Peach State Health Plan Covered Services & Authorization Guidelines Programs for Behavioral Health

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1 Peach State Health Plan Covered s & Guidelines Programs for Health n-participating providers (those that are not contracted and credentialed with Peach State Health Plan) require prior authorization for all services, unless otherwise noted in the tables below. All limits are per member per provider (TIN) unless otherwise noted in the tables below. Inpatient & Outpatient Facility s Provider Inpatient- Crisis 100 Facility Stabilization See tes 1 and 2. Inpatient Health See tes 1 and , 101, 110, 114,124, 126, 134, 136, 144, 146, 154, Facility Inpatient - Health / Eating Disorder See tes 1 and 2. Inpatient Substance Use Disorder See tes 1 and , ,150 With a primary diagnosis of one of the following eating disorders: Anorexia Nervosa, Eating Disorder, Bulimia Nervosa, Pica, Rumination Disorder, Psychogenic Vomiting, etc. 100, , 124, 126, 134, 144, 146, 156 Facility Facility Observation 760, 761, 762, 769 Facility Limited to 72 hours per episode. Discharge Follow-Up See te 1. ECT See te 1. RESIDENTIAL TREATMENT BH See tes 1 and 3. RESIDENTIAL TREATMENT CD See tes 1 and Facility 901 Facility 1001 Facility 1002 Facility auth required for participating or nonparticipating provider.

2 Inpatient & Outpatient Facility s Provider PARTIAL 912, 913 Facility HOSPITALIZATION (PHP) See tes 1 and 4. Intensive Outpatient Program (IOP) See tes 1 and , 906 Facility Facility Professional s Provider Limitation Initial Observation Care See te 1. Initial Hospital Care See te 1. Subsequent Observation Care See te 1. Subsequent Hospital Care See te 1. Observation or Inpatient Care See te 1. Hospital Discharge See te 1. Initial Inpatient Consultation See te , 99218, 99219, , 99222, , 99225, , 99232, , 99235, , , 99252, 99253, 99254, auth required for participating or nonparticipating provider. auth required for participating or nonparticipating provider. auth required for participating or nonparticipating provider. auth required for participating or nonparticipating provider. auth required for participating or nonparticipating provider. auth required for participating or nonparticipating provider. auth required for participating or nonparticipating provider. - Identification Assess - Observational Autism Spectrum Disorder Provider 0359T unit per 6 months for ages under T

3 Follow-up - Observational Follow-up - Exposure Follow-Up - Exposure Follow-Up - Exposure Follow-Up - Exposure Follow-Up - Group Adaptive Treatment by Protocol - Group Adaptive Treatment by Protocol Autism Spectrum Disorder Provider 0361T Add on code 0362T 0363T Add on code 0364T 0365T Add on code 0366T 0367T Add on code 0361T must be with 0360T 0363T must be billed with 0362T 0365T must be billed with 0364T 0367T must be billed with 0366T

4 - Adaptive Treatment with Protocol Modification - Adaptive Treatment with Protocol Modification - Family Adaptive Treatment Guidance -Multiple Family Group Adaptive Treatment Guidance -Adaptive Treatment Social Skills Group -Exposure Adaptive Treatment with Protocol Modification -Exposure Adaptive Treatment with Protocol Modification Autism Spectrum Disorder Provider 0368T 0369T Add on code 0370T 0371T 0372T 0373T 0374T 0369T must be billed with 0368T Limited to 2.

5 Other Professional s Billing Provider Codes Psychiatric Diagnostic Evaluation See te , Masters Level, every 3 years for ages over 22. Limited to 3 per year without an authorization for ages 22 and under. Individual Psychotherapy 90832, 90834, Family Therapy Add-on With Patient and/or Family in Conjunction With E/M Code See te 6. Limited to 2 units when billed with E & M codes Family Therapy Without Patient Present See te 6. Family Group Therapy, With Patient Present See te 6 and 8 Multi-Family Group See tes 1 and Masters Level, MASTERS LEVEL, MASTERS LEVEL, MASTERS LEVEL, MD, DO, Limited to 2 units YES, IF MORE THAN 12 VISITS (PER PROVIDER) CODES 90832, 90834,90837, 90845, 90846, 90847, 90849, 90853, YES, IF MORE THAN 12 VISITS (PER PROVIDER) CODES 90832, 90834,90837, 90845, 90846, 90847, 90849, 90853, YES, IF MORE THAN 12 VISITS (PER PROVIDER) CODES 90832, 90834,90837, 90845, 90846, 90847, 90849, 90853, YES, IF MORE THAN 12 VISITS (PER PROVIDER) CODES 90832, 90834,90837, 90845, 90846, 90847,,90849, 90853, YES, IF MORE THAN 12 VISITS (PER PROVIDER) CODES 90832, 90834,90837, 90845, 90846, 90847, 90849, 90853,

