Ambetter from Peach State Health Plan Covered Services & Authorization Guidelines
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1 Ambetter from Peach Health Plan Covered Services & orization Guidelines Arkansas, Florida, Georgia, Illinois, Indiana, Kansas, Massachusetts, Mississippi, Missouri, Nevada, New Hampshire, Ohio, Texas, and Washington Marketplaces Please refer to your provider agreeme with Ambetter from Peach Health Plan to ideify services you are coracted and eligible to provide. Services are covered in all states unless specifically stated otherwise under column below. All services provided by non-participating providers will require prior authorization except for emergency services. Service Description Inpatie Admission Behavioral Health Inpatie Admission Substance Use Disorder Inpatie Rehab Crisis Stabilization PRTF/RTC Behavioral Health s Hospital Services (private rooms only covered if medically necessary) Inpatie 114, n/a n/a 21, , Inpatie 134, 144, 154 Inpatie Inpatie Inpatie Inpatie Inpatie Inpatie n- Acute Inpatie Inpatie 116, 126, 136, 146, 156 n/a n/a 21, n/a n/a 21, , 101 n/a n/a 21, n/a n/a 21, 51, 55,56
2 s PRTF/RTC Substance Use Disorder HEDIS Bridge Appoime (7-day follow-up after discharge) Observation ECT Iensive Program Behavioral Health n- Acute Inpatie Inpatie Inpatie Inpatie Inpatie or Inpatie or Inpatie or Inpatie 1002 n/a n/a 21, 51, 55, , 513, , 761, with includin g covere d applica ble corresp onding CPT/H CPC s codes n/a 19, 21, 22, 51, 52 n/a 19, 22, 52 n/a 19,21, 22, 51 n/a 19, 22, 52
3 s Iensive Program Substance Use Disorder Day Treatme Behavioral Health Partial Hospitalization Program (PHP) Behavioral Health n- Residei al ( ) Substanc e Abuse Treatme Facility 906 includin g covere d applica ble corresp onding CPT/H CPC s codes 907 includin g covere d applica ble corresp onding CPT/H CPC s code 912 or 913 includin g covere d applica ble corresp onding CPT/H CPC s code n/a 19, 22, 57 n/a 19, 22, 52. n/a 19, 22, 52
4 Partial Hospitalization Program (PHP) Substance Use Disorder Methadone Detox Ambulatory Detox n- Residei al ( ) Substanc e Abuse Treatme Facility s 912 or 913 includin g covere d applica ble corresp onding CPT/H CPC s code 944, 945 includin g covere d applica ble corresp onding CPT/H CPC s code n/a 19, 22, 52 n/a n/a 55, 56 Professional Services Psych and Neuropsych Testing 96101, 96102, 96103, 96105, 96110, 96111, 96116, 96118, 96119, 96120, , 21, 22, 50, 51, 52, 53, 56, 72
5 Health and Behavioral Assessme ic Evaluation Behavioral Health Therapy Behavioral Health s , , 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, (do not bill with 90839, 90840, thru 90849) 19, 21, 22, 50, 51, 52, 53, 56, 72, 99 21, 22, 50, 51, 52, 53, 56, 72, 99 19, 21, 22, 50, 51, 52, 53, 56, 72, 99
6 Therapy Substance Use Disorders Medication Manageme CNS s 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, ECT MD/DO Biofeedback Administration of injectable medication CNS 90875, 90876, , 21, 22, 50, 51, 52, 53, 55, 72, 99 19, 21, 22, 50, 51, 52, 53, 56, 72, 99 19, 21, 22, 51 19, 21, 22, 50, 51, 52, 53, 56, 72 19, 21, 22, 50, 51, 52, 53, 56, 72 Covered in AR, FL, IN, MS, and OH. coverage in the other states.
