FREQUENCY LIMITS / BENEFIT STRUCTURE. 22 units per rolling12- months. 6 units per rolling 12-month period. 6 units per rolling 12-month period

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1 DESCRIPTION Prior Auth Req Diag Eval w/ medical No hours Encounter/ DOS = 1 unit 1 per 6 months Psychological testing, includes faceto-face time administering tests, time interpreting results, and preparing report Psychological testing, includes faceto-face time administering tests, and preparing report Alcohol and Drug Assessment w/o Physical (initial) Yes 1 hour 1 unit = 1 hour N/A Yes 1 hour 1 unit = 1 hour N/A No 15 hours Encounter/ DOS = 1 unit 1 per 6 months COMMENTS MOD MOD DESCRIPTOR SIGTURE AUTRITY Must be performed by a BA or above and must be signed off by a BA w/ CAC II or above when rendered by a BA in process or CAC I H0001 Alcohol and Drug Assessment w/o Physical (follow-up) 1 per 6 months A&D Nursing Services No 15 mins Encounter/ DOS = 1 unit 22 units per rolling12- months This code shoud be billed when providing IOP or discrete services *This code may be billed as a discrete service on the day of admission to a residential treatment program After the beneficiary is admitted to U2 a residential program, Nursing services are included as a part of the perdiem rate TS Must be performed by a BA or above and must be signed off by a BA w/ CAC II or above when rendered by a BA in process or CAC I May be performed by LPN or above H0032 H0032 Alcohol and/or substance abuse structured screening and brief intervention services Service Plan Development with patient present Service Plan Development without the patient present 12 per rolling 12-months 6 units per rolling 12-month period 6 units per rolling 12-month period H0001 and cannot be billed on the same DOS Billable screenings must be conducted face-to-face *Billed as prior to 6/01/13 File without a modifer *Billed as prior to 6/01/13 TD TE HF Registered Nurse (RN) Lic Pract Nurse (LPN) when rendered by a BA w/o CAC II, RN, or LPN Master's level or above Master's level or above

2 DESCRIPTION Prior Auth Req Psychotherapy 30 mins Yes 30 mins Encounter/ DOS = 1 unit Medical evaluation and management for a new patient No 30 mins Encounter/ DOS = 1 unit No benefit limit COMMENTS MOD MOD DESCRIPTOR SIGTURE AUTRITY Bill CPT for sessions that do not include med management and the session lasts less than 30 minutes Medical evaluation and management for an estalbished patient No 30 mins Encounter/ DOS = 1 unit No benefit limit E/M code would be for a E/M + new patient and for an add-on established patient, the add-on is mins No 45 mins Encounter/ DOS = 1 unit Psychotherapy 45 mins Yes 45 mins Encounter/ DOS = 1 unit Bill CPT for sessions that include med management and the session lasts less than 30 minutes The add on code is outside the bundled service package Bill CPT for sessions that do not include med management and the session lasts 30 minutes or more E/M code would be for a E/M + new patient and for an add-on established patient, the add-on is mins Family Psychotherapy (W/O patient present) Bill CPT for sessions that include med management and the session lasts 30 minutes or more The add on code is outside the bundled service package Family Psychotherapy( with patient present)

3 DESCRIPTION Prior Auth Req Group Psychotherapy Multiple Family Group Psychotherapy H0004 Substance Abuse Counseling - Yes 1 hour 1 unit = 15 mins 32 units per week Code established for dates of service after 11/1/13 File without a modifier COMMENTS MOD MOD DESCRIPTOR SIGTURE AUTRITY H0005 Substance Abuse Counseling - group 3 per week File without a modifier H0038 Peer support Services Yes 15 mins 1 unit = 15 mins 32 units per week HQ modifier to be ultilized in group setting Otherwise no modifier required HQ Group H2011 Crisis Intervention Services (face-toface and telephonic) No 15 mins 1 unit = 15 mins 16 per day PA as this is a crisis service Instead service may be reviewed restrospectively to ensure compliance HF Face-to-Face Telephonic

4 DESCRIPTION Prior Auth Req H2017 Rehabilitative Psychosocial Services Yes 15 mins 1 unit = 15 mins 32 units per week COMMENTS MOD MOD DESCRIPTOR SIGTURE AUTRITY HQ Group S9482 Family Support Yes 15 mins 1 unit = 15 mins 32 units per week H0034 Medication Training and Support (face-to-face) Yes 15 mins 1 unit = 15 mins Cannot bill on same DOS as and combination with and UB TD TE Pharmacist Registered Nurse (RN) Licensed Pract Nurse J2315 Injection Vivitrol Yes 1 per month Medication Administration Yes 5 mins Reimburses at the same rate as the 's fee schedule Must be billed in conjunction with J2315 Code will reject if not billed along with J2315 Appropriate Medical Professional H0011 Alcohol and Drug Services Acute 24 IP Detox Residential (III7) Yes 3-5 days H0011 1/day H0010 Alcohol and Drug Services Outpatient Subacute Detox (III2-D) Yes 3-5 days H0010 1/day

5 DESCRIPTION Prior Auth Req COMMENTS MOD MOD DESCRIPTOR SIGTURE AUTRITY H0015 Alcohol and Drug Intense Outpatient (II1) Yes up to 30 days H /week H0018 Behavioral Health - Short-Term Residential (III7-R) Yes up to 30 days H0018 1/day H0018 Behavioral Health - Short-Term Residential - Adolescent (III7-RA) Yes up to 30 days H0018 1/day HA H0019 Behavioral Health - Long-Term Residential (III5) Yes up to 30 days H0019 1/day H2035 Day Treatment Outpatient (II5) Yes up to 15/30 days H /week H2014 Skills Training and Development 0-6y/o Yes Unit=15 min Unit=15 min T1016 Targeted Case Management Telephone, Contacts other than client, Field Visit* Yes Unit=15 min Unit=15 min 32 Units per day would be carved out of responsibility from the MCO's would be carved out of responsibility from the MCO's Summary must be signed off by a BA staff with CAC II or higher credential staff N/A T1017 Targeted Case Management Face-to-Face Contact* Yes Unit=15 min Unit=15 min would be carved out of responsibility from the MCO's N/A *Bachelor's Level with Certified Addictions Counselor Certification and/or a 4-yr degreed nurse A bundle should be billed if services not outside a bundle are rendered for a total of 9 or more hours within one week Prior Authorization (PA) is specific to the Provider rendering the service Those services listed as not requring a PA may be billed without obtaining a PA so long as the rendering provider does not exceed the established frequency limits