Behavioral Health Providers: Frequently Asked Questions (FAQs)

Transcription

1 Behavioral Health Providers: Frequently Asked Questions (FAQs) Q. What has changed as far as behavioral health services? A1. Effective April 1, 2012, the professional and outpatient facility charges for licensed independent practitioners (LIPs) associated with Medicaid-covered behavioral health services became part of managed care organizations (MCOs) covered responsibilities. A2. Effective February 1, 2013, the services provided by the South Carolina Department of Alcohol and Other Drug Services became part of the MCO-covered responsibilities. A3. Effective July 15, 2014, Select Health of South Carolina (Select Health) no longer required prior for certain behavioral health outpatient therapy and medication management services for in-network/participating LIPS, psychiatrists, psychologists, and nurse practitioners. This no- requirement was retroactive to January 1, A4. Effective July 1, 2016, rehabilitative behavioral health services (RBHS) became a covered benefit under Select Health. Credentialed RBHS, credentialed therapeutic foster care (TFC), Department of Mental Health (DMH), credentialed Department of Education (DOE) and Department of Juvenile Justice (DCC), MUSC, and Department of Alcohol and Other Drug Abuse Services (DAODAS) can provide the following RBHS services: behavior modification (members under 18), psychosocial rehabilitative services, family support services (members 0 21), commy integration services (members over 18), therapeutic child care (members 6 years and under), and peer support services (PSS). PSS can only be provided by DMH and DAODAS for members over 18. A5. Effective July 1, 2017, autism spectrum disorder (ASD) services became a covered benefit under the Select Health plan for members under 21 years of age. This benefit includes ASD services rendered by LIPs who are approved by the South Carolina Department of Health and Human Services (SCDHHS) to provide evidence-based treatment (an ABA alternative therapy modality), Board Certified Behavior Analysts, and Board Certified Assistant Behavior Analysts. The following LIP are permitted to render ASD services for Select Heath members, once approved and registered with SCDHHS and Select Health: LIPs master s or doctoral: o Licensed psychologist. o Licensed psycho-educational specialist (LPES). o Licensed independent social worker-clinical practice (LISW-CP). o Licensed marriage and family therapist (LMFT). o Licensed professional counselor (LPC). ASD services may also be rendered by school districts that enroll with the SCDHHS as ASD group.

2 A6. Effective July 1, 2017, Select Health covers services rendered at psychiatric residential treatment facilities (PRTFs) for eligible members. This benefit includes psychiatric care provided to children under age 21. If services are provided immediately before the member reaches age 21, services may continue until the member no longer requires the services or the date the member reaches age 22. Members are referred for PRTF services by a licensed practitioner of the healing arts (LPHA) via the completion of the PRTF Treatment Request Form. The PRTF Referral Form can be completed by the admitting facility, current treatment provider, or referral source. For questions regarding a member who is receiving PRTF services, please contact Select Health Behavioral Health Utilization Management. Q. Will some services still be covered by Medicaid fee-for-service? A. Yes. Medicaid fee-for-service will still cover all services provided by the state agencies listed below. Medicaid fee-for-service will also cover all services that the below agencies refer for, even if the treating provider is participating with an MCO. Developmental evaluation centers (DEC). Adolescent treatment facilities (ATF). Q. Which will be affected by this change? A. Licensed independent practitioners (LIPs): Psychologists. Marriage and family therapists. Professional counselors. Independent social workers. Medical professionals: Psychiatrists. Physicians. Nurse practitioners. Federally qualified health centers (FQHC). Rural health clinics (RHC). Acute care hospitals. Department of Alcohol and Other Drug Abuse Service authorities (DAODAS).

3 Q. Which services will be included in this benefit? For licensed independent practitioners: CPT Description Time Frequency limits Modifiers auth. rules for PAR Individual OP therapy, 30 1 encounter 6 per month (in combination with 90832, 90834, 90837) AH, HO PAR not require prior Cannot use interactive Individual OP therapy, 45 1 encounter 6 per month (in combination with 90832, 90834, 90837) AH, HO PAR not require prior Cannot use interactive Individual OP therapy, 60 1 encounter 6 per month (in combination with 90832, 90834, 90837) AH, HO PAR not require prior Cannot use interactive Family therapy without client Family therapy with client 1 encounter 6 per day AH, HO PAR not require prior 1 encounter 6 per day AH, HO PAR not require prior Cannot use interactive Cannot use interactive Group therapy 1 30-minute encounter 6 per day AH, HO PAR not require prior Cannot use interactive