6 Other Professional s Billing Provider Codes Group Psychotherapy See te 6 and 8. Interactive Complexity Add on Code Individual Psychotherapy With Medication Management Add on codes: 90833, 90836, EMERGENCY DEPARTMENT SERVICES Electroconvulsive Therapy (ECT) See te MASTERS LEVEL, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, MASTERS LEVEL, MD, DO, MD, DO MD, DO YES, IF MORE THAN 12 VISITS IN A CALENDAR (PER PROVIDER) CODES 90832, 90834,90837, 90845, 90846, 90847,,90849, 90853, Psychological Testing MD, DO, PhD

7 Other Professional s Billing Provider Codes Developmental Psych Screening/ Testing See te 1. Neurobehavioral Status Exam 96110, MD, DO, PhD MD, DO, PhD Limited to 4 units Neuropsychological testing, interpretation and reporting by a psychologist (per hour) MD, DO, PhD 1 unit = 1 hour Limited to 8 units Neuropsychological testing per hour by a technician Neuropsychological testing by a computer, including time for the psychologist s interpretation and reporting MD, DO, PhD MD, DO, PhD BH Assessment MD, DO, PhD Injection Administration MD, DO, 1 Unit = 1 hour Limited to 6 hours 1 unit = 1 hour 1 unit = 1 hour Limited to 2 hour Limited to 4 units Office Consultation See te 1. Telemedicine- Originating Site of See te , 99242, 99243, 99244, Q3014 MD, DO, PhD MD, DO, CNP, FQHC, RHC

8 s delivered by a Facility (including IFI) All Community Health Providers () require prior auth unless otherwise noted. Billable Provider Psychotherapy for Crisis See note , unit, limited to 16 units Psychiatric Diagnostic Evaluation See note 7. unit combined with Psychiatric Diagnostic Evaluation See note unit, limited to 2 units unit, limited to 2 units unit when combined with Individual Psychotherapy 90832, 90834, unit, limited to 2 YES, IF MORE THAN 12 VISITS (PER PROVIDER) CODES 90832, 90834,90837, 90845, 90846, 90847, 90849, 90853,

9 s delivered by a Facility (including IFI) All Community Health Providers () require prior auth unless otherwise noted. Billable Provider Family Therapy Add-on With Patient and/or Family in Conjunction With E/M Code See te 6. Limited to 2 units when billed with E & M codes Family Therapy with and without patient present See te 6. Group Psychotherapy See te 6 and unit, limited to , minute code = 1 unit 6 Units minute code = 1 Unit Limited to 20 units YES, IF MORE THAN 12 VISITS (PER PROVIDER) CODES 90832, 90834,90837, 90845, 90846, 90847, 90849, 90853, YES, IF MORE THAN 12 VISITS (PER PROVIDER) CODES 90832, 90834,90837, 90845, 90846, 90847, 90849, 90853, YES, IF MORE THAN 12 VISITS (PER PROVIDER) CODES 90832, 90834,90837, 90845, 90846, 90847, 90849, 90853,

10 s delivered by a Facility (including IFI) All Community Health Providers () require prior auth unless otherwise noted. Billable Provider Psychological Testing: Psychodiagnostic assessment of emotionally, intellectual abilities, personality and psychopathology 96101, unit = 1 hour, limited to 5 units Health And Assessment and Reassessment 96150, minute code = 1 unit, limited to 16 units Therapeutic Prophylactic or Diagnostic Injection unit, limited to 1 unit per contact Individual Psychotherapy With Medication Management 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, unit, units Substance Abuse IOP H0015 Limited to 5 units YES eff 2/1/18

11 s delivered by a Facility (including IFI) All Community Health Providers () require prior auth unless otherwise noted. Billable Provider MH Assessment by a non- Physician Treatment Plan Development Crisis Intervention See note 9. H minute code = 1 unit Limited to 24 units per 6 Months. Limits combined with H0032 H minute code = 1 unit, Limited to 24 units per 6 Months. Limits combined with H0031 H minute code = 1 unit, limited to 48 units, if more than 24 units are billed within 6 months, if more than 24 units are billed within 6 months Nursing Assessment /Evaluation T minutes = 1 unit 6 units Limited to 32 units ambulatory detox RN s T minutes = 1 unit. 6 units Limited to 32 units ambulatory detox LPN s T minutes = 1 unit 6 units Limited to 32 units ambulatory detox

12 s delivered by a Facility (including IFI) All Community Health Providers () require prior auth unless otherwise noted. Billable Provider Psychiatric Treatment: E & M New Patient unit, units Psychiatric Treatment: E & M Established Patient Group Health Counseling and Therapy unit, units H minute code = 1 Unit Limited to 20 units Family/Couple Health Counseling and Therapy See te 6. H minute code = 1 Unit Limited to 20 units Group Skills Training and Development Family Skills Training and Development H minute code = 1 Unit 6 units ages under 21 and 8 units 21 and over. H minute code = 1 Unit 6 units ages under 21 and 8 units 21 and over.

