Behavioral Health Providers Frequently Asked Questions

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Behavioral Health Providers Frequently Asked Questions 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 the managed care organizations (MCO) covered responsibilities.

A2. Effective Feb. 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 SC (SHSC) will no longer require prior

authorization for certain behavioral health outpatient therapy and medication management services for in-network/participating LIPS, psychiatrists, psychologists, and nurse practitioners. This no authorization requirement will be retro-active to January 1, 2014.

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.

• Department of Mental Health (DMH) • Private residential treatment facilities (PRTF) • Developmental evaluation centers (DEC) • Adolescent treatment facilities (ATF)

• Referrals from state entities, such as schools and DHHS

Q. Which providers 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

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Q. Which services will be included in this benefit?

FOR LICENSED INDEPENDENT PRACTITIONERS:

CPT Code Description Time Frequency Modifiers Prior Auth Rules for _{Par Providers} Notes

90832 Individual OP

therapy, 30 minutes 1 encounter 1 per date of service AH, HO PAR providers do not require prior authorization

Cannot use 90785 interactive complexity code

90834 Individual OP

therapy, 45 minutes 1 encounter 1 per date of service AH, HO PAR providers do not require prior authorization

90837 Individual OP

therapy, 60 minutes 1 encounter 1 per date of service AH, HO PAR providers do not require prior authorization Cannot use 90785 interactive complexity code 90846 Family therapy without client 1 encounter 4 per month

AH, HO PAR providers do not

require prior authorization

90847 Family therapy with

client 1 encounter 4 per month AH, HO PAR providers do not require prior

authorization

90853 Group therapy 1 30-minute

encounter

8 per month

require prior authorization Cannot use 90785 interactive complexity code H0002 Behavioral health screening 15-minute unit

2 per day AH, HO PAR providers do not

H2011 Crisis intervention 15-minute

unit 16 per day AH, HO PAR providers do not require prior

authorization Authorization requests have to be submitted within 2 business days of service 99366 Service plan development with client

1 encounter PAR providers do not

99367 Service plan

development without client

1 encounter PAR providers do not

90791 Psychiatric diagnostic

evaluation 1 encounter 1 every 6 months AH, HO PAR providers do not require prior

authorization H2000 Diagnostic Assessment- Initial Comprehensive Assessment 1 encounter 1 every 6 months

H0031 Diagnostic

Assessment- Follow up comprehensive ax

1 encounter 12 per year AH, HO PAR providers do not

96101 Psychological Testing 60 minute

units All units require prior authorization Requires Psychological

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FOR MEDICAL PROFESSIONALS

MD (including specialists), Physician Assistant, Advance Practice Registered Nurse (APRN) Providers, Nurse Practitioners

CPT Codes Description Prior Auth Rules for Par _Providers Notes 90791

90792 Eval (no medical services) OR 90791 Psychiatric Diagnostic 90792 Psychiatric Diagnostic

Eval with medical services

PAR providers do not require

prior authorization Cannot use 90785 interactive complexity code

90832 Individual OP therapy, 30

minutes

PAR providers do not require prior authorization

E/M Code + add

on code 90833 E/M code + 30-minute psychotherapy PAR providers do not require prior authorization Cannot use 90785 interactive complexity code Must bill 90833 in conjunction with E/M

code; cannot be billed alone

minutes PAR providers do not require prior authorization Cannot use 90785 interactive complexity code E/M Code + add

on code 90833

E/M code + 45-minute psychotherapy

Must bill 90836 in conjunction with E/M code; cannot be billed alone

minutes PAR providers do not require prior authorization Cannot use 90785 interactive complexity code E/M code + add

on code 90838 E/M code + 60-minute psychotherapy PAR providers do not require prior authorization Cannot use 90785 interactive complexity code Must bill 90838 in conjunction with E/M

code; cannot be billed alone 90832 + 90785

add on minutes + Interactive complexity Individual OP therapy, 30 add on

PAR providers do not require prior authorization E/M code + add

on code 90833 + 90785 add on

E/M code + 30-minute psychotherapy + Interactive

complexity add on

prior authorization Must bill 90833 in conjunction with E/M code; cannot be billed alone

