Medicaid Only. Effective Date: February 1, AUTHORIZATION RQUIREMENT Notes (0= No Additional Comments) 101 All inclusive room and board On 0

Transcription

1 Effective Date: February 1, 218 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) 1 All inclusive room and board 11 All inclusive room and board 14 Anesthesia, ECT 114 Room and Board- private psychiatric 116 Room and Board- private room detoxification 118 Room and Board- private rehabilitation 12 Residential Treatment 124 Room and Board -semi private psychiatric 126 Room and Board- semi- private room detoxification 128 Room and Board - semi private rehabilitation 134 Room and Board bed psychiatric 136 Room and Board- 3-4 bed detoxification 138 Room and Board bed rehabilitation 144 Room and board private psychiatric 146 Room and board private- detoxification 154 Room and Board- ward psychiatric 156 Room and Board- detoxification ward 158 Room and Board- ward rehabilitation 18 leave of absence from residential 183 Therapeutic home time 19 Sub Acute Inpatient 24 Intensive Care -psychiatric PRO_23475E Internal Approved WellCare HI8CADLTR23475E_

2 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) 24 Intensive Care -psychiatric 45 Emergency Room 451 Emergency Room 51 Clinic encounter all inclusive 513 Psych clinic 516 Urgent Care Clinic 519 Other clinic- med supervised withdrawal 52 Freestanding clinic 521 Rural Clinic 529 Other freestanding clinic 9 BH treatment services 91 ECT- electroshock treatment 95 Intensive Outpatient - providers should be instructed to use proper code with Intensive Outpatient - providers should be instructed to use proper code with BH treatment services 911 Substance abuse rehabilitation 914 Psychiatric/Psychological Services- Individual therapy Intensive Outpatient - providers should be instructed to use 915 proper code with 915 2

3 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) 916 Psychiatric/Psychological Services- Family therapy 917 Biofeedback 918 Testing 919 Other BH treatment services 944 Drug Rehabilitation 945 Alcohol Rehabilitation 11 Behavioral Health Residential- psychiatric 12 Detox - Docimillary (DASA) 9785 Interactive complexity add-on code 9791 Psychiatric diagnostic evaluation (no medical Services) 9792 Psychiatric diagnostic evaluation with medical services 9832 Psychotherapy, 3 mins 3 min psychotherapy add on code when performed with E/M 9833 Service- (list separately) At visit Psychotherapy, 45 mins 45 minute psychotherapy add on code when performed with E/M 9836 Service (list separately) At visit 21 3

4 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) 9837 Psychotherapy, 6 mins 6 min psychotherapy when performed with E/M service (list 9838 separately At visit Psychotherapy for crisis, first 6 min. At visit crisis code add on for each additional 3 min Psychoanalysis 9846 Family Psychotherapy, without patient present At visit Family Psychotherapy, 45 min At visit Multiple-family group psychotherapy At visit Group psychotherapy At visit Pharmacologic management, add on code 9865 Narcosynthesis 9867 Therapeutic Repetitive Transcranial (TMS) 4

5 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) 9868 Therapeutic Repetitive Transcranial (TMS) 9869 Therapeutic Repetitive Transcranial (TMS) 987 Electroconvulsive Therapy 9875 Ind psycho therapy incorporating bio feedback 3 min 9876 Ind psycho therapy incorporating bio feedback 45 min 988 Hypnotherapy 9882 Complex care management 9885 Psych eval of hospital records Interpretation or explan of results of psych exam and procedures 9887 Outpatient Collateral, 15 min. At visit Prep of report of pt psych status 9899 Unlisted Psychiatric procedure 961 comp.comput.motion analysis 5

6 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) 962 Functional brain mapping 9611 Psychological testing 9612 Psychological testing 9613 Psychological testing after 5 Hours after 5 Hours after 5 Hours 9615 Assessment of Aphasia of speech/lang 9611 Developmental screening with interp Developmental testing Neurobehavioral status exam w clin assess Neuropsychological Testing per hour Neuropsych Testing Admin by Technician per hour 9612 Neuropsych Testing Admin by Computer per occurrence after 5 Hours after 5 Hours after 5 Hours after 5 Hours after 5 Hours 6

