Can request 24 units per day, 5 days per week, based on medical necessity. Initial and Concurrent authorizations will be for up to 1 year.

Transcription

1 -Funded I/DD Services Benefit Plan Adult Day Vocational Program (ADVP): YP620 Community Rehabilitation Program: YP650 Day Activity: YP660 Day Supports: YM580 YM580HQ Developmental Day YP610 (Child only) Developmental Therapy Professional: H2014 (Adult only) Family Living: YP740 -Low YP750 -Moderate YM755 -High authorizations will be for up to 6 months. Up 618 units per 90 days Page 1 of 5 Updated (6/28/2018)

2 -Funded I/DD Services Benefit Plan Group Living: YP760 -Low YP770 -Moderate YP780 -High Hourly Respite: YP010 (Child only) I/DD SE Long-Term Support: YA389 (Adult only) I/DD Supervised Living: YM811-YM813 I/DD Supported Employment: YA390 - Individual YP640 - Group Independent Living: YM700 Personal Assistance: YP020 (Adult only) 32 units per day, 384 units per year, based on medical necessity. Up to 288 units per year, based on medical necessity Initial/Continuing Authorization: Up to 40 hours weekly units per week, can request up to 516 units per 90 days N/A Page 2 of 5 Updated (6/28/2018)

3 -Funded I/DD Services Benefit Plan Supervised Living: YP710 -Low YP720 -Moderate NOTES *Indicates Partners In Lieu of Service Definition or Alternative Payment Agreement Services requiring a PCP includes the service order. A separate service order is indicated for those services for which a treatment plan and service order is required. Individual outpatient and family therapy services are not to exceed an average frequency of once weekly. Evaluation/Management services may be delivered by an MD, PA or NAP. Evaluation/Management service for adult and children are not limited and do not require authorization. Interactive Complexity Code (90785) is used for individual psychophysiological therapy that incorporates biofeedback training by any modality that occurs face to face. Child and Adolescent Needs and Strengths (CANS) Comprehensive Assessment is required for services to children ages 0-5 years. The purposes is to facilitate linkage between the assessment process and individualized service plan. Page 3 of 5 Updated (6/28/2018)

4 -Funded I/DD Services Benefit Plan MODIFIER INTERPRETATION AD Used to indicate that the service is for adolescent: Substance Abuse Intensive Outpatient: H0015AD Distinguishes Diversion & Assessment Program (DAP) PRTF, 911AD DJ Department of Justice for Transition to Community Living Program specific service codes EP Added to outpatient codes to designate smoking and tobacco use cessation GT Designates use of interaction telecommunication HE Designates use of Evidence Based Practice Family Centered Treatment H2022HE (Core Phase) versus (Engagement and Transition Phases) and Intensive In-Home Service H2022 HT Indicates Intensive Alternative Family Treatment (IAFT) Therapeutic Foster Care Code (S5145HT-TFC) M1-M5 Used with Multi-Systemic services to indicate the month of service H2033 (1-5) PB Added to Multi-Systemic Therapy (MST), H2033M to designate Problem Sexualized Behavior MST rate RR Indicates Rapid Response when attached to Therapeutic Foster Care code (S5145RR) SR Added to Outpatient Codes to designate In-Home Setting TF Added to Outpatient Codes and Residential Codes to indicate use of Trauma Focused Cognitive Behavioral Therapy delivered by a rostered provider who has a specialty contract with Partners. TI Designates the Trauma Intensive Comprehensive Clinical Assessment (TICCA) TI TK Attached to Alternative Codes to designate Transportation YA346TK; YA341TK Attached to an Outpatient Code and refers to Treatment Alternative for Sexualized Kids (TASK) 90791TK TL Therapeutic Leave U4 Designates B-3 services U5 In-Lieu of Service Definition ZI Added to Outpatient Codes to designate Trauma Focused Cognitive Behavioral Therapy 90837ZI; 90846ZI; 90847ZI Designates Family Centered Treatment (FCT) Engagement and Transition from Core Phases Page 4 of 5 Updated (6/28/2018)

5 -Funded I/DD Services Benefit Plan Revisions to Benefit Plan Date of Change Service and Section Revised Actual Change 7/1/17 Changes to various service limits See communication bulletin 7/7/2017 Ambulatory Detox Added a pass-through period 7/27/17 Non-Hospital Detox Added a pass-through period 8/30/17 Ambulatory Detox Corrected pass-through information 10/20/17 Transition Management Services Extended auth period to 180 days 12/18/17 Supported Employment & Peer Support Standardized auth limits with Medicaid limits 2/2/18 Peer Support Clarified Benefit Limit 3/23/18 HDPT, AE, PSS Removed notification SAR requirement 4/1/18 IDD Services: ADVP, DA, DS, Dev Day, FL, GL, SL, IL Extended auth period to 1 year/ 7/1/18 Update in Formatting Organization by Age and Disability Page 5 of 5 Updated (6/28/2018)