Billing Codes Modifiers Locations. Hospital Provider Services (private rooms only covered if medically necessary) 114, 124, 134, 144, 154, 204

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1 Covered Professional Services & orization Guidelines Arkansas, Florida, Georgia, Indiana, Massachusetts, Mississippi, Ohio, Texas, and Washington Exchange Marketplaces Please note that the listing below may not fully comprise all Ambetter covered services. Please refer to your Agreement with Ambetter to identify services you are contracted and eligible to provide. Services are covered in all states unless specifically stated otherwise under. All services provided by non-participating providers will require prior authorization except for emergency services. Service Admission Admission Disorder Crisis Stabilization PRTF/RTC PRTF/RTC Disorder HEDIS Bridge Appointment (7- day follow-up after discharge) Hospital Services (private rooms only covered if medically necessary) 114, 124, 134, 144, 154, , 126, 136, 146, 156 n/a 21, 51 n/a 21, 51 For TX, inpatient services only covered at a Chemical Dependency Treatment Center. 100, 101 n/a 21, n/a 1002 n/a 21, 51, 56 (56 not allowed in AR) 21, 51, 55 (55 not allowed in AR) All ages covered in AR, MA, and WA. Under 21 years of age covered in TX. MA, and WA only. 510, 513 n/a 21, 51

2 Observation ECT Intensive Program Intensive Program Disorder Day Treatment or or or n- Residential () Substance Abuse Treatment 760, 761, 762 n/a 21, 22, 51, with n/a 21, 22, with one of the following 906 with one of the following codes 907 with one of the following codes n/a 22, 52 n/a 22, 57 n/a 22, 52 GA, IN, MA, OH, TX. FL, MS, or WA. GA, IN, MA, OH, TX. FL, MS, or WA. Covered in IN, OH and TX. any state for day treatment with substance use disorder diagnosis.

3 Partial Hospitalization Program (PHP) Mental Partial Hospitalization Program (PHP) Substance Use Disorder Residential Detox Psych and Neuropsych Testing and Assessment n- Residential () Substance Abuse Treatment 912 or 913 with one of the following codes 912 or 913 with one of the following codes: 944, 945 with one of the following codes: Drug Rehab (944): 90832,, 90846, 90847, 90849, 90853, Alcohol Rehab (945): 90845, 90846, 90847, 90849, n/a 22, 52 n/a 22, 57 n/a Professional Services 96101, 96102, 96103, 96105, 96110, 96111, 96119, 96120, , 51, 55 (55 not allowed in AR) 56, FL, GA, IN, MA, MS, OH and WA. TX. GA, IN, MA, OH, and WA. FL, MS or TX. MA, and WA only.

4 Evaluation Interactive Complexity Add On Therapy Therapy Disorders Medication Management, 90791, , 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, , 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, ECT MD/DO Applied Analysis (ABA) Biofeedback Administration of injectable medication BCBA, MD/DO, LCSW, Ph.D., 06, 08, 21, , , 90876, , 56, Family therapy not covered in AR. Only individual therapy covered in AR. Family therapy not covered in AR. Only individual therapy covered in AR. Covered in IN, MA, and TX. Covered in WA until 7th birthday. Covered only in IN and OH. the other state.

5 Acupuncture Office Emergency Care Office Visit Observation Care Care and Discharge Home visits Methadone maintenance MD/DO 97810, 97811, 97813, , 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, , 99218, 99219, 99220, 99224, 99225, 99226, 99234, 99235, , 99222, 99223, 99231, 99232, 99233, 99238, , 99342, 99343, 99344, 99345, 99347, 99348, 99349, H0020 TF (individual counseling), HR (family counseling), HQ (group counseling), none or UA (dosing) 11 21, 22, 51, 52 Covered for substance use disorder only and only in WA. Services are paid for under the medical plan. 21, Covered in MA only.

6 Telemedicine Transmitting : Federally Qualified Center, Rural Center, Indian Services Center, Community Mental Center Receiving : Q3014 for transmitting facility, any therapy code (90832, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863) for receiving provider GT GA, and WA. Covered Diagnoses Covered diagnoses include a mental disease, disorder, or condition listed in the current Diagnostic and Statistical Manual of Mental Disorders of the American Association, as revised, or other diagnostic coding system used by Ambetter, with the following limitations and/or exceptions: Eating disorder diagnoses are covered only in Arkansas and Massachusetts. These diagnoses are not covered in Autism Spectrum Disorder diagnoses are covered in all states however Applied Behavior Analysis (ABA) services are covered only in Massachusetts and Texas with limitations indicated in the Covered Services and orization Guidelines. Diagnoses known as V Codes are allowed as primary diagnoses only in Washington and only for children under age of 5. Rape diagnoses (including applicable V code ) are allowed as primary diagnosis in Massachusetts. Developmental delay/intellectual disability (DD/ID) diagnoses are not covered as primary diagnosis in any state. Primary diagnosis for members with DD/ID must be behavioral health or substance use disorder related. Oppositional defiant disorder, conduct disorder, and adjustment reaction diagnoses are not covered in any state. Diagnoses with demonstrable organic disease including, but not limited to, dementia, Alzheimer s Disease, and acquired brain injury are covered under the medical plan in Texas.

7 Common Place of Service Codes 05 Indian Service freestanding facility 50 Federally qualified health center 06 Indian Service provider-based facility 51 psychiatric facility 07 Tribal 638 freestanding facility 52 facility - partial hospitalization 08 Tribal 638 provider-based facility 53 Community mental health center 11 Office 55 Residential substance abuse treatment facility 12 Home 56 residential treatment center 21 hospital 57 n-residential substance abuse treatment facility 22 hospital Rural health clinic 31 Skilled nursing facility 99 Other place of service