7 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) Standardized cognitive perf testing after 5 Hours Brief emotional needs assessment 9615 Nursing Assessment and Care-Initial Nursing Assessment and Care-Re-Assessment H&B individual intervention H&B group intervention Health & Behavior Intervention with patient present Health & Behavior Intervention without patient present 9616 Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument 7

8 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) Medication administration 9951 Services rendered after hours 9958 ice Emergency Services 9921 New Patient ice Visit Level New Patient ice Visit Level New Patient ice Visit Level New Patient ice Visit Level New Patient ice Visit Level Est Patient ice Visit Level Est Patient ice Visit Level Est Patient ice Visit Level 3 8

9 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) Est Patient ice Visit Level Est Patient ice Visit Level Initial Hospital Care-comprehensive; low complexity Initial Hospital Care-comprehensive; moderate complexity Initial Hospital Care-comprehensive; high complexity Subsequent observation Care Subsequent observation Care Subsequent observation Care Subsequent Hospital Care-focused; low complexity Subsequent Hospital Care-focused; moderate complexity Subsequent Hospital Care-focused; high complexity Observation-comprehensive; low complexity Observation-comprehensive; moderate complexity Observation-comprehensive; high complexity Discharge Day Management- 3 min or less Discharge Day Management-more than 3 min Problem focused; straightforward-15 min Expanded; straightforward-3 min Detailed; low complexity-4 min Comprehensive; moderate complexity-6 min 9

10 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) Comprehensive; high complexity-8 min Initial Consultation-focused, straightforward Initial Consultation-expanded, straightforward Initial Consultation-detailed, low complexity Initial Consultation-comprehensive, moderate complexity Initial Consultation-comprehensive, high complexity ER Consultation-focused, straightforward ER Consultation-expanded; low complexity ER Consultation-expanded; moderate complexity ER Consultation-detailed; moderate complexity ER Consultation-comprehensive; high complexity 9934 Nursing facility consultation 25 min 9935 Nursing facility consultation 35 min 9936 Nursing facility consultation 45 min 9937 Evaluation Management nursing facility 1 min 9938 Evaluation Management nursing facility 15 min 9939 Evaluation Management nursing facility 25 min 9931 Evaluation Management nursing facility 35 min Home visit, new patient Home visit, new patient Home visit, new patient Home visit, new patient 1

11 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) Home visit, new patient Home visit, est patient Home visit, est patient Home visit, est patient 9935 Home visit, est patient Prolonged evaluation and mgmt psycho therapy svs Prolonged evaluation and mgmt psycho therapy svs Medical team conference Medical team conference with family Medical team conference without family 9941 Preventive counseling, individual 9942 Preventive counseling, individual 3 min 9943 Preventive counseling, individual 45 min 11

12 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) 9944 Preventive counseling, individual 9946 Smoking cessation 9947 Smoking cessation 9948 Alcohol substance abuse BH change intervention 9949 Alcohol and substance abuse screening and brief intervention Preventive counseling, individual 6 min Preventive medicine group counseling- 6 min 9951 Home visit, single, family counseling 359T Behavior Identification Assessment (ABA) 36T & 361T Observational Behavioral Follow-up Assessment 362T, 363T Exposure Behavioral Follow-up Assessment 12

13 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) 364T, 365T Adaptive Behavior Treatment By Protocol 366T Group adaptive behavior treatment by protocol, In-Clinic 367T Group adaptive behavior treatment by protocol, Additional 3 mins 368T & 369T Adaptive Behavior Treatment With Protocol Modification 37T 371T Family Adaptive Behavior Treatment Guidance Multiple-family group adaptive behavior treatment guidance, In- Clinic 372T Adaptive behavior treatment social skills group, In-Clinic Exposure adaptive behavior treatment with protocol modification, In- 373T Clinic Exposure adaptive behavior treatment with protocol modification 374T Additional 3 mins, In-Clinic 97, H212 Community behavioral program (day treatment) 915 and G41, G411, or H35 Partial Hospitalization 915, H15 BH intensive outpatient substance abuse 13

