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Protocol for Self-Referred Substance Abuse Services

Protocol for Self-Referred Substance Abuse Services. Effective January 1, 2010. Medical Necessity Criteria. The Substance Abuse Improvement Initiative (SAII) uses the American Society of Addiction Medicine’s (ASAM) Patient Placement Criteria.

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Protocol for Self-Referred Substance Abuse Services

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  1. Protocol for Self-Referred Substance Abuse Services Effective January 1, 2010

  2. Medical Necessity Criteria The Substance Abuse Improvement Initiative (SAII) uses the American Society of Addiction Medicine’s (ASAM) Patient Placement Criteria. ASAM is a widely used and comprehensive national guideline for placement, continued stay and discharge of patients with alcohol and other drug problems.

  3. Covered Services for PAC Five services are covered under the new self-referral protocol: Comprehensive Substance Abuse Assessment; Individual Outpatient Therapy; Group Outpatient Therapy; Intensive Outpatient Therapy; and Methadone Maintenance.

  4. New Reimbursement Rates

  5. Comprehensive Substance Abuse Assessment (CSAA) The CSAA is generally considered part of treatment and is not reimbursed separately. However, MCOs or the BHO which administers the substance abuse services for certain MCOs, will pay for a self-referred Comprehensive Substance Abuse Assessment under the following conditions: Once per enrollee per program per 12-month period, unless there is more than a 30-day break in treatment; Only if the enrollee is not already in SA treatment; and If a patient returns to treatment after 30 days, the MCO/BHO will pay for another CSAA.

  6. Comprehensive Substance Abuse Assessment (CSAA) Additionally, MCOs/BHOs will pay for CSAA separately when: Provider does not offer level of care the enrollee requires and enrollee has to be referred to another provider; Provider conducts CSAA, but enrollee doesn’t return for treatment; and Provider determines enrollee doesn’t need treatment Please note that the HealthChoice rules above also apply to PAC enrollees.

  7. Outpatient ServicesIndividual or Group Therapy (Level 1) • Self-referred individual or group therapy services must be provided in the community (not in hospital rate regulated settings). • Preauthorization is required for such services provided in a hospital rate regulated clinics under HealthChoice. • MCO/BHO will pay for 30 self-referred sessions (any combination of individual, group, and family therapy) within 12-month period per client. • Providers must obtain preauthorization for more than 30 sessions within the 12-month period.

  8. Outpatient ServicesIndividual or Group Therapy(Level 1) • In order to bill for family counseling, the enrollee must be present for an appropriate length of time, but does not need to be present for the entire counseling session. • In some circumstances the counselor might spend part of the session with the family out of the presence of the enrollee. • Family therapy is billed under the individual enrollee’s Medicaid number. • All approval rules for HealthChoice apply for PAC, except that PAC only covers Level 1, individual, family, and group therapy in community-based settings.

  9. Intensive Outpatient Therapy(Level II) • IOP is reimbursed only when care is delivered in a community-based setting. • Preauthorization is required for such services provided in a hospital rate regulated clinics under HealthChoice. • If the treatment plan is approved: • MCO/BHO will pay for services provided within first 30 calendar days of IOP. • At the end of week three (3), for care coordination purposes, the provider must notify the MCO of discharge plan or need for remaining treatment. • Additional days must be approved based on medical necessity.

  10. Intensive Outpatient Therapy(Level II) • If determined that client does not meet ASAM LOC: • MCO/BHO will pay for all services delivered up until the point that they formally notify the provider of the denial. • If the client does not qualify for IOP, the MCO/BHO will work with the provider to determine the appropriate level of care. • All approval rules for HealthChoice apply for PAC, except that PAC providers must bill using the CMS 1500 form and the H0015 for PAC recipients.

  11. Methadone Maintenance • Under the self-referral protocol, HealthChoice covers methadone maintenance services provided in the community or in outpatient departments of hospitals. • However, PAC only covers services provided in a community-based setting. • If methadone treatment is approved: • MCO/BHO will pay for 26 weeks under the self-referral option. • Continued eligibility will be determined by medical necessity. • Additional approvals beyond the first 26 weeks will be at six-month intervals.

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