DraftclearhealthalliancePolicy 8A-10
Table of Contents for Policy 8A-10
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This section provides the table of contents and structural outline for Policy 8A-10, indicating sections, subsections, and topics to be covered throughout the policy document.
Policy Summary
Payerclearhealthalliance
PolicyTable of Contents for Policy 8A-10
Policy CodePolicy 8A-10
Change TypeStructural / TOC only
Effective Date
Next Review Date
Key ActionContact your Prepaid Health Plan (PHP) for questions about benefits and services after implementation.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
19chunks in this upload (0-19)
4major section numbers referenced (1.0-4.0)
multiplerepeated TOC entries and duplication present
no prior approval notedprior approval required?
Coverage Criteria and Limitations
COVERAGE CRITERIA: Structure for coverage and exclusions
Headings indicating where coverage and non-coverage criteria appear in the full policy.
Table of Contents entries identify sections for 'When the Procedure, Product, or Service Is Covered' and 'When the Procedure, Product, or Service Is Not Covered' (general and specific).
COVERAGE CRITERIA: Coverage sections (TOC references)
Table of contents references the major coverage sections and related subsections (coverage, non-coverage, Medicaid specifics, and requirements/limitations).
3.0 When the Procedure, Product, or Service Is Covered
3.1 General Criteria Covered
3.2 Specific Criteria Covered
3.2.1 Specific Criteria Covered by Medicaid
3.2.2 Medicaid Additional Criteria Covered
3.2.3 Continued Stay and Discharge Criteria
4.0 When the Procedure, Product, or Service Is Not Covered
4.1 General Criteria Not Covered
4.2 Specific Criteria Not Covered
4.2.1 Specific Criteria Not Covered by Medicaid
5.0 Requirements for and Limitations on Coverage (including Prior Approval sections)
COVERAGE CRITERIA: Coverage sections (TOC)
Locations of coverage-related sections as shown in the table of contents.
Section 3.1 — General Criteria Covered
Section 3.2 — Specific Criteria Covered (including Medicaid subsections)
Section 3.2.1 — Specific Criteria Covered by Medicaid
Section 3.2.2 — Medicaid Additional Criteria Covered
Section 3.2.3 — Continued Stay and Discharge Criteria
Section 4.0 — When the Procedure, Product, or Service Is Not Covered
Section 5.1 — Prior Approval
Section 5.2 — Prior Approval Requirements
Section 5.4 — Service Order
COVERAGE CRITERIA: Coverage (TOC)
Fragment contains headings only; substantive coverage criteria are not present here.
4.0 When the Procedure, Product, or Service Is Not Covered
4.1 General Criteria Not Covered
4.2 Specific Criteria Not Covered
5.5 Documentation Requirements
COVERAGE CRITERIA: Coverage (TOC) — headings only
TOC entries that list coverage stance and not-covered headings, including general and Medicaid-specific non-coverage.
4.0 When the Procedure, Product, or Service Is Not Covered
4.1 General Criteria Not Covered
4.2 Specific Criteria Not Covered
4.2.1 Specific Criteria Not Covered by Medicaid
5.0 Requirements for and Limitations on Coverage (includes Prior Approval and Service Order)
COVERAGE CRITERIA: Coverage scope and clinical appropriateness
Scope note describing clinical appropriateness for Clinically Managed Residential Withdrawal Management (ASAM Level 3.2 WM).
Service appropriate for beneficiaries who are intoxicated or experiencing withdrawal but are NOT at risk of severe withdrawal symptoms or severe physical/psychiatric complications.
Intended to manage moderate withdrawal symptoms safely at ASAM Level 3.2 WM with 24-hour supervision and emphasis on peer and social supports.
Programs must have clinical protocols developed and supported by a physician available 24 hours/day and coordinate with other levels of care to facilitate transition to ongoing treatment.