90834 + 90785

PAR providers do not require prior authorization E/M code + add

on code + 90785 add on

E/M code + 45 minute psychotherapy + Interactive

complexity add on

90837 + 90785

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MD (including specialists), Physician Assistant, Advance Practice Registered Nurse (APRN) Providers, Nurse Practitioners

CPT Codes Description Prior Auth Rules for Par

Providers Notes

E/M code + add on code 90838 + 90785 add on

E/M code + 60-minute psychotherapy + Interactive

complexity add on

90853 + 90785 add on

Group therapy +Interactive complexity add on

E/M Code E/M Code-(99201, 99202, 99203,

99204, 99205, 99212, 99213, 99214, 99215)

No authorization required for PAR providers only- any non-par providers require prior

auth for all services

90870 ECT All units require prior

authorization Prior authorization is based on medical necessity and requires an MD approval

90882 Environmental Intervention

Med Management (30-minute units)

All units require prior authorization

90887 Interpretation or Explanation of

results (event)

90899 Unlisted psychiatric service or

procedure (event)

Prior auth determination by a Physician Advisor

96101 Psychological Testing (60-minute

units)

Requires Psychological Advisor Review

96118 Neuro Psychological Testing by

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DAODAS PROVIDERS Service Type Bundles Description Service Code ASAM

Level Unit Prior Auth Rule Review Type

Bundle 1 Social Detox / _IP H0010 III.2-D 1 day _{prior authorization}All units require Telephonic Bundle 2 _{Detox / IP}Medical H0011 III.7-D 1 day _{prior authorization}All units require Telephonic Bundle 3 Residential _Rehab H0019 III.5-R 1 day _{prior authorization}All units require Telephonic Bundle 4 Residential _Rehab _H0018HAH0018 _III.7-RAIII.7-R 1 day _{prior authorization}All units require Telephonic Bundle 5 PHP H2035 II.5 1 hour _{prior authorization}All units require Telephonic Bundle 6 IOP H0015 II.1 1 hour _{prior authorization}All units require Written

Discrete OP Multiple I Varies See Discrete _{Services Tab} Written

Proc Code Description Unit

Frequency Limits / Benefit Structure Prior Auth Req Mnc Cluster Comments 90792 Diag Eval w/ medical Encount er/ DOS = 1 unit 1 per 6 months without authorization

No ASAM No *This code is outside

of all bundled service packages 96101 Psychological testing, includes face-to-face time administering tests, time interpreting results, and preparing report 1 unit = 1 hour

Yes InterQua l

No *This code is outside of all bundled service

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96102 Psychological testing, includes face-to-face time administering tests, and preparing report 1 unit =

1 hour All units require prior authorization

Yes InterQua

l No of all bundled service *This code is outside packages. H0001 Alcohol and Drug Assessment w/o Physical (initial) Encount er/ DOS = 1 unit 1 per 6 months without authorization

of all bundled service packages Alcohol and Drug Assessment w/o Physical (follow-up) Encount er/ DOS = 1 unit 1 per 6 months without authorization

of all bundled service packages A&D Nursing Services Encount er/ DOS = 1 unit 22 units per rolling 12-months without authorization

of all bundled service packages 99408 Alcohol and/or substance abuse structured screening and brief intervention services Encount er/ DOS = 1 unit 12 per rolling 12-months without authorization No ASAM No H0001 and 99408

cannot be billed on the same DOS. Billable

screenings must be conducted

face-to-face. *This code is outside

of all bundled service packages 99366 Service plan development with patient present Encount er/ DOS = 1 unit 6 units per rolling 12-month period without authorization, combined total of Cluster 2 codes

No ASAM Cluster 2 *This code is outside of all bundled service

packages 99367 Service plan development without the patient present Encount er/ DOS = 1 unit 6 units per rolling 12-month period without authorization, combined total of Cluster 2 codes

No ASAM Cluster 2 *This code is outside of all bundled service

packages

90832 Psychotherapy

30 minutes er/ DOS Encount = 1 unit

All units require

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99203 Medical evaluation and management for new patient Encount er/ DOS = 1 unit

No No If the prescriber also

does therapy, the use add on codes 90833 (30 minutes) or 90836 (45 minutes) 99213 Medical evaluation and management for established patient Encount er/ DOS = 1 unit