14 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) 915, S948 BH intensive outpatient psychiatric Recreation, related to the care and treatment of patients disabling G176 mental health problems; per session (45 minutes or more) Training and educational services related to the care and treatment of patients disabling mental health problems per session (45 minutes G177 or more) No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of G396 Alcohol/subs interv 15-3min No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of G397 Alcohol/subs interv >3 min Social work and psychological services, directly relating to and/or G49 furthering the patient s rehabilitation goals G41 Partial Hospitalization G411 BH intensive outpatient substance abuse G436 Tobacco-use counsel 3-1 min G437 Tobacco-use counsel>1min 14

15 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) G442 G443 Annual alcohol misuse screening 15 min Alcohol mis use and screening -various markets; Iowa=face to face BH counseling-15 min G444 Depression Screening G445 High intensity BH counseling 3 min G446 Intensive BH therapy G447 Face to face behavioral counseling-15 min G451 Developmental testing with I & R G463 Hospital outpatient clinic visit G473 Face to face behavioral counseling 15 min H1 H2 Alcohol and/or drug assessment Behavioral Health Screen to determine eligibility for admission to treatment program 15

16 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) Alcohol and/or drug screening; laboratory analysis of specimens for H3 presence of alcohol or drugs H4 Behavioral health counseling and therapy; per 15 minutes H5 Alcohol and/or drug services; group counseling by a clinician H6 Alcohol and/or drug services; case management No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of H7 Alcohol and/or drug services; crisis intervention (outpatient) H8 H9 H1 H11 H12 H13 Alcohol and/or drug services; sub acute detoxification (outpatient) Alcohol and/or drug services; acute detoxification (hospital inpatient) Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient) Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) Alcohol and/or drug services; sub-acute detoxification (residential addiction program outpatient) Alcohol and/or drug services; acute detoxification (residential addiction program outpatient) No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of. 16

17 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) H14 Alcohol and/or drug services; ambulatory detoxification H15 H17 Alcohol and/or drug services; intensive outpatient treatment (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan) including assessment, counseling, crisis intervention, and activity therapies or education Behavioral health; residential (hospital residential treatment program), without room and board; per diem H18 Behavioral health; short-term residential (non hospital residential treatment program), without room and board; per diem H19 Behavioral health; long term residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 3 days), without room and board; per diem Alcohol and/or drug services; methadone administration and/or service (provisions of the drug by a licensed program) No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of. H2 H21 Alcohol and Drug training service for staff H22 Alcohol and/or drug intervention service (planned facilitation) H23 Behavioral health outreach service (planned approach to reach a targeted population) 17

18 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical H24 H25 Behavioral health prevention information dissemination service (one way direct or non-direct contact with service audiences to affect knowledge and attitude); 15 minutes Behavioral health prevention education service (delivered of services with target population to affect knowledge, attitude and/or behavior); 15 minutes RQUIREMENT Notes (= No Additional Comments) H26 Alcohol and/or drug intervention service (planned facilitation) H27 H28 H29 Alcohol and drug prevention service Alcohol and/or drug prevention problem identification and referral service Alcohol and/or drug prevention alternatives service (services for populations that exclude alcohol and other drug use e.g. alcohol free social events) H3 Behavioral health hotline service H31 Mental health assessment, by non-physician H32 Mental health service plan development by non-physician H33 Oral medication administration, direct observation 18

19 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) H34 Medication training and support; per 15 minutes H35 Mental health partial hospitalization, treatment, less than 24 hours H38 Self-help/peer services; per 15 minutes H41 Foster Care child, non therapeutic per diem H42 Foster Care child, non therapeutic per month H43 Supported housing; per diem H44 Supported housing; per month H45 Respite care services, not in the home; per diem H46 Mental Health Services NOS Alcohol and/or other drug testing: collection and handling only, H48 specimens other than blood H49 Alcohol and/or drug Screening H5 Alcohol and/or Drug Service, Brief Intervention; per 15 minutes H1 Prenatal care, at-risk assessment H11 Prenatal care, at-risk enhanced service; antepartum management H12 Prenatal care, at risk enhanced service; care coordination H13 Prenatal care, at-risk enhanced service; education 19

