Initial Units Authorized - Mental Health As of 6/1/16 SERVICE TYPE CPT CODE/UNIT INFORMATION CENPATICO Fax 1-866-694-3649 Phone 1-866-896-7293 AMERIGROUP Fax 1-800-505-1193 Phone 1-800-454-3730 ANNUAL LIMITS. RESET EACH CALENDAR YEAR. NEED OTR IF EXCEED UNITS LISTED. UNITED Fax 1-855-268-9392 Phone 1-855-802-7095 Psychiatric Diagnostic Interview – No Medical Services CPT Code – 90791 Unit = Visit Maximum 1 unit per day 1 session within 6 rolling months 5 sessions 5 sessions Psychiatric Diagnostic Interview – With Medical Services CPT Code – 90792 Unit = Visit Maximum 1 unit per day 1 session within 6 rolling months Included in Psychiatric Diagnostic Interview – No Medical Services 5 sessions Admission Evaluation Not applicable Refer to Psychiatric Diagnostic Interview Refer to Psychiatric Diagnostic Interview Refer to Psychiatric Diagnostic Interview Outpatient Individual Psychotherapy CPT Codes – 90832, 90834, & 90837 Unit = Visit Maximum 1 unit of 90832, 90833, 90834, 90836, 90837, or 90838 per day Unlimited benefit Unlimited benefit Unlimited benefit Outpatient Individual Psychotherapy with Medical Management (Add on Services) CPT Codes – 90833, 90836, & 90838 Unit = Visit Maximum 1 unit of 90832, 90833, 90834, 90836, 90837, or 90838 per day Unlimited benefit Unlimited benefit Unlimited benefit Family Psychotherapy CPT Code – 90847 Unit = Visit Maximum 1 unit per day Unlimited benefit Unlimited benefit Unlimited benefit Family Psychotherapy in the Home CPT Code – 90847 HK Unit = equal to or less than 90 minutes Maximum 1 unit per day Unlimited benefit Unlimited benefit Unlimited benefit Group Psychotherapy CPT Code – 90853 Unit = Visit Maximum 1 unit per day Unlimited benefit Unlimited benefit Unlimited benefit
Initial Units Authorized - Substance Use Disorders SERVICE TYPE CENPATICO AMERIGROUP UNITED● Assessment/Referral Maximum 1 unit per day 1 within 6 rolling months Not listed Listed under Auxiliary Services (State Plan) though limit not identified Individual Counseling Maximum 9 hours per rolling 7 days 240 units over 6 months COMBINED WITH GROUP COUNSELING 60 hours over 6 months INCLUDES ALL LEVEL 1 60 hours over 6 months INCLUDES ALL LEVEL 1 Group Counseling Maximum 9 hours per rolling 7 days 240 units over 6 months COMBINED WITH INDIVIDUAL COUNSELING 60 hours over 6 months INCLUDES ALL LEVEL 1 60 hours over 6 months INCLUDES ALL LEVEL 1 Case Management Authorization required Number of units initially authorized not specified “Unlimited benefit” noted Unlimited benefit Unlimited benefit Crisis Intervention 288 units (72 hours) per episode Awaiting definition of an episode. Unlimited benefit 60 hours over 6 months Intensive Outpatient Program (IOP) Maximum 1 unit per day 45 days over 15 weeks 45 days over 15 weeks 45 days over 15 weeks Intermediate (Short Term Residential) Maximum 1 unit per day 14 days 14 days 14 days Reintegration (Long Term Residential) Maximum 1 unit per day 30 days 30 days 30 days Peer Support 1000 units (250 hours) Unlimited benefit 1000 units (250 hours) Social Detox Not covered Not covered Not covered Residential Acute Detox Acute detoxification 5 days Level 3.7D – To Be Determined Level 3.7D – Pending State Guidelines ●Prior authorization must be obtained for services other than Level 1, Level 2, Level 3.1, Level 3.3/5 & Level 3.7D.