Changes to Medicaid-Funded Peer Support

Effective November 1, 2019, Peer Support Services will be available in the Medicaid B Benefit Plan. Peer Support will not be offered as a B3 Service.

The new codes for this service are:

  • H0038-Peer Supports Individual
  • H0038 HQ-Peer Supports Group

The following codes will be discontinued as of October 31, 2019:

  • H0038 HQU4
  • H0038 U4

Providers will receive a contract amendment to reflect the current codes.

The new codes are in the process of being set up in Alpha-please hold billing in order to reduce denials, until you receive notification the new codes are set up in Alpha.

The rates for the service are:

  • H0038 $11.97
  • H0038HQ $2.88

Clinical Coverage Policy 8G and Alliance’s Benefit Plan indicate that:

  • The program is under the direction of a full-time Qualified Professional (QP).
  • Maximum program staff ratios are the following: QP to Certified Peer Support Specialist (CPSS) is 1:8; CPSS to beneficiary is 1:15; CPSS Group Facilitator to beneficiary is 1:12 for Peer Support Group.
  • The Peer Support Specialist must be certified by the NC Peer Support Specialist Certification Program.
  • By November 1, 2020 achieve national accreditation with at least one of the designated accrediting agencies.
  • Beneficiaries are eligible for 24 unmanaged units once per episode of care in a state fiscal year.
  • Prior approval is required for Peer Support Services provided beyond the unmanaged unit limitation.
  • A service order must be signed by a physician or other licensed clinician, per his or her scope of practice, prior to or on the first day service is rendered.
  • A Comprehensive Clinical Assessment is required to determine medical necessity of service prior to initial authorization request.
  • Clinical information must be obtained and documented in the beneficiary’s Person-Centered Plan prior to initial authorization request.
  • Peer Support may be provided in the beneficiary’s place of residence, community, in an emergency department or in an office setting.
  • Peer Support is not a first responder service. Peer Support service providers shall coordinate with other service providers to ensure “first responder” coverage and crisis response.
  • Active authorizations that cross over 11/1/19 will be transferred by the Utilization Management Department. The remaining days and units, will transferred under the new code for Peer Support Services. Providers will not need to submit SARs for this action. Concurrent authorizations after this process will need to be submitted by the provider for a MN review by the Utilization Management Department. Please refer to benefit plan and Clinical Coverage Policy 8G for authorization guidelines.
  • Utilization Management will require a CCA and PCP to be submitted for Medical Necessity review for initial authorization after the use of unmanaged units. Providers may request up to 270 units per 90 days Initial Authorization and up to 270 units per 90 days during subsequent reauthorization periods, if medically necessary. Additional units may be authorized if clinically appropriate.

Page last modified: November 12, 2019