240 Intensive Care -psychiatric On 0. PRO_14253E Internal Approved WellCare 2018 IL8PROLTR14253E_0000

Transcription

1 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity 100 All inclusive room and board On All inclusive room and board On Anesthesia, ECT On Room and Board- private psychiatric On Room and Board- private room detoxification On Room and Board- private rehabilitation On Residential Treatment On Room and Board -semi private psychiatric On Room and Board- semi- private room detoxification On Room and Board - semi private rehabilitation On Room and Board bed psychiatric On Room and Board- 3-4 bed detoxification On Room and Board bed rehabilitation On Room and board private psychiatric On Room and board private- detoxification On Room and Board- ward psychiatric On Room and Board- detoxification ward On Room and Board- ward rehabilitation On leave of absence from residential On Therapeutic home time On Sub Acute Inpatient On Intensive Care -psychiatric On Intensive Care -psychiatric On 0 PRO_14253E Internal Approved WellCare 2018 IL8PROLTR14253E_0000

2 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity 450 Emergency Room Off Emergency Room Off Clinic encounter all inclusive Off Psych clinic Off Urgent Care Clinic On Other clinic- med supervised withdrawal On Freestanding clinic Off Rural Clinic Off Other freestanding clinic Off BH treatment services On ECT- electroshock treatment On 0 Intensive Outpatient - providers should be instructed to use proper 905 code with 915 On 0 Intensive Outpatient - providers should be instructed to use proper 906 code with 915 On BH treatment services On Substance abuse rehabilitation On Psychiatric/Psychological Services- Individual therapy On Psychiatric/Psychological Services- Family therapy On Biofeedback On Testing On Other BH treatment services On Drug Rehabilitation On 0

3 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity 945 Alcohol Rehabilitation On Behavioral Health Residential- psychiatric On Detox - Docimillary (DASA) On Interactive complexity add-on code Off Psychiatric diagnostic evaluation (no medical Services) Off Psychiatric diagnostic evaluation with medical services Off Psychotherapy, 30 mins On On At visit min psychotherapy add on code when performed with E/M Service- (list separately) Off Psychotherapy, 45 mins On On At visit minute psychotherapy add on code when performed with E/M Service (list separately) Off Psychotherapy, 60 mins On On At visit min psychotherapy when performed with E/M service (list separately Off Psychotherapy for crisis, first 60 min. On On At visit crisis code add on for each additional 30 min. Off Psychoanalysis Off Only if billed by an encounter rate clinic Family Psychotherapy, without patient present On On At visit Family Psychotherapy, 45 min On On At visit Multiple-family group psychotherapy On On At visit Group psychotherapy On On At visit Pharmacologic management, add on code Off 0

4 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity Narcosynthesis Off Therapeutic Repetitive Transcranial (TMS) On Therapeutic Repetitive Transcranial (TMS) On Therapeutic Repetitive Transcranial (TMS) On Electroconvulsive Therapy On Ind psycho therapy incorporating bio feedback 30 min Off Ind psycho therapy incorporating bio feedback 45 min Off Hypnotherapy On 0 Interpretation or explan of results of psych exam and procedures Outpatient Collateral, 15 min. On On At visit Unlisted Psychiatric procedure On comp.comput.motion analysis Off Functional brain mapping Off Psychological testing On On after 5 Hours Psychological testing On On after 5 Hours Psychological testing On On after 5 Hours Assessment of Aphasia of speech/lang On Developmental screening with interp Off Developmental testing On On after 5 Hours Neuropsychological Testing per hour On On after 5 Hours Neuropsych Testing Admin by Technician per hour On On after 5 Hours Standardized cognitive perf testing On On after 5 Hours Nursing Assessment and Care-Initial Off 0

5 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity Nursing Assessment and Care-Re-Assessment Off H&B individual intervention Off H&B group intervention Off Health & Behavior Intervention with patient present Off Medication administration Off Community integration counseling On Office Emergency Services Off New Patient Office Visit Level 1 Off New Patient Office Visit Level 2 Off New Patient Office Visit Level 3 Off New Patient Office Visit Level 4 Off New Patient Office Visit Level 5 Off Est Patient Office Visit Level 1 Off Est Patient Office Visit Level 2 Off Est Patient Office Visit Level 3 Off Est Patient Office Visit Level 4 Off Est Patient Office Visit Level 5 Off Initial Hospital Care-comprehensive; low complexity Off Initial Hospital Care-comprehensive; moderate complexity Off Initial Hospital Care-comprehensive; high complexity Off Subsequent observation Care Off Subsequent observation Care Off Subsequent observation Care Off 0

