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Medicaid B - Child and Adolescent Day Treatment

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Medicaid B

Diagnosis Group(s)

Mental Health, Substance Use, Developmental Disability

Age Group(s)

Child, 18-20


Submission Requirements


  • Service Authorization Request (SAR)
  • Person Centered Plan (PCP) with Service Order
  • Comprehensive Clinical Assessment (CCA)


  • Service Authorization Request (SAR)
  • Updated Person Centered Plan (PCP)

Service Definition Authorization Parameters

  • 60 day authorization periods up to 129 units per month

COVID Prior Approval Flexibility:

  • Waive Prior Approval for Concurrent Requests

Calocus Level

1 2 3 4 5 6
Green check

ASAM Level of Care


Service Codes & Descriptions

  • H2012 HA U5 Co-occurring DayTx for up to 8 youth
  • H2012 HA- Day Tx Behavioral Health Child
  • H2012HA22 - Child and Adolescent Day Treatment Provided During Disaster or Emergency
  • H2012 HA CR- Day Tx Behavioral Health Child
  • H2012 HA-GT CR Day Tx Behavioral Health Child

Full Service Definition

<a target="_blank" href="">Download PDF</a>

Alliance Statement of Work