CurrentBlue Cross Blue Shield - North DakotaPolicy N/A

1915(i) Code Rate Limits for Community-Based Services

This document lists billing codes, rate types, service limits, telehealth limits, provider/specialty codes, age ranges, and authorization notes for 1915(i) community support services and related habilitation/support services for eligible participants.

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

Policy1915(i) Code Rate Limits for Community-Based Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain service authorization when submitted units exceed amounts suggested in the 1915(i) state amendment to avoid additional review or audit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~14distinct service types listed

8 hrs/dayfrequently used daily service limit

75%/motelehealth allowance after initial/quarterly face-to-face

Per 15 mincommon rate type

Service Coverage Criteria and Limits

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General services (example: Care Coordination)

General billing and coverage rules applicable across the listed 1915(i) services

Care Coordination is covered when provided to eligible participants and coordinates participant care, develops a person-centered Plan of Care, and assists individuals with gaining access to needed 1915(i) and other services; Age = 0+.

Service limits for Care Coordination: 8 hours per day.

Remote support/telehealth allowance for Care Coordination: up to 75% per month (use POS 02 or 10; audio-only requires modifier 93).

Provider and billing notes: NPI required for all services; Provider Type = 049; Specialty Code = 641.

Service authorization: submissions with units greater than what is suggested in the 1915(i) state amendment may be subject to additional review or audit.

Behavioral health support services

Peer support and benefits planning coverage

Peer Support is provided by trained and certified individuals with lived experience to promote recovery; Age = 18+.

Peer Support billing and limits: code H0038; rate type per 15 minutes; service limit 8 hours per day.

Peer Support telehealth allowance: up to 75% per month following initial and quarterly face-to-face visits (use POS 02 or 10; audio-only requires modifier 93).

Provider and specialty: Provider Type = 049; Specialty Code = 646.

Service authorization: submissions with units greater than what is suggested in the 1915(i) state amendment may be subject to additional review or audit.

Benefits Planning assists individuals considering employment with informed decisions about public benefits and work incentives; Age = 0+.

Benefits Planning billing: code H2021; rate type per 15 minutes; service limit 8 hours per day.

Benefits Planning provider and specialty: Provider Type = 049; Specialty Code = 648.

Employment/education/housing supports

Employment, education, and housing supports

Prevocational Training: assists participants with developing general strengths and skills that contribute to paid employment; Age = six months prior to 18th birthday.

Prevocational Training billing and limits: code H2023; rate type per 15 minutes (group setting allowed); service limit 8 hours per day; telehealth up to 75% per month.

Supported Education: assists participants to start or return to school or formal training; Age = 5+.

Supported Education billing and limits: code H2025; rate type per 15 minutes; service limit 8 hours per day; telehealth up to 75% per month.

Supported Employment: assists participants with obtaining and keeping competitive employment; Age = 14+.

Supported Employment billing and limits: code H2025; rate type per 15 minutes; initial period prior to finding employment and during the first 6 months: 8 hours per day; after maintaining employment for 6 months: no more than 20% of hours worked by the individual.

Supported Employment telehealth and provider info: telehealth up to 75% per month (use POS 02 or 10; audio-only requires modifier 93); Provider Type = 049; Specialty Code = 642.

Housing Support Services: assists participants with accessing and maintaining stable housing; Age = six months prior to 18th birthday.

Housing Support billing and limits: code H2021; rate type per 15 minutes; service limit 8 hours per day; telehealth up to 75% per month; Provider Type = 049; Specialty Code = 650; individual taxonomies 251S00000X, 171M00000X.

Service authorization for employment/education/housing supports: claims submitted with units greater than suggested in the 1915(i) state amendment may be subject to additional review or audit (Housing Support noted as No for auth but such claims may be audited).

Transition and caregiver services

Community transition and caregiver supports

Community Transition Services provide nonrecurring basic household set-up expenses for individuals transitioning from certain institutions to a private residence; Age = 0+.

Community Transition billing and limits: code T5999; rate type per service; service limit = 90 consecutive day pre-discharge/pre-eligibility and 90 consecutive day post-discharge/post-eligibility per participant lifetime; telehealth 0%.

Community Transition provider and auth: Provider Type = 049; Specialty Code = 649; submissions with units greater than suggested in the 1915(i) state amendment may be subject to additional review or audit.

Training and Supports for Unpaid Caregivers: services directed to individuals providing unpaid support to a 1915(i) recipient to preserve, educate, and support the family and support system.

Caregiver supports billing and limits: codes H0039 and T2025; rate type per 15 minutes (group allowed); service limit 8 hours per day; telehealth up to 75% per month.