13 s delivered by a Facility (including IFI) All Community Health Providers () require prior auth unless otherwise noted. Billable Provider Psychosocial Rehabilitation Alcohol and/or Drug s; Ambulatory Detoxification H2017 1unit = 1 hour, limited to 5 per day H unit = 15 minutes Limited to 32 units. Alcohol and/or Drug s; Methadone Administration and/or s H unit, limited to 1. Community Support and Addictive Diseases Support s H unit = 15 minutes Limited to 48 units. Community based wraparound services, monthly Task Oriented Rehabilitation s Intensive Customized Care Coordination H unit = 1 month, limited to 12 per year H unit = 15 minutes Limited to 8 units T unit=month, limited to 12 per year Effective 10/01/2017, effective 10/01/2017

14 s delivered by a Facility (including IFI) All Community Health Providers () require prior auth unless otherwise noted. Billable Provider Intensive Customized Care Coordination Intensive Case Management, and Case Management Intensive Family Intervention Peer Support s Group (BH & CD) T unit=month, limited to 4 per year T unit = 15 minutes Limited to 24 units. H unit = 15 minutes Limited to 48 units. H unit = 1 hour, limited to 5 units, effective 10/01/2017 Peer Support s Individual (BH & CD) H unit = 1 hour, limited to 5 units Community Support Team Assertive Community Treatment, Multidisciplinary Team Meeting H unit = 15 minutes Limited to 60 units H unit = 15 minutes Limited to 60 units

15 s delivered by a Facility (including IFI) All Community Health Providers () require prior auth unless otherwise noted. Billable Provider Health Prevention Education Health - Short Term Residential Comprehensive Medication s H unit = 15 minutes Limited to 6 units. H0018 per day H2010 per contact Health Home Medical Home Program Coordination and Planning, Initial Plan Health Home Medical Home Program Coordination and Planning, S0280 Agency Pending limitations and authorization requirements from GA Medicaid. S0281 Agency Pending limitations and authorization requirements from GA Medicaid Maintenance tes: 1. limited to one (1). 2. Inpatient services for children (18 years of age and younger) and adults are covered in General hospitals. Children are covered at private psychiatric hospitals, but not state hospitals. Adults aged are not covered at an IMD (psych hospital with > 16 beds) or state hospitals. 3. Only covered for children (18 years of age and younger). 4. Partial hospitalization is also covered under Community Based s. Covered up to 5 days per week. Limited to 60 days per episode of care and 120 days total per calendar year. 5. Intensive outpatient services are limited to 180 days per calendar year 6. If there are multiple family members in the Family Therapy session who are enrolled consumers for whom the focus of treatment is related to goals on their treatment plans, the provider should do the following:

16 a. Document the family session in the charts of each individual consumer for whom the treatment is related to a specific goal on the individual s IRP b. Charge the Family Counseling session units to one of the consumers. c. Indicate NC ( Charge) on the documentation for the other consumer(s) in the family session and have the note reflect that the charges for the session are assigned to another family member in the session. 7. may be reported/billed in conjunction with one of the following codes: 90791, 90792, 90832, 90837, and with the following codes only when paired with 90833, or 90836: 99201, 99212, 99203, 99213, 99204, 99214, 99205, Reimbursement for psychotherapy (90847 and is limited to a maximum of twelve (hours per member, per provider per calendar year). Only one hour per date of service can be billed. s in excess of this limitation may be available through local community mental health programs and cannot be submitted by the same practitioner in the same day as H2011, it also cannot be submitted for billing in the same day as 90791, 90792, 90833, or s must be billed with the appropriate modifiers per the Community Health Rehabilitation Manual. ET GT HA Emergency Via Interactive audio and video telecommunication systems Child/Adolescent Program Modifiers TS Follow up UK Collateral Contact U1 Practitioner Level 1 Physician, Psychiatrist HK HQ HR High Risk Population Group Setting Family/Couple with client present U2 Practitioner Level 2 Psychologist, Physician s Assistant, Nurse Practitioner, Clinical Nurse Specialist, Pharmacist U3 Practitioner Level 3 Registered Nurse, Licensed Dietician, Licensed Professional Counselor (LPC), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT) U4 Practitioner Level 4 Licensed Practical Nurse (LPN); Licensed Associate Professional Counselor (LAPC); Licensed Social Worker (LMSW); Licensed Associate Marriage and Family Therapist (LAMFT); Certified/Registered Addictions Counselors (e.g. CAC-II, CADC, CCADC, GCADC, MAC, CCDP, CCDP-D), Certified Peer Specialists, Trained Paraprofessionals and Certified Psychosocial Rehabilitation Professionals (CPRP) with Bachelor s degrees or higher in the social sciences/helping professions HS Family/Couple without client present U5 Practitioner Level 5 Trained Paraprofessionals, Certified/Registered

17 Addiction Counselors (CAC-I, RADT), Certified Peer Specialists, Certified Psychosocial Rehabilitation Professionals, and Qualified Medication Aides with at least a high school diploma/equivalent HT TG Multidisciplinary team U6 U7 In Clinic Identifies location Complex/High Level of Care Out-of-Clinic Identifies Location