CurrentAnthemPolicy N/A

Mental Health Skill-Building Services (MHSS) H0046

Defines eligibility, required documentation, coordination, treatment planning, and provider attestation for Medicaid Mental Health Skill-Building Services (MHSS) H0046 for Anthem HealthKeepers Plus members. Governs initial authorization requests, required clinical criteria, and service provision expectations.

Policy Summary

PayerAnthem

PolicyMental Health Skill-Building Services (MHSS) H0046

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionInclude completed assessment, diagnosis, treatment goals, units/dates/hours requested, and LMHP attestation when requesting authorization for MHSS (H0046).

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Covered HCPCS code

6Primary diagnosis categories listed

Coverage Summary

Defines eligibility, required documentation, coordination, treatment planning, and provider attestation for Medicaid Mental Health Skill-Building Services (MHSS) H0046 for Anthem HealthKeepers Plus members. Covered with criteria: MHSS is covered_with_criteria when all medical necessity and documentation requirements are met (see Eligibility / Medical Necessity, Provider Assessment and Attestation, Treatment Planning and Progress, and Care Coordination and Discharge Planning sections).

Medical Necessity / Eligibility & Clinical Requirements

Eligibility / Medical Necessity

Covered when ALL of the following are met:

ALL of the following

Individual demonstrates clinical necessity arising from a mental, behavioral, or emotional illness that results in significant functional impairments in major life activities.
Individual requires individualized training to achieve or maintain stability and independence in the community.
Primary diagnosis (ONE of)
- Schizophrenia or other psychotic disorder as set out in the DSM
- Major Depressive Disorder - Recurrent
- Bipolar I or Bipolar II
- Any other DSM mental health disorder documented by a physician within the past year that: i) is a serious mental illness; ii) results in severe and recurrent disability; iii) produces functional limitations in major life activities documented in the medical record; and iv) requires individualized training to achieve or maintain independent living in the community.
Individual requires training in basic living skills (e.g., symptom management; adherence to psychiatric and medication treatment plans; development and use of social skills and personal support system; personal hygiene; food preparation; money management).
Prior history requirement (ONE of)
- Prior history of psychiatric hospitalization, residential crisis stabilization, ICT or Program of Assertive Community Treatment (PACT) services, placement in a psychiatric residential treatment facility, or Temporary Detention Order because of decompensation related to serious mental illness.
- If prior history not met, other documentation must justify need (implicit in assessment and attestation).
Psychotropic medication history (ONE of)
- Prescription for antipsychotic, mood stabilizing, or antidepressant medication within 12 months prior to assessment date.
- Signed documentation from a physician or licensed prescribing practitioner that psychotropic medications are contraindicated.
Age-specific independent living requirement (if under 21)
- If under 21 years old: member is in an independent living situation or actively transitioning into an independent living situation (not living with a parent/guardian or in a supervised setting and providing own financial support).
- Not applicable for members 21 and over.

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Provider Assessment and Attestation

Covered when ALL of the following are documented and attested:

ALL of the following

Appropriate assessment or addendum completed by an LMHP, LMHP-R, LMHP-S, or LMHP-RP and psychiatric history reviewed.
LMHP (or equivalent) signature attesting the individual meets the medical necessity criteria for the service and date of completion of assessment/addendum recorded.

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Treatment Planning and Progress

Services must include and document ALL of the following:

ALL of the following

Person-centered, recovery-oriented, trauma-informed treatment goals related to requested treatment, including strengths/barriers and written in the individual's own words or understandable to the individual.
Goal-directed training/interventions enabling individuals to learn skills to achieve or maintain stability in the least restrictive environment.
Demonstration of objective progress toward goals or documentation of modifications when lack of progress is identified.
Documentation of appointments and medication adherence issues and plans to address them, if applicable.
Specific measurable objectives with meaningful tracking values and documentation of current skill level, frequency per week addressing the goal, interventions, and measurement method.

Care Coordination and Discharge Planning

Services require documentation of coordination and transition planning including:

ALL of the following

Indication of other medical/behavioral health concerns that could impact services and plan to coordinate with PCP and other providers.
List of current services/supports to avoid duplication and explanation of necessity of additional MHSS.
Discharge plan identifying step down services/supports, identified providers/supports, plan to assist transition, recommended level of care at discharge, and estimated date of discharge.

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Provider Actions & Administrative Requirements

Prior Authorization

Authorization / Prior Approval Required

Requests for authorization/prior approval must include completed form items (assessment, diagnosis, treatment goals, units requested, start/end dates, hours per week) and an LMHP attestation. The form includes a checkbox to indicate a retro review request for retroactive approvals.

Affected code: H0046
Retro review checkbox present on form

Documentation Required

Required Clinical Documentation and Attestation

Providers must document primary and secondary ICD-10 diagnoses, current functional impairments and skill level, prior psychiatric/crisis history, medication history or signed documentation of contraindication, trauma assessment/plan, measurable person-centered treatment goals with progress tracking, coordination with other services, and LMHP signature and date certifying medical necessity.

Affected code: H0046

Billing Rule

Service Request Details

Authorization requests must specify service from/to dates, total units of service requested, and planned hours of service per week.

Required fields on request: From/To dates
Total units of service
Planned hours of service per week
Affected code: H0046

OpenPayer

Mental Health Skill-Building Services (MHSS) H0046

Coverage Summary

Medical Necessity / Eligibility & Clinical Requirements

Coding

Provider Actions & Administrative Requirements

Background

Revision History