20 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) H14 Prenatal care, at-risk enhanced service; follow-up home visit H15 Prenatal care, at-risk enhanced service package (includes H11-H H11 Non-medical family planning education; per session Family assessment by licensed behavioral health professional for H111 state defined purposes No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of H2 Comprehensive multidisciplinary evaluation No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of H21 Rehab program 1/2 day H21 Comprehensive medication services; per 15 minutes No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of H211 Crisis Intervention Services; per 15 Minutes. H212 Behavioral health day treatment; per hour No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of H214 Skills training and development; per 15 minutes. 2

21 Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical H215 H216 H217 H219 H22 Comprehensive community support services; per 15 minutes Comprehensive community support services; per diem Psychosocial rehabilitation services; per 15 minutes Therapeutic behavioral services; per 15 minutes Medicaid ly Therapeutic behavioral services; per diem In NE Therapeutic group home RQUIREMENT Notes (= No Additional Comments) No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of. No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of. No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of. No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of H221 Community-based wrap-around services; per 15 min H223 Supported employment; per 15 minutes H224 Supported employment; per diem H225 going support to maintain employment; per 15 minutes H226 going support to maintain employment; per diem 21

22 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) H227 See Notes - per 15 minutes No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of H228 Sexual offender treatment service, per 15 minutes No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of H23 Clubhouse services ; per 15 min No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of H231 Clubhouse services; per diem H232 Activity Therapy No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of H234 Alcohol and/or drug abuse halfway house services; per diem No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of H235 Alcohol and/or drug treatment program; per hour. No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of H236 Alcohol and/or other drug treatment program; per diem. Developmental delay prevention activities, dependent child of client, H237 per 15 minutes 22

23 Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical Medicaid ly RQUIREMENT Notes (= No Additional Comments) Brief ice Visit for the Sole Purpose of Monitoring or Changing Drug Prescriptions Used in the Treatment of Mental Psychoneurotic M64 and Personality Disorders Q314 Telehealth original site facility S518 Home care training to home care client, per 15 minutes S511 Home care training, family; per 15 minutes S515 Unskilled respite care, not hospice; per 15 minutes S911 In home telemonitoring No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of S9484 Crisis intervention mental health services; per hour No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of S9485 Crisis intervention mental health services; per diem T11 Nursing Assessment/ Evaluation T12 RN services up to 15 minutes T13 LPN/ LVN services up to 15 minutes T15 Respite care services, up to 15 minutes No auth requirement up to 2 units. Prior Authorization Request =ON after 2 Units Total of T16 Alcohol and/or substance abuse services, family/couple counseling 23

24 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) No auth requirement up to 2 units. Prior Alcohol and/or substance abuse services, treatment plan Authorization Request =ON after 2 Units Total of T17 development and/or modification T112 Alcohol and/or substance abuse services, skills development T113 Sign language or oral interpretive services; per 15 minutes T114 Telehealth telemedicine T115 Clinic encounter all inclusive T116 Case management, each 15 minutes Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project or T123 treatment protocol; per encounter T124 Team evaluation & management T127 Family training & counseling T152 Psychotropic Medication Administration Preadmission screening and resident review (pasrr) level i T21 identification screening; per screen Preadmission screening and resident review level ii evaluation; per T211 evaluation T212 Children s Day Treatment T214 Pre-vocational Services - per diem 24

25 Medicaid ly Auth Required Key: = Authorization Required for Medical Necessity review; = No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical RQUIREMENT Notes (= No Additional Comments) T215 Pre-Vocational Services - per hour T217 Community integration counseling T218 Supported Employment Job Development T219 Supported Employment T22 Day Habiliitation T221 Pre admission PASSR assessment T224 Service Assessment Plan of Care Dev T225 Waiver Services; Not Otherwise Specified (NOS) T227 Specialized childcare, waiver; per 15 minutes T233 Psychiatric residential treatment facility- per diem T236 Therapeutic camping, overnight, waiver; each session T237 Therapeutic camping, day, waiver; each session T248 Behavioral health; long-term care residential (non-acute care in a residential treatment program community based per diem 25