6 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity Subsequent Hospital Care-focused; low complexity Off Subsequent Hospital Care-focused; moderate complexity Off Subsequent Hospital Care-focused; high complexity Off Observation-comprehensive; low complexity Off Observation-comprehensive; moderate complexity Off Observation-comprehensive; high complexity Off Discharge Day Management- 30 min or less Off Discharge Day Management-more than 30 min Off Problem focused; straightforward-15 min Off Expanded; straightforward-30 min Off Detailed; low complexity-40 min Off Comprehensive; moderate complexity-60 min Off Comprehensive; high complexity-80 min Off Initial Consultation-focused, straightforward Off Initial Consultation-expanded, straightforward Off Initial Consultation-detailed, low complexity Off Initial Consultation-comprehensive, moderate complexity Off Initial Consultation-comprehensive, high complexity Off ER Consultation-focused, straightforward Off ER Consultation-expanded; low complexity Off ER Consultation-expanded; moderate complexity Off ER Consultation-detailed; moderate complexity Off ER Consultation-comprehensive; high complexity Off 0

7 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity Nursing facility consultation 25 min Off Nursing facility consultation 35 min Off Nursing facility consultation 45 min Off Evaluation Management nursing facility 10 min Off Evaluation Management nursing facility 15 min Off Evaluation Management nursing facility 25 min Off Evaluation Management nursing facility 35 min Off Home visit, new patient Off Home visit, new patient Off Home visit, new patient Off Home visit, new patient Off Home visit, new patient Off Home visit, est patient Off Preventive counseling, individual Off Smoking cessation Off Smoking cessation Off 0 907, H2012 Community behavioral program (day treatment) On and G0410, G0411, or H0035 Partial Hospitalization On Use 912 & S9485 code combination 915, H0015 BH intensive outpatient substance abuse On Bill H0004-TF or H0005-TF 915, S9480 BH intensive outpatient psychiatric On Use PHP MN Criteria and bill revenue code 913, S9480

8 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity G0396 Alcohol/subs interv 15-30mn On identified HCPC Series Codes G0397 Alcohol/subs interv >30 min On identified HCPC Series Codes G0410 Partial Hospitalization On 0 G0411 BH intensive outpatient substance abuse On 0 Behavioral Health Screen to determine eligibility for admission to H0002 treatment program Off 0 H0004 Behavioral health counseling and therapy; per 15 minutes Off 0 H0005 Alcohol and/or drug services; group counseling by a clinician Off DASA MCO guidelines allow ONLY POS 3,22,57,and 99 H0009 Alcohol and/or drug services; acute detoxification (hospital inpatient) On 0 H0010 Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient) On identified HCPC Series Codes. H0011 Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) On 0 H0012 Alcohol and/or drug services; sub-acute detoxification (residential addiction program outpatient) On 0

9 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity Alcohol and/or drug services; acute detoxification (residential H0013 addiction program outpatient) On 0 H0014 Alcohol and/or drug services; ambulatory detoxification On 0 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 H0015 therapies or education On 0 Alcohol and/or drug services; medical/somatic (medical H0016 intervention in ambulatory setting) On 0 Behavioral health; residential (hospital residential treatment H0017 program), without room and board; per diem On 0 H0018 H0019 H0020 Behavioral health; short-term residential (non hospital residential treatment program), without room and board; per diem On 0 Behavioral health; long term residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board; per diem On 0 Alcohol and/or drug services; methadone administration and/or service (provisions of the drug by a licensed program) On identified HCPC Series Codes. Only POS covered = 11 & 55

10 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity H0031 Mental health assessment, by non-physician Off Per Rule 132, only POS covered = 11, 12, and 99 H0032 Mental health service plan development by non-physician Off Per Rule 132, only POS covered = 11, 12, and 99 H0033 Oral medication administration, direct observation Off 0 H0034 Medication training and support; per 15 minutes Off Per Rule 132, only POS covered = 11, 12, and 99 H0035 Mental health partial hospitalization, treatment, less than 24 hours On 0 H0036 Community psychiatric supportive treatment, face to face On identified HCPC Series Codes. H0037 Community psychiatric supportive treatment program; per diem On 0 H0039 Assertive Community Treatment; per 15 min On Per Rule 132, only POS covered = 11, 12, and 99 H0040 Assertive Community Treatment; per diem On 0 H0046 Mental Health Services NOS Off 0 H0047 Alcohol and drug services not otherwise specified On Use SA Rehab MN Criteria H1000 Prenatal care, at-risk assessment Off 0 H1001 Prenatal care, at-risk enhanced service; antepartum management Off 0 H1002 Prenatal care, at risk enhanced service; care coordination Off 0 H1003 Prenatal care, at-risk enhanced service; education Off 0 H1004 Prenatal care, at-risk enhanced service; follow-up home visit Off 0 H1005 Prenatal care, at-risk enhanced service package (includes H1001-H Off 0

