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Medicaid B - Clinical/Diagnostic Assessment and Comprehensive Evaluation of Sexual Harm (CESH)

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About

Coverage

Medicaid B

Diagnosis Group(s)

Mental Health, Substance Use, Developmental Disability, Assessment Only

Age Group(s)

All, Adult, Child, 18, 18-20

Authorization

Submission Requirements

Clinical Assessment (90791, 90792)

  • Child and Adult
  • Clinical Coverage Policy 8C
  • No prior approval up to maximum of 2 per fiscal year
  • Service Authorization Request (SAR) required beyond maximum of 2 per fiscal year

Diagnostic Assessment (T1023)

  • Child and Adult
  • Clinical Coverage Policy 8A-5
  • No Prior Approval up to maximum of 1 per fiscal year
  • Service Authorization Request (SAR) required beyond maximum of 1 per fiscal year

Comprehensive Evaluation of Sexual Harm-CESH (90899)

  • Child Only (up to age 21)
  • Service Authorization Request (SAR)

Trauma Focused Assessment (90791 22 Z1)

  • Child Only (up to age 21)
  • Clinical Coverage Policy 8C
  • Unmanaged benefit limited to scope in provider network contract
  • Maximum of 1 Assessment per fiscal year

Trauma Informed Comprehensive Clinical Assessment – TICCA (90791 22 Z2)

  • Child Only (up to age 21)
  • Clinical Coverage Policy 8C
  • Service Authorization Request (SAR)
  • Assessment identifying justification

Service Definition Authorization Parameters

Clinical Assessment (90791, 90792)

  • Maximum of 2 per fiscal year

Diagnostic Assessment (T1023)
Comprehensive Evaluation of Sexual Harm-CESH (90899)
Trauma Focused Assessment (90791 22 Z1)
Trauma Informed Comprehensive Clinical Assessment – TICCA (90791 22 Z2)

  • Maximum of 1 per fiscal year

Authorization Guidelines

Locus Level

1 2 3 4 5 6
Green check Green check Green check Green check Green check

Calocus Level

1 2 3 4 5 6
Green check Green check Green check Green check Green check

Service Codes & Descriptions

  • 90791 22 Z1 GT CR- Trauma Focused Assessment
  • 90791 U3 SE - SOSE Assessments
  • 90791 - SP Psychiatric Diagnostic Evaluation
  • 90791 - SP GT CR Psychiatric Diagnostic Evaluation
  • 90791 - SP GT Psychiatric Diagnostic Evaluation
  • 90791 - SP GT CR Psychiatric Diagnostic Evaluation
  • 90899- Comprehensive Evaluation for Sexual Harm (CESH)
  • 90899 GT CR- Comprehensive Evaluation for Sexual Harm (CESH)
  • 90791 - Psychiatric Diagnostic Evaluation (No Medical Services)
  • 90791 ES - Access
  • 90791 22 Z1 - Trauma Focused Assessment
  • 90791 22 Z1 CR - Trauma Focused Assessment
  • 90791 22 Z1 GT - Trauma Focused Assessment
  • 90791 22 Z2- Psychiatric Diagnostic Evaluation; Specialty Child Service
  • 90791 CA -Facility Based assessment
  • 90791 IN - LOC Assessment
  • T1023 - Diagnostic Assessment
  • 90791 CR - Psychiatric Diagnostic Evaluation (No Medical Services)
  • 90791 GT- Psychiatric Diagnostic Evaluation (No Medical Services)
  • 90791 GT CR- Psychiatric Diagnostic Evaluation (No Medical Services)
  • 90792 - Psychiatric Diagnostic Evaluation With Medical Services
  • 90792GT - Psychiatric Diagnostic Evaluation With Medical Services
  • 90792 GT CR- Psychiatric Diagnostic Evaluation With Medical Services
  • 90791 22 IN - LOC Assessment
  • 90791TICR- Comprehensive Truma
  • 90791TIGTCRComprehensive TRAUMA
  • H0031 - Mental Health Assessment
  • T1023GT-Diagnostic Assessment
  • 90791U3SECR - SOSE Assessment
  • H0031 SE-Triangle Assessment
  • H0001 - Alcohol and/Substance Abuse Assessment

Full Service Definition

<a target="_blank" href="https://medicaid.ncdhhs.gov/media/10107/open">Download PDF</a>
<a target="_blank" href="https://medicaid.ncdhhs.gov/media/10115/open">Download PDF</a>

Alliance Statement of Work