COVERAGE CRITERIA: Medicaid Coverage Criteria for Clinically Managed Residential WM
Medicaid-specific admission, assessment, continued stay, and discharge criteria for Clinically Managed Residential Withdrawal Management (ASAM 3.2 WM).
Medicaid covers the service when medically necessary and the service is individualized, consistent with diagnosis/symptoms, safe to furnish, and not primarily for convenience (3.1).
Specific criteria: beneficiary has a substance use disorder diagnosis per DSM-5; meets ASAM Level 3.2 WM admission criteria as defined in The ASAM Criteria, Third Edition (3.2.1).
Admission assessment rules: initial abbreviated assessment at admission to establish medical necessity and develop a service plan; provider may take up to 24 hours to complete if beneficiary cannot cooperate; within 3 calendar days a comprehensive clinical assessment (CCA) or diagnostic assessment (DA) must be completed by a licensed clinician to determine ASAM level for discharge planning (Admission Criteria).
ANY of the following
- Continued stay if any ONE applies: withdrawal symptoms not sufficiently resolved to allow discharge to lower level of care or safe management in less intensive environment; OR CIWA-Ar (or comparable standardized tool) score has not improved (3.2.3 a).
- Discharge if any ONE applies: withdrawal signs/symptoms sufficiently resolved for self-directed recovery/ongoing treatment without further medical withdrawal monitoring; OR signs/symptoms have intensified indicating transfer to more intensive services; OR beneficiary unable to complete service indicating need for more intensive care; OR beneficiary or legal representative requests discharge (3.2.3 b).
Each of the six ASAM dimensions must be reviewed and documented to support continued stay, discharge, or transfer determinations (3.2.3 note).
COVERAGE CRITERIA: Coverage criteria and limitations
Coverage limitations, billing rules, provider and documentation requirements, and personnel/provider qualifications and constraints under Medicaid.
Prior approval: Medicaid shall not require prior approval for Clinically Managed Residential Withdrawal Management Services (5.1).
Billing and concurrent service limitations: service must not be billed on the same day (except admission/discharge days) with residential levels of care, other withdrawal management, outpatient treatment, SAIOP, SACOT, ACT, CST, Supported Employment, Psychiatric Rehabilitation, Peer Support Services, MCM, Partial Hospitalization, Facility Based Crisis (Adult). Only one provider organization may provide this service during an active episode of care (5.3).
Service order requirements: signed service order by physician or physician extender required and valid for the episode; verbal orders permitted in urgent situations but must be documented and countersigned within 72 hours; backdating not allowed; service order must be in place on or before first day of service to bill Medicaid (5.4 and supporting text).
Documentation requirements: service record must document nature and course of treatment; shift note required for every shift; staff must document services billed per DHHS Records Management and Documentation Manual; MAR/eMAR must meet 10A NCAC 27G .0209 (c)(4) or equivalent (5.5).
Provider eligibility and qualifications: providers must meet Medicaid participation qualifications, have DHHS Provider Administrative Participation Agreement, bill within scope of practice, meet NC Medicaid provider qualification policies, comply with 10A NCAC 27G rules or equivalent, be credentialed/contracted by DHHS designated contractor, achieve national accreditation within one year of enrollment, and be a legally constituted entity; facilities must be licensed under 10A NCAC 27G .3200 or equivalent tribal/IHS provisions (6.1).
COVERAGE CRITERIA: Coverage criteria for Clinically Managed Residential Withdrawal Management
Program-level clinical, staffing, medication access, and operational requirements for Clinically Managed Residential Withdrawal Management services.
Clinical indication: beneficiary experiencing signs of intoxication and withdrawal with symptoms sufficiently severe to require 24-hour structure/support but not extensive medical or nursing care; designed to assist through withdrawal and transition to ongoing treatment (6.3.a).
