTERNET PRIOR AUTH

4 Code1 Code2 Code3 Code Psychotherapy, s Psychotherapy, s Psychotherapy, s Pharmacologic management, add on MD,NP NO Pharmacologic management, add on MD,NP NO Pharmacologic management, add on MD,NP NO orization Parameters: Psychotherapy for crisis, first. HD, Other NO crisis add on for each additional. HD, Other NO Nursing Assessment & Care - Initial NP, other NO Nursing Assessment & Care - Re-assessment NP, other NO Therapeutic, Prophylactic or Diagnostic Injection MD, NP NO Office Emergency Services MD, NP NO

5 Code1 Code2 Code3 Code orization Parameters:

6 Code1 Code2 Code3 Code orization Parameters:

7 Code1 Code2 Code3 Code orization Parameters:

8 Code1 Code2 Code3 Code Initial Hospital Carecomprehensive; low MD, NP NO Initial Hospital Carecomprehensive; moderate MD, NP NO Initial Hospital Carecomprehensive; high MD, NP NO Subsequent Hospital Care-focused; low MD, NP NO Subsequent Hospital Care-focused; moderate MD, NP NO Subsequent Hospital Care-focused; high MD, NP NO Observationcomprehensive; low MD, NP NO Observationcomprehensive; moderate MD, NP NO orization Parameters:

9 Code1 Code2 Code3 Code Observationcomprehensive; high MD, NP NO Discharge Day Management- or less MD, NP NO Discharge Day Management-more than MD, NP NO Problem focused; straightforward-15 min MD, NP NO Expanded; straightforward- MD, NP NO Detailed; low min MD, NP NO Comprehensive; moderate min MD, NP NO Comprehensive; high min MD, NP NO orization Parameters: Initial Consultationfocused, straightforward MD, NP NO Initial Consultationexpanded, straightforward MD, NP NO Initial Consultationdetailed, low MD, NP NO Initial Consultationcomprehensive, moderate MD, NP NO Initial Consultationcomprehensive, high MD, NP NO ER Consultationfocused, straightforward MD, NP NO ER Consultationexpanded; low MD, NP NO ER Consultationexpanded; moderate MD, NP NO ER Consultationdetailed; moderate MD, NP NO ER Consultationcomprehensive; high MD, NP NO