New York Medicaid BEHAVIORAL HEALTH PRIOR AUTHORIZATION GRID AUTHORIZATION IS NOT A GUARANTEE OF PAYMENT

Transcription

1 NEW YORK MEDICAID HIGHER LEVEL OF CARE - BH PRIOR AUTH GRID OCT 2015 New York Medicaid BEHAVIORAL HEALTH PRIOR AUTHORIZATION GRID AUTHORIZATION IS T A GUARANTEE OF PAYMENT AUTHORIZATION REV CODE LEVEL OF CARE REQUIRED Provider Responsibility 104 ANESTH, ELECTROSHOCK YES PRIOR AUTH REQUIRED 114 ROOM AND BOARD - PRIVATE -PSYCHIATRIC YES 116 ROOM AND BOARD - PRIVATE -DETOXIFICATION YES 124 ROOM AND BOARD - SEMI PRIVATE TWO BED -PSYCHIATRIC YES 126 ROOM AND BOARD - SEMI PRIVATE TWO BED -DETOXIFICATION YES 128 ROOM AND BOARD - SEMI PRIVATE TWO BED -REHABILITATION YES FAX,PHONE, INTERNET TIFICATION FAX,PHONE, INTERNET TIFICATION FAX,PHONE, INTERNET TIFICATION FAX,PHONE, INTERNET TIFICATION FAX,PHONE, INTERNET TIFICATION 136 DETOX/3&4 BED YES FAX,PHONE, INTERNET TIFICATION 156 DETOX/WARD YES FAX,PHONE, INTERNET TIFICATION 240 FAX,PHONE, INTERNET TIFICATION ALL INCL ANCIL YES 510 CLINIC 513 PSYCH CLINIC 521 RURAL/CLINIC 529 OTHER FR/STD CLINIC 900 PSTAY TREATMENT YES PRIOR AUTH REQUIRED 901 ELECTROSHOCK TREATMENT YES PRIOR AUTH REQUIRED 905 BH INTENSIVE OUTPATIENT PSYCH YES PRIOR AUTH REQUIRED 906 BH INTENSIVE OUTPATIENT CHEM DEP YES PRIOR AUTH REQUIRED 910 PSTAY SERVICES YES PRIOR AUTH REQUIRED

2 MEDICAID BEHAVIORAL HEALTH PRIOR AUTHORIZATION GRID Authorization is not a guarantee of payment NEW YORK MEDICAID 10/1/ Interactive complexity add-on code Psychiatric diagnostic evaluation (no medical Services) Psychiatric diagnostic evaluation with medical services MD,NP Psychotherapy, 30 mins min psychotherapy add-on code MD,NP Psychotherapy, 45 mins min psychotherapy add-on code MD,NP Psychotherapy, 60 mins min psychotherapy add-on code MD,NP Psychotherapy for crisis, first 60 min crisis code add on for each additional 30 min Family Psychotherapy, without patient present PHD, Family Psychotherapy, 45 min PHD, Multiple-family group psychotherapy PHD, Group psychotherapy PHD, Pharmacologic management, add on code MD,NP Environmental Manipulation Complex Care Coordination Outpatient Collateral, 15 min Psychological testing PHD YES Prior Authorization Required Psychological testing PHD YES Prior Authorization Required Psychological testing PHD YES Prior Authorization Required Developmental Testing - limited Developmental Testing - Extended YES Prior Authorization Required

3 96116 Psychological Testing - Neurobehavioral NEUROPSYCH TST BY PSYCH/PHYS PHD, YES Prior Authorization Required Psychological Testing - Various YES Prior Authorization Required Injection Only New Patient Office Visit Level 1 MD,NP New Patient Office Visit Level 2 MD,NP New Patient Office Visit Level 3 MD,NP New Patient Office Visit Level 4 MD,NP New Patient Office Visit Level 5 MD,NP Est Patient Office Visit Level 1 MD,NP Est Patient Office Visit Level 2 MD,NP Est Patient Office Visit Level 3 MD,NP Est Patient Office Visit Level 4 MD,NP Est Patient Office Visit Level 5 MD,NP Initial Hospital Care-comprehensive; low complexity MD, NP Initial Hospital Care-comprehensive; moderate complexity MD, NP Initial Hospital Care-comprehensive; high complexity MD, NP Subsequent Hospital Care-focused; low complexity MD, NP Subsequent Hospital Care-focused; moderate complexity MD, NP Subsequent Hospital Care-focused; high complexity MD, NP Observation-comprehensive; low complexity MD, NP Observation-comprehensive; moderate complexity MD, NP Observation-comprehensive; high complexity MD, NP Discharge Day Management- 30 min or less MD, NP Discharge Day Management-more than 30 min MD, NP Initial Consultation-focused, straightforward MD, NP Initial Consultation-expanded, straightforward MD, NP Initial Consultation-detailed, low complexity MD, NP Initial Consultation-comprehensive, moderate complexity MD,NP Initial Consultation-comprehensive, high complexity MD,NP ER Consultation-focused, straightforward MD,NP ER Consultation-expanded; low complexity MD,NP