4 CPT Description Time Frequency limits Modifiers auth. rules for PAR H0002 Behavioral health screening 15-minute 2 per day AH, HO PAR not H2011 Crisis intervention 15-minute 16 per day AH, HO PAR not requests have to be submitted within two business days of service H0031 Assessment update 1 encounter 12 per year AH, HO PAR not H0032 Mental health service plan development 12 s Per year N/A PAR not Service plan development with client Service plan development without client 15-minute 15-minute 12 per day AH, HO PAR not 12 per day AH, HO PAR not Psychiatric diagnostic evaluation 1 encounter 1 per every 6 months AH, HO PAR not

5 CPT Description Time Frequency limits Modifiers auth. rules for PAR H2000 Child Adolescent Level of Care Utilization System (CALOCUS) 1 encounter 1 per day with a maximum of 2 per month AH, HO PAR not require prior Psychological testing, includes face-to-face time administering tests, time interpreting results, and preparing report 1 = 1 hour N/A AH All s Requires psychological advisor review Psychological testing, includes face-to-face time administering 1 = 1 hour N/A AH All s Requires psychological advisor review RBHS s that Select Health has carved in for all its members as of July 1, 2016, that requires prior (these services can only be provided by credentialed RBHS provider) CPT Description Time Frequency limits Modifiers auth. rules for PAR H0038 Peer Support Services (PSS) 1 = s per day 0HM Requires prior PSS can only be provided by DMH and DAODAS. Members over 18. H2014 Behavior Modification (B-Mod) 1 = s per day OHO, OHN Requires prior Members under 18 years H2017 Psychosocial Rehabilitation Services (PRS) 1 = s per day OHO, OAF OHN,OHM OTE, OTD Requires prior All ages

6 CPT Description Time Frequency limits Modifiers auth. rules for PAR S9482 Family Support (FS) 1 = s per day OTD, OHO OHN, OUA Requires prior 0 21 H2030 Commy Integration Services (CIS) 1 = 15 None CIS Credentialed Providers Only Requires prior Members 18 years and older H2037 Therapeutic Child Care Centers (TCC) 1 = 15 None TCC credentialed only Requires prior Members 6 years and under PRTF Codes that SHSC has carved in for all SHSC members as of July 1, 2017 Rev (BH IP episodes) Description Time Frequen cy limits Modifiers auth. rules for PAR 0124/0153 PRTF 1 = 1 day N/A N/A Requires prior 0183 Therapeutic Home Time (THT) 1 = 1 day 14 days per fiscal year per member N/A Does not require a prior Notification is required for tracking purposes

7 ASD s that Select Health has carved in for all its members as of July 1, 2017 (only approved and credentialed can provide these services) ABA specific: procedure description Procedure and s Medical necessity criteria Frequency limits Service line requirements Behavior Identification Assessment (ABA): detailed assessment of client already diagnosed with autism 0359T: 30 minute s InterQual Mandatory PA Review 16 s per year Adaptive Behavior Treatment with Protocol Modification: 0368T: 1 st T: additional 30 minute increments InterQual Mandatory PA Review 32 s per month Observational Behavioral Follow-Up Assessment 0360T: 1 st T: additional 30 minute increments InterQual Mandatory PA Review 12 s per week Exposure Behavioral Follow-Up Assessment 0362T: 1 st T: additional 30 minute increments InterQual Mandatory PA Review 80 s per week for all 4 s combined: 0362T, 0363T, 0364T, 0365T Adaptive Behavior Treatment by Protocol 0364T: 1 st T: additional 30 minute increments InterQual Mandatory PA Review Family Adaptive Behavior Treatment Guidance 0370T: 30 minute s InterQual Mandatory PA Review 12 s per 6 months

8 Non-ABA specific: procedure description Procedure and s Medical necessity criteria Frequency limits Diagnostic Evaluation 96101: 1 hour InterQual Mandatory PA Review N/A Therapeutic Behavioral Service (evidenced based practice/service for ASD members) H2019: 15 minute InterQual: BH OPT 4 s per week Behavior Assessment 90791: 1 encounter No PA required for in network 1 per every 6 months For medical professionals Medical doctor (including specialists), physician assistant, advance practice registered nurse (APRN) CPT Codes Description auth. rules for PAR Psychiatric Diagnostic Eval (no medical services) OR Psychiatric Diagnostic Eval with medical services Cannot use interactive add on Interactive Psychiatric Diagnostic Evaluation Individual OP therapy, 30 Cannot use interactive

