CurrentCareSource GeorgiaPolicy N/A

Intensive Outpatient Program (IOP) - Behavioral Health reimbursement

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Defines CareSource Georgia's reimbursement, billing, prior authorization, and coverage stance for Intensive Outpatient Program (IOP) behavioral health services for Marketplace products; applies to providers and claims processing for covered members.

Policy Summary

PayerCareSource Georgia

PolicyIntensive Outpatient Program (IOP) - Behavioral Health reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2024

Last ReviewSep 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization after 5 calendar days of IOP services; CareSource uses MCG and ASAM criteria for medical necessity reviews.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 daysPrior auth grace period

>=9/wkASAM IOP hours (adults)

Cond. code 92Claim identifier

APC/componentBilling requirement

GA, IN, KY, OH, WVMarketplaces

Coverage Criteria

COVERAGE CRITERIA

Coverage applies when services are medically necessary, are delivered under an individualized physician-established and periodically reviewed plan of treatment, and meet intensity/duration and billing requirements per federal guidance (MCG/ASAM referenced).

Services must be medically necessary and part of an individualized, physician-established and periodically reviewed treatment plan specifying diagnosis, type, amount, frequency, and duration; treatment goals must be measurable, functional, time-framed, directly related to the reason for admission, and medically necessary.

IOP must provide active treatment under physician supervision and include multidisciplinary coordination of services (team approach) appropriate to the member's needs.

Intensity/visit minimums: Per federal guidance and ASAM for SUD IOP, services are generally provided for a minimum of 9 hours per week for adults (ASAM: 9+ hours/week adults; 6+ hours/week for adolescents in SUD treatment).

Covered IOP services may include individual and group therapy, occupational therapy requiring a qualified OT, social work, psychiatric nursing, drugs/biologicals not self-administered, individualized activity therapies (not primarily recreational), family counseling focused on treatment, patient training/education, diagnostic services, and other reasonable and necessary items and services (excluding meals and transportation).

Services that are NOT medically necessary and therefore not covered include: day care programs that are primarily social/recreational or custodial/respite; programs maintaining psychiatric wellness without relapse risk; services for psychiatrically stable members requiring medication management only; inpatient hospital services (meals, self-administration of meds, transportation, vocational training); members unable or refusing to participate or unable to tolerate IOP intensity; and treatment of chronic stable conditions without an acute exacerbation that places the member at risk of relapse or hospitalization.

Billing and claim identification requirements: Providers must report service units, dates of service, patient/discharge status, and revenue codes/charges for each covered service; IOP services must be identified on claims using condition code 92; appropriate type-of-bill (TOB) for institutional outpatient billing (eg, 13X, 85X, 76X) and APC/component billing rules apply when applicable.

Prior authorization / review: Prior authorization is required beginning after 5 calendar days of IOP services in a benefit period; CareSource uses MCG criteria for mental health and ASAM criteria for SUD for medical necessity reviews. (State note) In West Virginia, the first 5 days are provided without retrospective review; benefits beginning day 6 and every 6 days thereafter are subject to concurrent review.

Intensive Outpatient (IOP) Level of Care Criteria

Treatment Modalities and Components

IOP components

IOP may include the following active treatment modalities when reasonable and necessary for the member's individualized plan:

Individual and group therapy with physicians, psychologists, or other authorized mental health professionals; family counseling for treatment of the individual’s diagnosis; patient training and education closely related to care; and individualized activity therapies that are not primarily recreational or diversionary.

Occupational therapy delivered by a qualified occupational therapist, services of social workers, trained psychiatric nurses, and other staff trained to work with members with psychiatric diagnoses.

Drugs and biologicals furnished for therapeutic purposes that cannot be self‑administered, and diagnostic services when reasonable and necessary for diagnosis or active treatment.

Coordination with in‑house treatment and peer services, referral or collaboration with community providers for services such as medication‑assisted treatment, psychological assessments, vocational rehabilitation, and trauma‑specific treatment; note that meals and transportation are not billable items under IOP.

Visit Limits and Minimum Hours

IOP minimum hours per week

Minimum weekly hours (adults)9 or more hours per week (ASAM/federal guidance)

Minimum weekly hours (adolescents)6 or more hours per week for adolescents (ASAM IOP LOC 2.1)

Treatment plan frequencyIndividualized written plan established and periodically reviewed by a physician (at least every other month) specifying type, amount, frequency, and duration

Claim Identifiers, Billing & APC Rules

Claim identifiers and institutional billingmixedCovered

Condition code 92	Identifies IOP services on claims
TOB 13X, 85X, 76X	Type of bills for outpatient hospital, CAH, CMHC institutional billing

IOP service day components and billing

APC component days - 3 servicesDays with 3 services a day are reported as one APC component grouping; bill under IOP ambulatory payment classifications

APC component days - 4+ servicesDays with 4 or more services a day are reported under a separate APC component grouping

Revenue codes & chargesHospitals must report a revenue code and the charge for each individual covered service furnished under an IOP, including required HCPCS/CPT codes

Type of Bill (TOB) for institutional billingTOB 13X (outpatient hospital), TOB 85X (CAH), TOB 76X (CMHC) — use appropriate TOB for claim submission

Prior Authorization & Provider Requirements

Prior Authorization

Prior authorization required after 5 days; MCG/ASAM criteria used

Prior authorization (concurrent review/predetermination) is required once a member exceeds 5 days of IOP services in a calendar year; CareSource uses MCG criteria for mental health reviews and ASAM criteria for substance use disorder reviews. In West Virginia, the first 5 days are provided without retrospective review; benefits beginning on day 6 and every 6 days thereafter are subject to concurrent review.