No No If the prescriber also

does therapy, the use add on codes 90833 (30 minutes) or 90836

(45 minutes) 90834 Psychotherapy

45 mins er/ DOS Encount = 1 unit

Yes ASAM Cluster 3 Modifiers in red require PA review 90846 Family Psychotherapy (W/O patient present) Encount er/ DOS = 1 unit

Yes ASAM Cluster 3 Modifiers in red require PA review 90847 Family Psychotherapy( with patient present) Encount er/ DOS = 1 unit

Yes ASAM Cluster 3 Modifiers in red require PA review 90853 Group Psychotherapy other than a multiple family group Encount er/ DOS = 1 unit

Yes ASAM Cluster 3 Modifiers in red require PA review H0004 Substance Abuse Counseling - Individual 1 unit = 15 minutes

All units require prior authorization Yes ASAM No H0005 Substance Abuse Counseling - group Encount er/ DOS = 1 unit

All units require prior authorization Yes ASAM No H0038 Peer support Services 1 unit = 15 minutes

All units require prior authorization Yes DHHS Svc Desc No H2011 Crisis Intervention Services (face-to-face and telephonic) 1 unit = 15 minutes 16 per day without prior authorization No DHHS

Svc Desc No PA not required as this is a crisis service. Instead, service may

be reviewed retrospectively to ensure compliance. *This code is outside of all bundled service

packages. H2017 Rehabilitative Psychosocial Services 1 unit = 15 minutes

Yes DHHS

Svc Desc

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S9482 Family Support 1 unit = 15 minutes

All units require prior authorization Yes DHHS Svc Desc No H0034 Medication Training and Support (face-to-face) 1 unit = 15 minutes

Yes DHHS

Svc Desc No Cannot be billed on same DOS as med check (E/M code) J2315 Injection –

Vivitrol 1 per month is the manufacturer's recommended

limit All units require

prior authorization

Yes ASAM No Reimburses at the

same rate as the physician's fee

schedule. *This code is outside of all bundled service

packages. 96372 Medication

Administration All units require prior authorization

Yes ASAM No Must be billed in

conjunction with J2315. Code will reject if not billed along with

J2315. *This code is outside of all bundled service

packages.

Q. What is the turnaround time for authorizations?

A. Please allow 14 calendar days for authorization decisions (BH OP, BH IP, DAODAS IOP

and Discrete).

Q. What do I need to submit when trying to obtain authorization for additional/extension of services for behavioral health outpatient treatment?

A. If the service does not require prior authorization, obtaining authorization for

additional/extension of services is not required.

Q. What is the reimbursement rate?

A. 100 percent Medicaid fee schedule

Q. Will authorizations be required for any outpatient services? A. Yes, some outpatient services require authorization:

For PAR MDs: 90870, 90882, 90887, 90889, 96101 and 96118 require prior

authorization

For PAR LIPS: 96110 requires prior authorization

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FOR ALL NON-PAR PROVIDERS - prior authorization is required for any and all services.

Contact Select Health Behavioral Health at 1.866.341.8765 for information on authorization requirements.

Q. Are services for private residential treatment facilities (PRTF), developmental evaluation centers (DEC) services or adolescent treatment facilities (ATF) covered?

A. No. Services in these facilities 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. No. If the DJJ (or any state agency) refers a non-incarcerated member for behavioral health

services, those services are not covered by Select Health and remain fee-for-service.

Q. Are services for a primary diagnosis of autism covered?

A. No. Per the South Carolina Department of Health and Human Services, autism services are a

non-covered benefit under Medicaid managed care.

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. Are mental health or substance abuse services provided by the following programs covered?

• Lighthouse Care Center of Conway Acute • Palmetto LowCountry BH

• Three Rivers BHS • Carolina Center for BH • Springbrook BH System

A. No. Services through these providers will continue to be handled by Medicaid’s fee-for-service

program.

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 co-pays apply to these services?

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Q. Where are claims submitted? A. Submit claims to:

Select Health of South Carolina Claims Processing Department P.O. Box 7120

London, KY 40742

Q. Is a LPC-I able to provide services and bill under an LPC-S?

A. Yes, the LPC-I can provide the services but the LPC will be responsible for signing off on all

notes and submitting the claims.

Q. Whom 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