9 Medical doctor (including specialists), physician assistant, advance practice registered nurse (APRN) CPT Codes Description auth. rules for PAR E/M Code + add on E/M + 30-minute psychotherapy Cannot use interactive Must bill in conjunction with E/M ; cannot be billed alone Individual OP therapy, 45 Cannot use interactive E/M Code + add on E/M + 45-minute psychotherapy Cannot use interactive Must bill in conjunction with E/M ; cannot be billed alone Individual OP therapy, 60 Cannot use interactive E/M + add on E/M + 60-minute psychotherapy Cannot use interactive Must bill in conjunction with E/M ; cannot be billed alone add on Individual OP therapy, 30 + Interactive complexity add on E/M + add on add on E/M + 30-minute psychotherapy + Interactive complexity add on Must bill in conjunction with E/M ; cannot be billed alone add on Individual OP therapy, 45 + Interactive complexity add on

10 Medical doctor (including specialists), physician assistant, advance practice registered nurse (APRN) CPT Codes Description auth. rules for PAR E/M + add on add on E/M + 45 minute psychotherapy + Interactive complexity add on Must bill in conjunction with E/M ; cannot be billed alone add on Individual OP therapy, 60 + Interactive complexity add on E/M + add on add on E/M + 60-minute psychotherapy + Interactive complexity add on Must bill in conjunction with E/M ; cannot be billed alone add on Group therapy +Interactive complexity add on E/M Code) E/M Code-(99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215) No required for PAR only. Any nonpar auth for all services ECT All s requires Telephonic Review Required For medical professionals CPT Description Time Frequency limits Modifiers auth. rules for PAR Neuropsychological Testing 1 1 hour N/A AH All s require prior

11 DAODAS Service type bundles Description Service ASAM level Unit auth. rule Review type Bundle 1 Social Detox / IP H0010 III.2-D 1 day All s require prior Telephonic Bundle 2 Medical Detox / IP H0011 III.7-D 1 day All s require prior Telephonic Bundle 3 Residential Rehab H0019 III.5-R 1 day All s require prior Telephonic Bundle 4 Residential Rehab H0018 H0018HA III.7-R III.7-RA 1 day All s require prior Telephonic Bundle 5 PHP H2035 II.5 1 hour All s require prior Telephonic Bundle 6 IOP H0015 II.1 1 hour All s require prior Written Discrete OP Multiple I Varies Written Proc Description Unit Frequency limits/ benefit structure auth. Req. MNC Cluster Comments Diag Eval with medical 1 per 6 months without No ASAM No *This is packages

12 Proc Description Unit Frequency limits/ benefit structure auth. Req. MNC Cluster Comments Psychological testing, includes faceto-face time administering tests, time interpreting results, and preparing report 1 = 1 hour All s Yes InterQual No *This is packages Psychological testing, includes faceto-face time administering tests, and preparing report 1 = 1 hour All s Yes InterQual No *This is packages. H0001 Alcohol and Drug Assessment without Physical (initial) 1 per 6 months without No ASAM No *This is packages Alcohol and Drug Assessment without Physical (follow up) 1 per 6 months without No ASAM No *This is packages A&D Nursing Services 22 s per rolling 12- months without No ASAM No *This is packages

13 Proc Description Unit Frequency limits/ benefit structure auth. Req. MNC Cluster Comments Alcohol and/ or substance abuse structured screening and brief intervention services 12 per rolling 12-months without No ASAM No H0001 and cannot be billed on the same DOS. Billable screenings must be conducted faceto-face. *This is packages Service plan development with patient present 6 s per rolling 12- month period without, combined total of Cluster 2 s No ASAM Cluster 2 *This is packages Service plan development without the patient present 6 s per rolling 12- month period without, combined total of Cluster 2 s No ASAM Cluster 2 *This is packages Psychotherapy 30 Does not require a No ASAM Cluster 3

14 Proc Description Unit Frequency limits/ benefit structure auth. Req. MNC Cluster Comments Medical evaluation and management for new patient No No If the prescriber also does therapy, the use add on s (30 ) or (45 ) Medical evaluation and management for established patient No No If the prescriber also does therapy, the use add on s (30 ) or (45 ) Psychotherapy 45 mins Does not require a No ASAM Cluster Family Psychotherapy (WITHO patient present) Does not require a No ASAM Cluster Family Psychotherapy( with patient present) Does not require a No ASAM Cluster Group Psychotherapy other than a multiple family group Does not require a No ASAM Cluster 3