Definitions

Intensive Outpatient Program (IOP) definition

DefinitionIntensive Outpatient Program (IOP) — active behavioral health treatment provided under physician supervision pursuant to an individualized written treatment plan; typically at least 3 hours/day, 2–3 days/week; step-up/step-down level of care

SettingsMay be provided in HOPD, CAH outpatient departments, CMHCs, RHCs, FQHCs, and OTPs for OUD treatment

Treatment componentsIncludes individual and group therapy, multidisciplinary coordination, patient education, diagnostic services; excludes meals and transportation as billable items

ASAM IOP Level of Care (LOC 2.1)

ASAM IOP LOC hours (adults)9 or more hours of SUD treatment services per week (ASAM Intensive Outpatient LOC 2.1)

ASAM IOP LOC hours (adolescents)6 or more hours of SUD treatment services per week for adolescents

PurposeTo treat multidimensional instability and complex needs of members with addiction and co-occurring conditions

Review types

Concurrent ReviewA request for prior authorization or a predetermination that is submitted before or during the course of receiving a health care service

Retrospective ReviewA request for medical review that is submitted after the health care service has been received

Prior authorization timing notePrior authorization is required after 5 days per calendar year; CareSource follows MCG for mental health and ASAM for SUD reviews

Policy Summary

PayerCareSource Georgia

PolicyIntensive Outpatient Program (IOP) - Behavioral Health reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2024

Last ReviewSep 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization after 5 calendar days of IOP services; CareSource uses MCG and ASAM criteria for medical necessity reviews.

SourceLink

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Intensive Outpatient Program (IOP) - Behavioral Health reimbursement

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Sign up for all CareSource Georgia policy alerts

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Coverage Criteria

COVERAGE CRITERIA

IOP must provide active treatment under physician supervision and include multidisciplinary coordination of services (team approach) appropriate to the member's needs.

Treatment Modalities and Components

IOP components

IOP may include the following active treatment modalities when reasonable and necessary for the member's individualized plan:

Occupational therapy delivered by a qualified occupational therapist, services of social workers, trained psychiatric nurses, and other staff trained to work with members with psychiatric diagnoses.

Drugs and biologicals furnished for therapeutic purposes that cannot be self‑administered, and diagnostic services when reasonable and necessary for diagnosis or active treatment.

Visit Limits and Minimum Hours

IOP minimum hours per week

Minimum weekly hours (adults)9 or more hours per week (ASAM/federal guidance)

Minimum weekly hours (adolescents)6 or more hours per week for adolescents (ASAM IOP LOC 2.1)

Treatment plan frequencyIndividualized written plan established and periodically reviewed by a physician (at least every other month) specifying type, amount, frequency, and duration

Claim Identifiers, Billing & APC Rules

Claim identifiers and institutional billingmixedCovered

Condition code 92	Identifies IOP services on claims
TOB 13X, 85X, 76X	Type of bills for outpatient hospital, CAH, CMHC institutional billing

IOP service day components and billing

APC component days - 3 servicesDays with 3 services a day are reported as one APC component grouping; bill under IOP ambulatory payment classifications

APC component days - 4+ servicesDays with 4 or more services a day are reported under a separate APC component grouping

Revenue codes & chargesHospitals must report a revenue code and the charge for each individual covered service furnished under an IOP, including required HCPCS/CPT codes

Type of Bill (TOB) for institutional billingTOB 13X (outpatient hospital), TOB 85X (CAH), TOB 76X (CMHC) — use appropriate TOB for claim submission

Prior Authorization & Provider Requirements

Prior Authorization

Prior authorization required after 5 days; MCG/ASAM criteria used

Definitions

Intensive Outpatient Program (IOP) definition

SettingsMay be provided in HOPD, CAH outpatient departments, CMHCs, RHCs, FQHCs, and OTPs for OUD treatment

Treatment componentsIncludes individual and group therapy, multidisciplinary coordination, patient education, diagnostic services; excludes meals and transportation as billable items

ASAM IOP Level of Care (LOC 2.1)

ASAM IOP LOC hours (adults)9 or more hours of SUD treatment services per week (ASAM Intensive Outpatient LOC 2.1)

ASAM IOP LOC hours (adolescents)6 or more hours of SUD treatment services per week for adolescents

PurposeTo treat multidimensional instability and complex needs of members with addiction and co-occurring conditions

Review types

Concurrent ReviewA request for prior authorization or a predetermination that is submitted before or during the course of receiving a health care service

Retrospective ReviewA request for medical review that is submitted after the health care service has been received

Prior authorization timing notePrior authorization is required after 5 days per calendar year; CareSource follows MCG for mental health and ASAM for SUD reviews