7 Office Emergency Care Office Visit Observation Care Inpatie Care and Discharge Home Visits APNP, A CNS APNP, A CNS APNP, A CNS APNP, A CNS APNP, A CNS s , 22, 50, 52, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, , 99218, 99219, 99220, 99224, 99225, 99226, 99234, 99235, , 99222, 99223, 99231, 99232, 99233, 99238, , 99342, 99343, 99344, 99345, 99347, 99348, 99349, ,19, 22, 50, 52, , 22, , 51, 55,
8 Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, (e.g., immunoassay) read by instrumeed assisted direct optical observation (e.g., dipstick, cups, cards, cartridges) includes sample validation performed, per date of service (maps to or G0478). s (G0477 replace d) 11,19, 22, 50, 52, Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by instrume chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) Behavior Ideification Assessme 80307( G0477 replace d) 11,19, 22, 50, 52, 0359T 03, 04, 99
9 Observational behavioral follow-up assessme: first 30 minutes Observational behavioral follow-up assessme: Each additional 30 minutes Exposure Behavioral Follow-up Assessme: First 30 minutes Exposure Behavioral Follow-up Assessme: Each Additional 30 minutes Adaptive behavior treatme by protocol; First 30 minutes Adaptive behavior treatme by protocol; Each additional 30 minutes Group Adaptive Behavior Treatme by Protocol- Group Adaptive Behavior s 0360T 03, 04, T 03, 04, T 03, 04, T 03, 04, T 03, 04, T 03, 04, 0366T/ 0367T 99 03, 04, 99 Adaptive behavior treatme with protocol modification; First 30 minutes Adaptive behavior treatme with protocol modification; Each additional 30 minutes Family Behavior Treatme Guidance 0368T 03, 04, T 03, 04, T 03, 04, 53, 99
10 Pare Training; Multiple-family group adaptive behavior treatme guidance Adaptive Behavior Treatme Social Skills Group-Adaptive Behavior s 0371T 03, 04, 53, T 03, 04, 53, 99 Exposure Adaptive Behavior Treatme with Protocol Modification-Exposure 0373T 03, 04, 53, 99 Exposure Adaptive Behavior Treatme with Protocol Modification-Exposure 0374T 03, 04, 53, 99 HCPCS Group psychotherapy other than of a multiple-family group, in a partial hospitalization setting, approximately 45 to 50 minutes APNP, A CNS G ,19, 22, 50, 52, Ieractive group psychotherapy, in a partial hospitalization setting, approximately 45 to 50 minutes APNP, A CNS G ,19, 22, 50, 52, FQHC MH New Patie FQHC/R HC G ,72
11 FQHC MH Established Patie FQHC/R HC s G ,72 ALCOHOL AND/OR DRUG ASSESSMENT MD, DO, PsyD, EdD, Clin Psych, P Pysch- NP,, LMFT, LMHC, CAP- Masters Level H , 11, 12, 53, 99 BHVAL HLTH SCR DETRM ADMIS MD, DO, PsyD, EdD, Clin Psych, P Pysch- NP,, LMFT, LMHC, CAP- Masters Level H , 11, 12, 53, 99
12 LAB URINALYSIS BEHAVIORAL HEALTH CNSL&TX-15 MIN AL &/OR DRG SRV;GRP CNSLG- CLINICIAN CRISIS INTERVENTION SERVICE, PER HOUR s H0003 H0004 H ,19, 22, 50, 52, 11,19, 22, 50, 52, 11,19, 22, 50, 52, H , 04, 55, 56, 57, 72, 99 - After 3 hours authoriza tion is required
13 s Alcohol and/or drug services; sub-acute detoxification (resideial addiction program) Hospitals / H , 21, 22, 51, 55, 56, 57 AL &/OR DRG SRV; ACUTE DETOX- RESIDENTIAL ADDICTION INPT Alcohol and/or Drug Services; Ambulatory Detoxification IOP AL &/OR DRG SRV->=3HRS BHVAL HLTH; SHRT- TERM RES PER DIEM Hospitals / Hospitals /, Hospitals, Hospitals H0011 H , 21, 22, 51, 55, 56, 57 19, 21, 22, 51, 55, 56, 57 H , 04, 55, 56, 57, 72, 99 H , 04, 55, 56, 57, 72, 99