Medication access and naloxone: providers shall provide access to FDA-approved medications for MAT covered by the Medicaid formulary when medically necessary; MAT may be administered on-site or via MOA/MOU with a provider within 60 minutes; programs must have naloxone or other FDA-approved opioid antagonist on site and staff trained in its use with policies for use/storage/education (6.3.d and 6.3.e).
Staffing and availability: facility must operate 24/7; physician available 24 hours for medical evaluations/consultation; staff to screen and accept admissions minimum 12 hours/day with at least 5 hours during second shift; staffing ratios must not exceed 1:9 and at least two staff on-site at all times (6.3.c and 6.3.g).
Clinical components and services: required components include initial abbreviated assessment, CCA/DA within 3 days, physical exam when indicated, daily monitoring of progress and vitals, crisis interventions, lab/toxicology capability, supervised medication administration as needed, counseling, peer support, family involvement as appropriate, linkage and referral coordination, and discharge planning beginning at admission (6.3.f and 6.3.f.1-23).
Operational and compliance requirements: providers must comply with applicable federal, state, and local laws including HIPAA and 42 CFR Part 2; tribal/IHS providers may have exemptions under federal law (program requirements).
COVERAGE CRITERIA: Reimbursement and separable billing rules
Reimbursement guidance and rules for separable billing related to Clinically Managed Residential Withdrawal Management services.
Providers shall bill their usual and customary charges; refer to state Medicaid rate schedule for rates (Reimbursement).
Evaluation and Management CPT codes for addiction-focused history, assessments (CCA/DA), physical exam, labs, toxicology, and medical evaluation/consultation may be billed separately from Clinically Managed Residential Withdrawal Management Service; follow coding and billing guidance (Attachment A).
North Carolina Medicaid will not reimburse for conversion therapy (exclusion).
Coding and Billing Codes
Documented coding referencesICD-10
| ICD-10-CM / PCS | Reference to ICD-10-CM and Procedural Coding System (PCS); report to highest level of specificity and use current edition in effect at time of service. |
Primary service codeHCPCSCovered
| H0011 | Clinically Managed Residential Withdrawal Management service; Billing Unit = 1 Day |
Unlisted procedure codingmixed
| Unlisted CPT/HCPCS | Follow Instructions for Use of the CPT Codebook and HCPCS National Level II for unlisted procedures and submit Special Report when required; if no specific CPT or HCPCS code exists, report the service using the appropriate unlisted procedure or service code. |
Table of contents structure — sections 1.0 through 4.0 with multiple subsections listed
1.0 DescriptionDescription of the Procedure, Product, or Service; Definitions
2.0 Eligibility RequirementsProvisions; Special Provisions; EPSDT Special Provision (2.2.1)
3.0 When the Procedure, Product, or Service Is Covered3.1 General Criteria Covered; 3.2 Specific Criteria Covered; 3.2.1 Specific Criteria Covered by Medicaid; 3.2.2 Medicaid Additional Criteria Covered; 3.2.3 Continued Stay and Discharge Criteria
4.0 When the Procedure, Product, or Service Is Not Covered4.1 General Criteria Not Covered; 4.2 Specific Criteria Not Covered; 4.2.1 Specific Criteria Not Covered by Medicaid
5.0 Requirements for and Limitations on Coverage5.1 Prior Approval; 5.2 Prior Approval Requirements (General and Specific); 5.3 Additional Limitations and Requirements; 5.4 Service Order; 5.5 Documentation Requirements
6.0 Provider(s) Eligible to Bill6.1 Provider Qualifications and Occupational Licensing Entity Regulations; 6.2 Provider Certifications; 6.3 Program Requirements; 6.4 (additional provider requirements)
AttachmentsAttachment A: Claims-Related Information (ICD-10-CM/PCS, Codes, Modifiers, Billing Units, Reimbursement), Policy Implementation and History
Coding specificity — report ICD-10-CM/PCS to highest level; use current editions at time of service
Coding specificityReport ICD-10-CM and PCS to the highest level of specificity that supports medical necessity; use the current ICD-10 edition and any subsequent editions in effect at the time of service.