4 ER Consultation-expanded; moderate complexity MD,NP ER Consultation-detailed; moderate complexity MD,NP ER Consultation-comprehensive; high complexity MD,NP Home visit, new patient YES PRIOR AUTHORIZATION REQUIRED Home visit, new patient YES PRIOR AUTHORIZATION REQUIRED Home visit, new patient YES PRIOR AUTHORIZATION REQUIRED Home visit, new patient YES PRIOR AUTHORIZATION REQUIRED Home visit, new patient YES PRIOR AUTHORIZATION REQUIRED Home visit, est patient YES PRIOR AUTHORIZATION REQUIRED Home visit, est patient YES PRIOR AUTHORIZATION REQUIRED Home visit, est patient YES PRIOR AUTHORIZATION REQUIRED Home visit, est patient YES PRIOR AUTHORIZATION REQUIRED Home visit, single, family counseling YES PRIOR AUTHORIZATION REQUIRED Physical Exam New Patient MD,NP Physical Exam New Patient MD,NP Physical Exam New Patient MD,NP Physical Exam New Patient MD,NP Physical Exam New Patient MD,NP Physical Exam New Patient MD,NP Physical Exam Existing Patient MD,NP Physical Exam Existing Patient MD,NP Physical Exam Existing Patient MD,NP Physical Exam Existing Patient MD,NP Physical Exam Existing Patient MD,NP Physical Exam Existing Patient MD,NP Health Monitoring Health Monitoring Health Monitoring Health Monitoring Behavior change Smoking prevention intervention counseling Smoking Cessation Treatment Behavior change Smoking prevention noncounseling Smoking Cessation Treatment Health Monitoring Health Monitoring Alcohol/Substance assessment and brief G0396 intervention YES Prior Authorization Required G0397 Alcohol/Substance assessment and brief intervention YES Prior Authorization Required H0001 Alcohol / drug assessment H0002 Behavioral health screening to determine admission eligibility H0002 PROS-Pre Admission H0004 Alcohol &/or Drug Svcs, Brief Treatment 15 min service H0005 Alcohol/Substance ; group counseling by a clinician H0010 Part 820 Residential--Stabilization YES Prior Authorization Required H0014 Alcohol &/or Drug Svcs, Ambulatory Detox

5 H0018 Part 820 Residential--Rehabilitation YES Prior Authorization Required H0019 Part 820 Residential--Re-Integration YES Prior Authorization Required H0020 Alcohol / drug services methadone admin H0033 Oral Medication, direct observation H0035 Partial Hospitalization YES Prior Authorization Required H0037 Interim Crisis Visit H0038 Self-Help/Peer Services-per 15 minutes H0040 Assertive Community Treatment YES Prior Authorization Required H0049 Alcohol &/or Drug Screening H0050 Alcohol &/or Drug Svcs, Brief Intervention 15 min service H2001 Rehab program per ½ day H2010 Injectable Med Admin with Monitor and Education H2011 Crisis Intervention - 15 Min H2012 Continuing Day Treatment YES Prior Authorization Required H2012 Intensive Psychiatric Rehabilitation Treatment YES Prior Authorization Required H2018 PROS-Initial Rehabilitation YES Prior Authorization Required H2019 PROS-Community Rehabilitation Services YES Prior Authorization Required H2025 PROS-Ongoing Rehabilitation YES Prior Authorization Required H2034 Alcohol and/or drug halfway house services, per diem YES Prior Authorization Required H2036 Alcohol / drug program per diem S9480 Intensive Outpatient Program S9484 Partial Hospitalization Crisis S9485 Comprehensive Psychiatric Emergency Program (CPEP) T1006 Alcohol/Substance services family / couple counseling T1015 PROS-Clinical Treatment Add-On YES Prior Authorization Required T1023 Determine appropriateness of individual for participation in a program