15 Proc Description Unit Frequency limits/ benefit structure auth. Req. MNC Cluster Comments H0004 Substance Abuse Counseling - Individual 1 = 15 Does not require a No ASAM No H0005 Substance Abuse Counseling - group Does not require a No ASAM No H0038 Peer support Services 1 = 15 All s Yes DHHS Svc Desc No H2011 Crisis Intervention Services (faceto-face and telephonic) 1 = per day without prior No DHHS Svc Desc No PA not required as this is a crisis service H2017 Rehabilitative Psychosocial Services 1 = 15 All s Yes DHHS Svc Desc No S9482 Family Support 1 = 15 All s Yes DHHS Svc Desc No H0034 Medication Training and Support (faceto-face) 1 = 15 All s Yes DHHS Svc Desc No Cannot be billed on same DOS as med check (E/M )

16 Proc Description Unit Frequency limits/ benefit structure auth. Req. MNC Cluster Comments J2315 Injection Vivitrol Medication Administration 1 per month is the recommended limit All s All s Yes ASAM No Reimburses at the same rate as the physician's fee schedule. *This is packages. Yes ASAM No Must be billed in conjunction with J2315. Code will reject if not billed along with J2315. *This is packages. H2014 Behavior Modification (B-Mod) 1 = 15 Requires 32 s per day Yes DHHS Svc Def Medical necessity is determined by the same MH medical necessity you use for any other request.

17 Q. What is the turnaround time for s? A. Please allow 14 calendar days for decisions (RBHS, BH OP, BH IP, DAODAS IOP and Discrete). Please allow seven calendar days for s for PRTF. Q. What do I need to submit when trying to obtain for additional/extension of services for behavioral health outpatient treatment? A. If the service does not, obtaining for additional/extension of services is not required. Q. What is the reimbursement rate? A. 100 percent Medicaid fee schedule. Q. Will s be required for any outpatient services? A. Yes, some outpatient services require : For PAR M.D.s: 90870, 90882, 90887, 90889, and require prior. For PAR LIPS: requires prior. For DAODAS : check your service spreadsheet for guidance. For RBHS, all services. For ASD, all services. For PRTF, rev s 0124 and 0153 ; 0183 does not. FOR ALL NON-PAR PROVIDERS prior is required for any and all services. Contact Select Health Behavioral Health at for information on requirements. Q. Are services for private residential treatment facilities (PRTF), developmental evaluation centers (DEC) services or adolescent treatment facilities (ATF) covered? A. Services for private residential treatment facilities (PRTF) were covered by Select Health as of July 1, Services for developmental evaluation centers (DEC) and adolescent treatment facilities (ATF) are not eligible for Select Health or other managed care plans, and must be billed to fee-for-service. Q. Are any Departments of Juvenile Justice (DJJ) services covered? A. RBHS services and psychological testing are covered by Select Health for members referred by DJJ. All of other behavioral health services for a nonincarcerated member referred by DJJ (or any other state agency) remain fee-for-

18 service. Psychological testing must be performed by a licensed psychologist or a medical doctor (M.D.). Q. Are mental health or substance abuse services provided by the MUSC Institute of Psychiatry (IOP) covered? A. Department of Mental Health (DMH) services through MUSC IOP will continue to be handled by Medicaid s fee-for-service program. However, non-dmh services through MUSC are covered by Select Health. Q. If a provider is part of a practice and the practice does not wish to participate with Select Health, can the individual provider still participate? A. Yes, the individual provider can be credentialed, but it would have to be under his or her individual tax ID, and the provider would bill separately from the group. Q. Do copays apply to these services? A. No, there are no copays or deductibles for persons receiving behavioral health care. Q. Where are claims submitted? A. Submit claims to: Select Health of South Carolina Claims Processing Department P.O. Box 7120 London, KY Q. Is an LPC-Intern (LPC-I) able to provide services and bill under an LPC-Supervisor (LPC-S)? A. Yes, the LPC-I can provide the services but the LPC-S will be responsible for signing off on all notes and submitting the claims. Q. Who do I contact if I am interested in becoming a participating provider? A. If you are interested in becoming a participating provider, contact Network Management at (ext ) or (Charleston).