Code description sourceRefer to the applicable ICD-10 edition for code descriptions; descriptions are not documented in the policy.
Claims attachmentAttachment A includes ICD-10-CM and PCS guidance for claims-related reporting.
Provider Actions, Prior Approval, and Billing Instructions
Note
Beneficiary contact for PHP enrollees
To all beneficiaries enrolled in a Prepaid Health Plan (PHP): for questions about benefits and services available on or after implementation, please contact your PHP.
Prior Authorization
Prior Approval referenced in TOC — details not present
Prior Approval and Prior Approval Requirements are listed in the table of contents (sections 5.1 and 5.2) but this extract contains no procedural details for obtaining prior approval.
Prior Authorization
Prior Approval and Prior Approval Requirements in TOC
The table of contents explicitly lists 'Prior Approval' and 'Prior Approval Requirements' under Requirements for and Limitations on Coverage (sections 5.1 and 5.2).
Prior Authorization
Prior Approval sections noted (5.1, 5.2)
Prior Approval is referenced as section 5.1 and Prior Approval Requirements as section 5.2 in the policy's table of contents.
Prior Authorization
Authorization and prior approval topics listed in TOC
The table of contents groups authorization topics including Prior Approval; Prior Approval Requirements (general and specific); Service Order; and Documentation Requirements under the Requirements and Limitations on Coverage section.
Prior Authorization
Prior Approval listed in TOC
Prior Approval appears as a listed section in the table of contents for this policy (section 5.1).
Prior Authorization
EPSDT and prior approval requirement
EPSDT does not waive prior approval requirements: prior approval requirements still must be obtained when required for beneficiaries under 21.
- EPSDT may allow exceeding policy limits when medically necessary, but prior approval requirements still apply when required.
Prior Authorization
Prior approval not required for this service
Medicaid shall not require prior approval for Clinically Managed Residential Withdrawal Management Services; the policy explicitly states that general and specific prior approval requirements do not apply.
- 5.1 Prior Approval: 'Medicaid shall not require prior approval for Clinically Managed Residential Withdrawal Management Services.'
- 5.2.1 General: 'None Apply.'
- 5.2.2 Specific: 'None Apply.'
Billing Rule
Billing code and billing unit (H0011)
Report the most specific billing code that accurately and completely describes the service; H0011 is the listed code for Clinically Managed Residential Withdrawal Management with a billing unit of 1 day.
- H0011 — Billing Unit = 1 Day
- Use current CPT, HCPCS, and UB-04 specifications and the most specific valid code available.
Documentation Required
Coding instructions and Special Report for unlisted procedures
When no specific CPT or HCPCS code exists, follow the Instructions for Use of the CPT Codebook and HCPCS National Level II for unlisted procedures and submit a Special Report as required by the current codebook editions.
- CPT: Comply with 'Unlisted Procedure or Service' instructions and Special Report in current CPT.
- HCPCS: Comply with 'Unlisted Procedure or Service' instructions and Special Report in current HCPCS.
Definitions and Policy Terms
EPSDT Special Provision — Exception to policy limitations for Medicaid beneficiaries under 21
EPSDT provisionEPSDT Special Provision: Exception to Policy Limitations for a Medicaid beneficiary under 21 years of age is listed in the TOC (2.2.1).
ScopeEPSDT may override policy limitations when services are medically necessary for beneficiaries under 21, subject to Medicaid rules.
Prior approval noteEPSDT does not waive prior approval requirements when prior approval is required by policy.
Medicaid-specific subsections (referenced) — TOC entries referencing Medicaid-specific covered/not covered criteria
Medicaid-covered subsections3.2.1 Specific Criteria Covered by Medicaid; 3.2.2 Medicaid Additional Criteria Covered; 3.2.3 Continued Stay and Discharge Criteria
Medicaid-not-covered subsections4.2.1 Specific Criteria Not Covered by Medicaid
TOC references onlyThese entries are listed in the TOC indicating Medicaid-specific covered and not-covered criteria appear in the full policy extract.
