ALL SERVICES REQUIRE PRIOR AUTHORIZATION UNLESS OTHERWISE NOTED IN THE MEDICAID AND NON-MEDICAID BENEFIT PLANS.

Service and CodeMedicaidStateScope of Work
ACT Step-Down (H0040 TS)Alternative Service DescriptionN/A
Ambulatory Detoxification (H0014)Clinical Coverage Policy 8AN/A
Assertive Community Treatment Team (H0040)Clinical Coverage Policy 8A-1State-Funded ACT Policy

Assertive Engagement (YA323)N/AAlternative Service Definition
Child and Adolescent Day Treatment (H2012 HA)Clinical Coverage Policy 8A2017 State-Funded Enhanced MH/SA Services
Clinical and Diagnostic Assessment (90791, 90792, T2013)90791 and 90792
Clinical Coverage Policy 8C

T1023
Clinical Coverage Policy 8A
90791 and 90792
Clinical Coverage Policy 8C

T1023
N/A
Community Support Team (H2015 HT)Clinical Coverage Policy 8A
2017 State-Funded Enhanced MH/SA Services
Community Support Team PlusN/A


N/AScope of Work
Community Transition-One-Time Transitional Costs (H0043 U4)B3 Service DefinitionN/A
Crisis Evaluation and Observation (YA 324)N/AAlternative Service Definition
Criterion V (902)Clinical Coverage Policy 8BN/A
Dialectical Behavior Therapy (DBT) (Individual YA386; Group YA387)N/AN/AScope of Work
Enhanced Therapeutic Foster Care (S5145 Z1)N/AN/AScope of Work
Evaluation and Management (multiple codes 99xxx)Clinical Coverage Policy 8CClinical Coverage Policy 8C
Facility-Based Crisis Program (S9484-Adult; S9484HA-Child)Clinical Coverage Policy 8A2017 State-Funded Enhanced MH/SA Services
Family Centered Treatment (H2022 U3 HE)Alternative Service DefinitionN/A
Group Living (High-YP 780, Moderate-YP 770, Low-YP 760)N/AState-Funded Enhanced MH/DD/SA Service Definitions
Hospital Discharge Transition Service (YA346)N/AAlternative Service Definition
Individual Support (T1019 U4)

B3 Service DefinitionN/A
Inpatient Hospital Psychiatric Treatment-MH (RC100) Clinical Coverage Policy 8BN/A
Inpatient Hospitalization (YP 820, YP 821)N/AClinical Coverage Policy 8B
Intensive In-Home Services (H2022)Clinical Coverage Policy 8A2017 State-Funded Enhanced MH/SA ServicesScope of Work
Intercept (H0036 U3 HK)N/AN/AScope of Work
Level II Group Home (H2020)Clinical Coverage Policy 8D-2N/A
Level II Therapeutic Foster Care (S5145)Clinical Coverage Policy 8D-2N/AScope of Work
Medication-Assisted Treatment-Buprenorphine (99212 22, 99213 22, 99214 22)N/AN/AScope of Work
Mobile Crisis Management (H2011)Clinical Coverage Policy 8A2017 State-Funded Enhanced MH/SA Services
Multisystemic Therapy (MST) (H2033)Clinical Coverage Policy 8A2017 State-Funded Enhanced MH/SA Services
Non-Hospital Medical Detoxification (H0010)Clinical Coverage Policy 8A2017 State-Funded Enhanced MH/SA Services
Outpatient Behavioral Health Services Provided by Direct-Enrolled ProvidersClinical Coverage Policy 8CClinical Coverage Policy 8C
Opioid Treatment (H0020)Clinical Coverage Policy 8A2017 State-Funded Enhanced MH/SA Services
Outpatient Plus (90837 U3 HE)Alternative Service DescriptionN/A
Parent Child Interaction Therapy-PCIT (90837 22 Z2)Clinical Coverage Policy 8CN/AScope of Work
Partial Hospitalization (H0035)Clinical Coverage Policy 8AN/A
Peer Support (H0038 U4, H0038 HQ U4)
B3 Service DefinitionN/A
Physician Consultation (99241 U4, 99242 U4, 99244 U4)B3 Service DefinitionN/A
Psychiatric Residential Treatment Facility (PRTF) (RC911)Clinical Coverage Policy 8D-1N/A
Psychological and Developmental Testing (Medicaid: 96112, 96113, 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96146;
State: 96130, 96131, 96136, 96137, 96146)
Clinical Coverage Policy 8CClinical Coverage Policy 8C
Psychosocial Rehabilitation (H2017)Clinical Coverage Policy 8A2017 State-Funded Enhanced MH/SA ServicesScope of Work
Rapid Response (S5145 22 Z3)Alternative Service DescriptionN/A
Research Based Behavioral Health Treatment for Autism Spectrum Disorder State Plan AmendmentN/A
Residential Level I (H0046)Clinical Coverage Policy 8D-2N/A
Residential Level III-4 Or Less Beds (H0019 HQ)Clinical Coverage Policy 8D-2N/A
Residential Level III-5 Or More Beds (H0019 TJ)Clinical Coverage Policy 8D-2N/A
Residential Level IV-4 Beds Or Less (H0019 HK)Clinical Coverage Policy 8D-2N/A
Respite B3 (Individual H0045 U4, Group H0045 HQ U4)B3 Service DefinitionN/A
Substance Abuse Comprehensive Outpatient Treatment Program (H2035)Clinical Coverage Policy 8A2017 State-Funded Enhanced MH/SA Services
SA Halfway House (H2034)N/A2017 State-Funded Enhanced MH/SA Services
Substance Abuse Intensive Outpatient Program (H0015)Clinical Coverage Policy 8A2017 State-Funded Enhanced MH/SA Services
Substance Abuse Medically Monitored Community Monitored Residential Treatment (H0013)Clinical Coverage Policy 8AN/A
SA Medically Monitored Intensive Inpatient Detox (H2036)Clinical Coverage Policy 8AN/A
Substance Abuse Non-Medical Community Residential Treatment (H0012 HB)Clinical Coverage Policy 8AN/A
Supervised Living (Low-YP710, Moderate-YP720)N/AState-Funded Enhanced MH/DD/SA Service Definitions
Supported Employment (H2023 U4 HE, H2026 U4 HE)B3 Service DefinitionN/A
Supported Employment (State Funded YP630)N/AState Funded IPS-SE for AMH/SAS
TF-CBT (90791 22 Z1, 90837 22 Z1)Clinical Coverage Policy 8CN/AScope of Work
Transition Management Services (YM130)N/AState Funded Transition Management Services



Page last modified: March 14, 2019