11 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity H2000 Comprehensive multidisciplinary evaluation On identified HCPC Series Codes H2001 Rehab program 1/2 day On identified HCPC Series Codes DASA MCO IL guidelines only POS acceptable = H2010 Comprehensive medication services; per 15 minutes Off 3,21,22,55,57,99 Off Per Rule 132 only POS acceptable H2011 Crisis Intervention Services; per 15 Minutes Off = 3, 4, 12, 13, 14, 31, 32, 33, 49, 50, 71, 72, 99 H2012 Behavioral health day treatment; per hour On 0 H2013 Psychiatric health facility service per diem On 0 H2014 H2015 Skills training and development; per 15 minutes Comprehensive community support services; per 15 minutes On On identified HCPC Series Codes. identified HCPC Series Codes. Per Rule 132 only POS acceptable = 11, 12, 99 H2016 Comprehensive community support services; per diem On identified HCPC Series Codes

12 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity identified HCPC Series Codes. H2017 Psychosocial rehabilitation services; per 15 minutes On Per Rule 132 only POS acceptable = 11, 12, 99 H2018 Psychosocial rehabilitation services; per diem On 0 H2019 Therapeutic behavioral services; per 15 minutes On identified HCPC Series Codes. Therapeutic behavioral services; per diem In NE Therapeutic group H2020 home On identified HCPC Series Codes H2021 Community-based wrap-around services; per 15 min On identified HCPC Series Codes Community-based wrap-around services; per diem (intensive inhome H2022 services) On 0 H2028 Sexual offender treatment service, per 15 minutes On identified HCPC Series Codes H2029 Sex Offend Tx Svc, Per Diem On 0 H2030 Clubhouse services ; per 15 min On identified HCPC Series Codes

13 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity H2031 Clubhouse services; per diem On identified HCPC Series Codes H2033 Multi-systemic Therapy for Juveniles; per 15 minutes On 0 H2034 Alcohol and/or drug abuse halfway house services; per diem On identified HCPC Series Codes H2035 Alcohol and/or drug treatment program; per hour On identified HCPC Series Codes. H2036 Alcohol and/or other drug treatment program; per diem On identified HCPC Series Codes. Developmental delay prevention activities, dependent child of H2037 client, per 15 minutes On 0 Q3014 Telehealth original site facility Off Per Rule 132 only POS acceptable = 11, 12, 99 S0109 Methadone, oral, 5mg Off 0 S0201 Alcohol and/or drug treatment program; per hour On 0 S5108 Home care training to home care client, per 15 minutes On 0 S5110 Home care training, family; per 15 minutes On 0 S5145 Behavioral health specialized foster care On 0 S5150 Unskilled respite care, not hospice; per 15 minutes On 0 S9123 In home psychiatric nursing On 0

14 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity Ambulatory setting substance abuse treatment or detoxification S9475 services; per diem On 0 Intensive outpatient psychiatric services; per diem; in IL use 913 in S9480 combination with this code On 0 S9482 Family stabilization services; per 15 minutes On 0 T1001 Nursing Assessment/ Evaluation On 0 T1002 RN services up to 15 minutes On 0 T1003 LPN/ LVN services up to 15 minutes On 0 T1006 Alcohol and/or substance abuse services, family/couple counseling On identified HCPC Series Codes Alcohol and/or substance abuse services, treatment plan T1007 development and/or modification On identified HCPC Series Codes T1013 Sign language or oral interpretive services; per 15 minutes Off 0 T1015 Clinic encounter all inclusive Off 0 T1016 Case management, each 15 minutes Off Per Rule 132 only POS acceptable = 11, 12, 99 T1017 Targeted case management, each 15 minutes On 0 T1019 Personal care services; per 15 minutes On 0 T1020 Personal care services; per diem On 0

15 Auth Required Key: On = Authorization Required for Medical Necessity ; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project or T1023 treatment protocol; per encounter Off 0 T1502 Psychotropic Medication Administration Off 0