Service Order (TOC) — Service Order listed as subsection (5.4) under Requirements and Limitations on Coverage
TOC locationService Order is listed as subsection 5.4 under Requirements for and Limitations on Coverage in the Table of Contents.
Service order purposeService Order: mechanism to demonstrate medical necessity for the service.
Service order related requirementsSee Service Order subsection for details on signed orders, verbal orders, and timing relevant to billing Medicaid.
Table of Contents — lists major sections and related subsections
Major sections1.0 Description; 2.0 Eligibility Requirements; 3.0 When Covered; 4.0 When Not Covered; 5.0 Requirements/Limitations; 6.0 Provider(s) Eligible to Bill; Attachments
Subsections notedExamples include 3.2.1 Specific Criteria Covered by Medicaid, 4.2.1 Specific Criteria Not Covered by Medicaid, 5.4 Service Order, 5.5 Documentation Requirements, 6.1 Provider Qualifications
Attachments and claims informationAttachment A includes claims-related guidance (codes, modifiers, billing units, reimbursement).
Prior Approval — definition / reference to Prior Approval
Prior Approval (definition)Prior Approval is listed as section 5.1 in the TOC under Requirements for and Limitations on Coverage; referenced as a formal requirement when applicable.
Prior Approval RequirementsSection 5.2 contains general and specific prior approval requirements as listed in the TOC.
Medicaid exception noteThe policy also states whether Medicaid requires or does not require prior approval for specific services in the Requirements section (see full policy).
Provider Qualifications — referenced provider qualifications
Provider qualifications header6.1 Provider Qualifications and Occupational Licensing Entity Regulations is listed in the TOC.
Eligibility to billProviders must meet Medicaid provider qualifications, licensing, certifications, and program requirements as specified under section 6.0.
Administrative requirementsProviders must have required agreements, accreditation timelines, and meet DHHS provider participation rules (detailed in full policy).
Clinically Managed Residential Withdrawal Management (ASAM Level 3.2 WM) — definition and summary of service level
Service levelClinically Managed Residential Withdrawal Management (ASAM Level 3.2 WM): facility-based service with 24-hour supervision for beneficiaries not at risk of severe withdrawal or severe medical/psychiatric complications.
Care emphasisEmphasizes peer and social supports and coordination with other levels of care to facilitate transition to ongoing treatment.
Medical oversightRequires established clinical protocols developed and supported by a physician who is available 24 hours a day.
CIWA-Ar — Clinical Institute Withdrawal Assessment of Alcohol Scale definition/reference
CIWA-ArClinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar): a tool used to assess an individual's alcohol withdrawal.
ASAM Criteria referenceThe ASAM Criteria, Third Edition uses six dimensions for holistic biopsychosocial assessment to guide service planning and placement.
Assessment contextCIWA-Ar is referenced as the standardized withdrawal assessment instrument used in the policy's assessment and continued-stay criteria.
The ASAM Criteria, Third Edition — definition/reference
ASAM Criteria, 3rd Ed.The ASAM Criteria, Third Edition: comprehensive treatment standards using six dimensions (Acute Intoxication & Withdrawal Potential; Biomedical Conditions; Emotional/Behavioral/Cognitive Conditions; Readiness to Change; Relapse/Continued Use Potential; Recovery and Living Environment) for assessment and service planning.
Use in policyASAM Criteria are the referenced standard for level-of-care determination, admission, continued stay, and discharge planning in the policy.
Holistic approachSix-dimension biopsychosocial model guides individualized service planning and transitions across care levels.
Service order — signed physician/physician extender order requirements, verbal orders rules, countersignature and timing, billing implications
Signed order requirementA signed service order must be completed by a physician or physician extender and is valid for the episode of care.
