CurrentAnthemPolicy N/A

Virginia Medicaid Peer Support Services UM Guideline

Utilization Management guideline for Peer Support Services and Family Support Partners under Anthem HealthKeepers Plus (Virginia Medicaid), defining eligibility, service delivery, supervision, documentation, continued stay, non-medical necessity conditions, coding, and billing/authorization requirements.

Policy Summary

PayerAnthem HealthKeepers Plus (Virginia Medicaid)

PolicyVirginia Medicaid Peer Support Services UM Guideline

Policy CodePolicy N/A

Change TypeNo material change on 01/20/2021; original creation 08/24/2017

Effective DateAug 24, 2017

Next Review Date

Key ActionSubmit service authorization/registration prior to service delivery and maintain required documentation (recommendation, plan, quarterly reviews, progress notes, supervision logs) to support reimbursement.

SourceLink

POLICY UPDATE CHANGES

Policy created from Virginia Peer Support training materials effective 08/24/2017.

Reviewed on 01/20/2021 with no changes.

2Targeted age groups (adults, youth)

4Required plan components

16Max units per day

3600Max units per year

This guideline applies to Anthem HealthKeepers Plus (Virginia Medicaid) and defines coverage for Peer Support Services and Family Support Partners. It covers adults aged 21 years and older for Peer Support Services (with allowance for 18–20 year olds to receive adult peer services if they choose and meet medical necessity) and caretakers/families of youth under 21 for Family Support Partners. Coverage stance: Covered with criteria — services are covered when eligibility, service delivery, supervision, plan, and documentation requirements in the guideline are met, and billing/authorization rules (including specified codes and unit definitions) are followed.

Key Thresholds

Service frequencyAt least twice monthly with at least one face-to-face contact

Plan development timeframeRecovery, Resiliency, and Wellness Plan developed within 30 calendar days of initiation of services

Plan review frequencyReviewed every 90 calendar days; review documented by PRS in medical record no later than 15 calendar days from date of review

Daily unit limit4 hours / 16 units per calendar day

Annual unit limitUp to 900 hours / 3600 units per calendar year

Medical Necessity & Eligibility Criteria

Eligibility for Peer Support Services (Adults 21+)

Covered when ALL of the following are met:

ALL of the following

Individual is 21 years or older (allowance for 18-20 year olds to receive adult peer services if they choose and meet medical necessity).
Has documented mental health disorder, substance use disorder, or co-occurring mental health and substance use disorder.
Requires recovery-oriented assistance and support for acquisition of recovery skills; development of self-advocacy skills; and increasing responsibilities/wellness potential/shared accountability.
Demonstrates moderate to severe functional impairment that interferes with or limits performance in at least one domain (educational, social, vocational, self-maintenance).
Services are provided through a Recovery, Resiliency, and Wellness Plan.

Authorization, Documentation & Billing Rules

Prior Authorization

Service authorization required prior to service delivery

Service authorization or registration must be submitted by the enrolled/credentialed provider prior to service delivery in order for reimbursement to occur; provider information supplied to DMAS or its contractor must be fully substantiated in the individual's record.

Service authorization/registration must be submitted prior to service delivery for reimbursement.
Provider information supplied to DMAS/contractor must be fully substantiated in the individual's record.

Documentation Required

Maintain required documentation

Maintain the following required documentation in the individual's record; documentation must be written, signed, and dated at the time of service or within one business day:

Recommendation for services
Recovery, Resiliency, and Wellness Plan
Quarterly review of the Recovery, Resiliency, and Wellness Plan (documented by PRS within 15 calendar days of review)
Progress notes
Supervision logs
Collaboration documentation (plans and releases as applicable)

Billing Rule

Unit definition and billing frequency

Unit = 1 unit per 15 minutes. Per-day limit = 4 hours (16 units) per calendar day. Per-year limit = up to 900 hours (3600 units) per calendar year. Codes affected include T1012, S9445, H0024, and H0025. Peer Support Services are billed separately from per diem or DRG in ARTS and Mental Health settings.

Unit definition: 1 unit = 15 minutes
Per-day limit: 4 hours = 16 units per calendar day
Per-year limit: up to 900 hours = 3600 units per calendar year
Affected codes: T1012, S9445, H0024, H0025
Peer services billed separately from per diem/DRG for ARTS and Mental Health settings

Denial Risk

Risk of non-payment for insufficient contacts

Claims may be denied or deemed not medically necessary if contacts are not made a minimum of twice each month with at least one contact face-to-face. In the absence of the required face-to-face contact, denial risk exists unless at least two unsuccessful attempts to make a face-to-face contact are tried and documented; discharge is required after two consecutive months of unsuccessful attempts.

Service must be rendered at least twice monthly with at least one face-to-face contact
If face-to-face contact not completed, at least two unsuccessful attempts must be documented to avoid denial
Discharge required after two consecutive months of unsuccessful face-to-face contact attempts

Documentation Required

Supervision documentation

Documentation of all supervision sessions must be maintained in a supervisor's log or in the PRS' personnel file; maintain supervisor log or equivalent PRS personnel file documentation for all supervision as required by supervision and PRS qualifications.

Maintain a supervisor's log or PRS personnel file documentation for every supervision session
Supervision must be provided under the oversight/clinical direction of the recommending practitioner who is enrolled/credentialed with Medicaid or within an enrolled provider agency
Direct supervisors must meet the specified ARTS or Mental Health supervisor qualifications and have completed DBHDS PRS supervisor training

Background & Definitions

Peer Support Services are a recovery-focused component of treatment for addiction and mental health conditions that facilitate recovery from serious mental illness and substance use disorders. The guideline is derived from Virginia DBHDS training materials and the Peer Services Supplement Manual and aligns Peer Recovery Specialist (PRS) qualifications, supervision, and service delivery with ARTS and mental health licensing contexts. PRS provide peer-based, lived-experience support within multidisciplinary teams and collaborate with licensed providers and DBHDS-licensed settings to promote community integration, self-advocacy, and sustained recovery.

Term	Definition
ASAM	Clinical guidelines developed by the American Society of Addiction Medicine to improve assessment and outcomes-driven treatment and recovery services.
Caregiver	Family members, friends, or neighbors who provide unpaid assistance to a Medicaid member; does not include paid caregivers.
Peer Recovery Specialist (PRS)	Person who meets DBHDS qualifications and certification, with lived experience, trained to provide peer support; may be employee or contractor of licensed providers or facilities.
Recovery	A process in which people are able to live, work, learn and fully participate in their communities.
Resiliency
Recovery, Resiliency, and Wellness Plan	Written set of goals, strategies, and actions developed by the individual/caregiver, PRS, and direct supervisor within 30 days to guide peer support services.

OpenPayer

Virginia Medicaid Peer Support Services UM Guideline

Coverage Summary & Scope

Medical Necessity & Eligibility Criteria

Billing Codes and Groups

Authorization, Documentation & Billing Rules

Background & Definitions

Revision History

T1012	ARTS Individual, 2
	ARTS Individual, 1 = 1 unit = 15 minutes (no specific CPT/HCPCS code listed)

S9445	ARTS Group, 2
	ARTS Group, 1 = 1 unit = 15 minutes (no specific CPT/HCPCS code listed)

H0024	Mental Health Individual, 2
	Mental Health Individual, 1 = 1 unit = 15 minutes (no specific CPT/HCPCS code listed)

H0025	Mental Health Group, 2
	Mental Health Group, 1 = 1 unit = 15 minutes (no specific CPT/HCPCS code listed)