14 Methadone Maienance Meal health assessme, by nonphysician Meal health service plan developme by non-physician Oral medication administration, direct observation Meal health partial hospitalization, treatme, less than 24 hours BCBA, PhD BCBA, PhD, CM n- Residei al ( ) Substanc e Abuse Treatme Facility s H0020 TF (individua l counselin g), HR (family counselin g), HQ (group counselin g), none or UA (dosing) 11, 22, 50, 52, H , 04, 99 H , 04, H0033 H ,19, 22, 50, 52, 19, 22,52
15 Behavioral Health Services: Specimen Collection, Substance Abuse Alcohol and/or drug services, brief ierveion, per 15 minutes MD, DO, PsyD, EDD, Clin Psych, NP,, LMFT, LMHC,, Masters Level MD, DO, PsyD, EDD, Clin Psych, NP,, LMFT, LMHC,, Masters Level s H0048 H , 04, 55, 56, 57, 72, 99 03, 04, 55, 56, 57, 72, 99
16 Crisis ierveion service, per 15 minutes Alcohol and/or other drug treatme program, per hour MD, DO, PsyD, EDD, Clin Psych, NP,, LMFT, LMHC,, Masters Level MD, DO, PsyD, EDD, Clin Psych, NP,, LMFT, LMHC,, Masters Level s H2011 H , 04, 55, 56, 57, 72, 99 03, 04, 55, 56, 57, 72, 99 PA after 6 Units
17 PHP Ambulatory Detox. Ambulatory setting substance abuse treatme or detoxification services, per diem. n- Residei al ( ) Substanc e Abuse Treatme Facility Hospitals / s S0201 S , 22,52 19, 21, 22, 51, 55, 56, 57 INTENSIVE OUTPT PSYCH SERV PER DIEM CRISIS INTERVEN MENTL HLTH SRVC- HR Hospitals / MD, DO, PsyD, EDD, Clin Psych, NP,, LMFT, LMHC,,H ospitials, Masters Level S9480 S , 21, 22, 51, 55, 56, 57 11,19, 22, 51, 50, 51, 52, - After 3 hours authoriza tion is required
18 CRISIS INTERV MENTAL HEALTH/DIEM MD, DO, PsyD, EDD, Clin Psych, NP,, LMFT, LMHC,,H ospitials, Masters Level s S ,19, 22, 51, 50, 51, 52,
19 Telemedicine Transmitt ing Facility: Federally Qualified Health Ceer, Rural Health Ceer, Indian Health Services Ceer, Commun ity Meal Health Ceer Receivin g : s Q3014 for transmi tting facility, any therapy code (90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863) for receivi ng provide r GT 11,19, 22, 50, 52, Covered Diagnoses Covered diagnoses include a meal disease, disorder, or condition listed in the curre Diagnostic and Statistical Manual of Meal Disorders of the American ic Association, as revised, or other diagnostic coding system used by Cenpatico, with the following limitations and/or exceptions: Diagnoses known as V s are not allowed as primary diagnoses.
20 Developmeal delay/iellectual disability (DD/ID) diagnoses, if covered in a specific market, are covered under the medical plan. Diagnoses with demonstrable organic disease including, but not limited to, demeia, Alzheimer s disease, and acquired brain injury are covered under the medical plan. Common Place of Service s 05 Indian Health Service freestanding facility 06 Indian Health Service provider-based facility 07 Tribal 638 freestanding facility 08 Tribal 638 provider-based facility 11 Office 12 Home 21 Inpatie hospital 22 hospital 31 Skilled nursing facility 50 Federally qualified health ceer 51 Inpatie psychiatric facility 52 ic facility - partial hospitalization 53 Community meal health ceer 55 Resideial substance abuse treatme facility 56 ic resideial treatme ceer 57 n-resideial substance abuse treatme facility 72 Rural health clinic 99 Other place of service
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