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UM Resources – MH/SUD

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

Assertive Engagement (YA323)Alternative Service Definition
Behavioral Health Urgent Care (BHCAI) T2106 U5 In Lieu Of DefinitionScope of Work
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 Definition
Criterion V (902)Clinical Coverage Policy 8B
Dialectical Behavior Therapy (DBT) (Individual YA386; Group YA387)Scope of Work
Enhanced Therapeutic Foster Care (S5145 Z1)Scope 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)In Lieu of Definition
Group Living (High-YP 780, Moderate-YP 770, Low-YP 760)State-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)Alternative Service Definition
IAFT (Intensive Alternative Family Treatment S5145 22 HA-IAFT)Scope of Work
Individual Support (T1019 U4)

B3 Service Definition
Inpatient Hospital Psychiatric Treatment-MH (RC100) Clinical Coverage Policy 8B
Inpatient Hospitalization (YP 820, YP 821)Clinical Coverage Policy 8B
Intensive In-Home Services (H2022)Clinical Coverage Policy 8AState-Funded Enhanced MH and SA Services
Intercept (H0036 U3 HK)Scope of Work
Level II Group Home (H2020)Clinical Coverage Policy 8D-2
Level II Therapeutic Foster Care (S5145)Clinical Coverage Policy 8D-2
Medication-Assisted Treatment-Buprenorphine (99212 22, 99213 22, 99214 22)Scope 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)In Lieu of Definition
Parent Child Interaction Therapy-PCIT (90837 22 Z2)Clinical Coverage Policy 8CScope of Work
Partial Hospitalization (H0035)Clinical Coverage Policy 8A
Peer Support (H0038, H0038HQ)
Clinical Coverage Policy 8G
Physician Consultation (99241 U4, 99242 U4, 99244 U4)B3 Service Definition
Psychiatric Residential Treatment Facility (PRTF) (RC911)Clinical Coverage Policy 8D-1
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 Code S5145 22 Z3 In Lieu Of Definition
Research Based Behavioral Health Treatment for Autism Spectrum Disorder Clinical Coverage Policy 8F
Residential Level I (H0046)Clinical Coverage Policy 8D-2
Residential Level III-4 Or Less Beds (H0019 HQ)Clinical Coverage Policy 8D-2
Residential Level III-5 Or More Beds (H0019 TJ)Clinical Coverage Policy 8D-2
Residential Level IV-4 Beds Or Less (H0019 HK)Clinical Coverage Policy 8D-2
Respite B3 (Individual H0045 U4, Group H0045 HQ U4)B3 Service Definition
Substance Abuse Comprehensive Outpatient Treatment Program (H2035)Clinical Coverage Policy 8A2017 State-Funded Enhanced MH/SA Services
SA Halfway House (H2034)State-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 8A
SA Medically Monitored Intensive Inpatient Detox (H2036)Clinical Coverage Policy 8A
Substance Abuse Non-Medical Community Residential Treatment (H0012 HB)Clinical Coverage Policy 8A
Supervised Living (Low-YP710, Moderate-YP720)State-Funded Enhanced MH/DD/SA Service Definitions
Supported Employment (H2023 U4 HE, H2026 U4 HE)B3 Service Definition
Supported Employment (State Funded YP630)State Funded IPS-SE for AMH/SAS
TF-CBT (90791 22 Z1, 90837 22 Z1)Clinical Coverage Policy 8CScope of Work
Transition Management Services (YM130)State 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
This page was last reviewed for accuracy on 10/13/2021