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
BHUC (Behavioral Health Urgent Care -T2016 U5)Service Definition

N/A
Child and Adolescent Day Treatment (H2012 HA)Clinical Coverage Policy 8AState-Funded Enhanced MH and 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-6
State-Funded Community Support Team (CST)
Community Transition-One-Time Transitional Costs (H0043 U4)B3 Service DefinitionN/A
Criterion V (902)Clinical Coverage Policy 8BN/A
Dialectical Behavior Therapy (DBT) (Individual YA386; Group YA387)N/AN/A
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 8A (Adult)

Clinical Coverage Policy 8A-2 (Child)
2017 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
High Fidelity Wraparound Team (H0032 U3 Monthly; H0032 U3 Z1 Encounter)In Lieu of Definition
Hospital Discharge Transition Service (YA346)N/AAlternative Service Definition
IAFT (Intensive Alternative Family Treatment S5145 22 HA-IAFT)N/AN/AScope of Work
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 8AState-Funded Enhanced MH and SA Services
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/A
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 8AState-Funded Enhanced MH and SA Services 2019 Effective 11/1/19
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, H0038HQ)
Clinical Coverage Policy 8GN/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 8AState-Funded Enhanced MH/SA Services
Rapid Response (S5145 22 Z3)Alternative Service DescriptionN/A
Research Based Behavioral Health Treatment for Autism Spectrum Disorder Clinical Coverage Policy 8FN/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/AState-Funded Enhanced MH and SA Services 2019 Effective 11/1/19
Substance Abuse Intensive Outpatient Program (H0015)Clinical Coverage Policy 8A2017 State-Funded Enhanced MH/SA Services
Substance Abuse Medically Monitored Community 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
COVID-19 SERVICES AND CODES
Residential Level II Group Home, (H2020)
Residential Level III, Service Codes H0019 HQ and H0019 TJ
Residential Level IV, Service Codes H0019 HK and H0019 UR
Rapid Response, Service Code S5145 22 Z3
Psychiatric Residential Treatment Facility (PRTF), Service Code RC 911
Residential Level I, Family Type, Service Code H0046
Residential Level II, Family Type, Service Code S5145
Enhanced Therapeutic Foster Care, Service Code S5145 22 Z1
IAFT, Service Code S5145 22 HA
IDD/MH Therapeutic Foster Care, Service Code S5145 22 Z2
PSR During Disaster H2017 U5COVID In-Lieu of Service Definition
Day Treatment During Disaster H2012 HA 22COVID In-Lieu of Service Definition