Verbal orders rulesVerbal service orders allowed in urgent/emergent situations must be documented on the date given (who gave/received order, services ordered, reason) and countersigned within 72 hours.
Timing and billing implicationBackdating is not allowed; a service order must be in place before or on the first day of service to bill Medicaid; providers cannot bill Medicaid without a valid service order even if beneficiary is retroactively eligible.
Service record / documentation — documentation requirements referenced
Documentation standardService record must document the nature and course of treatment; documentation must be consistent with this policy to bill Medicaid.
Shift notesA shift note is required for every shift of service provided; additional events/interventions must be documented beyond minimum frequency.
MAR requirementsMedication administration records (MARs) or eMARs must meet 10A NCAC 27G .0209 (c)(4) or equivalent tribal/federal regulations; staff must document services billed per DHHS Records Management and Documentation Manual.
Clinically Managed Residential Withdrawal Management Service — service definition emphasizing 24-hour supervision and scope
24-hour supervisionClinically Managed Residential Withdrawal Management Service: organized facility-based service delivered by trained clinicians and certified staff providing clinically supervised evaluations and withdrawal management with 24-hour structure and support.
Scope of careIntended for beneficiaries needing 24-hour supervision for withdrawal who do not require extensive medical or nursing care; staff refer for medical evaluation if clinically necessary.
Program protocolsPrograms must have protocols developed/supported by a Medical Director to determine when physician care or transfer to medically monitored settings is necessary.
Modifier guidance — use of applicable modifiers guided by coding conventions and payer rules
Modifier guidanceProvider(s) shall follow applicable modifier guidelines as directed by coding conventions and payer rules.
Use with unlisted codesModifiers apply when reporting unlisted procedures/services per CPT/HCPCS guidance (see Attachment A).
Follow codebook guidanceProviders must follow current codebook and payer-specific conventions when applying modifiers.
Billing units and utilization monitoring — report appropriate codes determining billing units; tribal/IHS alternate reimbursement notes
Billing units determinationProvider(s) shall report the appropriate code(s) which determine the billing unit(s); for H0011 the billing unit is 1 day.
Tribal/IHS alternate reimbursementFederally recognized tribal or IHS providers may be entitled to alternate reimbursement methodologies under federal law.
Utilization monitoringPHPs, PIHPs and provider agencies shall monitor utilization via record reviews and internal audits of units billed and assess adherence to service guidelines.
Place of Service — designation that this service is facility-based
Place of Service designationThis service is designated as facility-based (organized facility-based Clinically Managed Residential Withdrawal Management Service).
Operational requirementsPrograms must provide 24-hour supervision, staff screening/admissions minimum 12 hours/day, staffing ratios, and program protocols; see program requirements for details.
Billing and reimbursement linksClaims must follow NCTracks guidance and applicable billing specifications; see Attachment A and state Medicaid rate schedules for reimbursement.
Reimbursement and exclusions — bill usual and customary charges; state rate schedules; E/M separable; exclusions noted
Reimbursement expectationProviders shall bill their usual and customary charges; refer to the state Medicaid rate schedule for rates.
E/M separable billingEvaluation and Management CPT codes for addiction-focused assessments, CCA/DA, physical exams, labs, toxicology, and medical evaluation/consultation can be billed separately from the Clinically Managed Residential Withdrawal Management Service.
ExclusionsNorth Carolina Medicaid will not reimburse for conversion therapy; certain services (room and board, childcare, services not on the service plan) are noted as not covered under Medicaid policy sections.
Policy Summary
Payerclearhealthalliance
PolicyTable of Contents for Policy 8A-10
Policy CodePolicy 8A-10
Change TypeStructural / TOC only
Effective Date
Next Review Date
Key ActionContact your Prepaid Health Plan (PHP) for questions about benefits and services after implementation.
SourceLink
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