Caregiver provider and auth: Provider Type = 049; Specialty Code = 645; submissions with units greater than suggested in the 1915(i) state amendment may be subject to additional review or audit.

Transportation

Non-Medical Transportation (Private Vehicle) assists participants with nonmedical transportation needs to gain access to services, activities, and resources; Age = 0+.

Transportation billing and limits: code T2001; rate type per 15 minutes; service limits = none; telehealth 0%.

Provider and specialty: Provider Type = 049; Specialty Code = 387.

Service authorization: submissions with units greater than what is suggested in the 1915(i) state amendment may be subject to additional review or audit.

Billing Codes, Rate Types, and Service Limits

TransportationHCPCSCovered

T2001

Non-Medical Transportation (Private Vehicle)

Peer Support CodesHCPCSCovered

H0038

Peer Support (per 15 minutes)

Benefits Planning / Housing SupportHCPCSCovered

H2021

Benefits Planning / Housing Support Services

Employment & Education supportsHCPCSCovered

H2023	Prevocational Training (per 15 minutes)
H2025	Supported Education / Supported Employment (per 15 minutes)

Caregiver supportsHCPCSCovered

H0039	Training and Supports for Unpaid Caregivers (per 15 minutes)
T2025	Training and Supports for Unpaid Caregivers (alternate code)

Community transitionHCPCSCovered

T5999

Community Transition Services (nonrecurring household set-up)

Community Transition Services lifetime limit

Lifetime limit90 consecutive day pre-discharge and 90 consecutive day post-discharge per participant lifetime

Service descriptionNonrecurring basic household set-up expenses for individuals transitioning from certain institutions to a private residence

Remote support/telehealth0%

Provider type / specialtyProvider Type = 049; Specialty Code = 649

Authorization noteSubmitted with units greater than what is suggested in the 1915(i) state amendment may be subject to additional review or audit

Supported Employment initial period

Initial period service limitPrior to finding employment and during initial 6 months: 8 hours per day

Post-initial limitAfter maintaining employment for 6 months: no more than 20% of hours worked by the individual

Remote support/telehealth75% per month (Use POS 02 or 10; audio-only requires Modifier 93)

Provider type / specialtyProvider Type = 049; Specialty Code = 642

Authorization noteSubmitted with units greater than what is suggested in the 1915(i) state amendment may be subject to additional review or audit

Authorization, Claims, and Audit Notes

Prior Authorization

Service authorization / audit note

Service authorization required = submitted with units greater than what is suggested in the 1915(i) state amendment may be subject to additional review or audit.

Claims with units exceeding suggested 1915(i) state amendment limits may trigger additional review or audit

Note

Housing Support authorization exception

Housing Support Services — Service auth required: No. However, claims submitted with units greater than what is suggested in the 1915(i) state amendment may be subject to additional review or audit. Service limits: 8 hours per day. Remote support/telehealth limits: 75% per month (use Place of Service Code 02 or 10); audio-only requires Modifier 93.

Provider Type: 049
Specialty Code: 650
Individual Taxonomy: 251S00000X, 171M00000X
Service Limits: 8 hours per day
Telehealth: 75% per month (Place of Service 02 or 10); audio-only requires Modifier 93
Service Authorization: Not required, but excess units may be audited

Service Definitions and Descriptions

Care Coordination

DefinitionCoordinates participant care, develops a person-centered Plan of Care, and assists individuals with gaining access to needed 1915(i) and other services

Service limit8 hours per day

Remote support/telehealth75% per month (Use Place of Service Code 02 or 10; audio-only requires Modifier 93)

Provider type / specialtyProvider Type = 049; Specialty Code = 641

Peer Support

DefinitionTrained and certified individuals with lived experience who promote hope, self-determination, and recovery skills for participants

Billing code / rate typeH0038 — per 15 minutes

Service limit8 hours per day

Remote support/telehealth75% per month following initial and quarterly face-to-face visits; Use POS 02 or 10; audio-only requires Modifier 93

Provider type / specialtyProvider Type = 049; Specialty Code = 646

Prevocational Training

DefinitionAssists participants in developing general, non-job-task-specific strengths and skills that contribute to paid employment

Billing code / rate typeH2023 — per 15 minutes (group setting allowed)

Service limit8 hours per day

Remote support/telehealth75% per month (Use Place of Service Code 02 or 10; audio-only requires Modifier 93)

Provider type / specialtyProvider Type = 049; Specialty Code = 643

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

Policy1915(i) Code Rate Limits for Community-Based Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain service authorization when submitted units exceed amounts suggested in the 1915(i) state amendment to avoid additional review or audit.

SourceLink

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