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    v1.0.28
    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthMontana DPHHS SUD TCM Coverage Update | OpenPayer
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    CurrentMontana Department of Public Health & Human ServicesPolicy N/A

    Substance Use Disorder Targeted Case Management (SUD TCM) Coverage Criteria

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    Defines Montana Medicaid coverage, eligibility, provider requirements, and billing for targeted case management services for adults and youth with substance use disorder (SUD). Applies to state-approved SUD programs and enrolled case managers providing TCM for Medicaid members.

    Policy Summary
    PayerMontana Department of Public Health & Human Services
    PolicySubstance Use Disorder Targeted Case Management (SUD TCM) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionEnsure SUD TCM is provided by state-approved SUD programs and delivered by qualified case managers with required documentation of assessment, care plan, referrals, monitoring, and follow-up.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    15-minutebilling unit for SUD TCM services
    moderate or severerequired functional impairment level
    bachelor'sminimum case manager qualification
    State-approved

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    authorized provider type

    Coverage and Eligibility

    Covered SUD TCM eligibility

    Covered when ALL of the following are met

    Eligibility: Member has a diagnosis of a substance use disorder (SUD) with moderate or severe functional impairment

    From Program Eligibility/Limits

    Concurrent Service: Member is receiving at least one other adult mental health or substance use disorder service

    Concurrent service required

    Provider Qualification: Services are provided by state-approved SUD programs and delivered by case managers meeting minimum qualifications (bachelor's degree in a human services field or comparable experience, or equivalent lived/provider experience as described)

    From Provider Requirements

    Medicaid-ineligible clients may not be billed to Montana Medicaid. State-approved SUD programs that have a contract or task order including targeted case management (TCM) may bill the Substance Abuse Prevention and Treatment Block Grant for Medicaid-ineligible clients who are under 200% of the federal poverty level (FPL).

    Services do not meet SUD TCM eligibility when the member lacks a diagnosis of a substance use disorder with moderate or severe functional impairment, or when the member is not receiving at least one other adult mental health or substance use disorder service. Coverage requires both the documented SUD diagnosis with the specified level of functional impairment and concurrent receipt of another MH/SUD service.

    Regulatory Citations & Billing Codes

    Regulatory citationsmixed
    42 CFR 440.169Federal regulatory citation for targeted case management
    Title 37, chapter 86, subchapter 33 and 40State regulatory citations referenced
    Income threshold for Block Grant billing
    Income thresholdMedicaid-ineligible clients may be billed to the Substance Abuse Prevention and Treatment Block Grant if under 200% of the federal poverty level (FPL)
    Eligible billing programState-approved SUD programs with a contract or task order that includes TCM may bill the Block Grant
    PopulationMedicaid-ineligible clients only (Block Grant billing does not apply to Medicaid-eligible members)

    Provider Requirements, Documentation, and Risk

    Prior Authorization

    Provider approval required: state-approved SUD programs and qualified case managers

    Services must be delivered by state-approved SUD programs and by case managers who meet the minimum qualifications; state-approval is initiated through the Addictive and Mental Disorder Division and finalized through the Quality Assurance Division.

    • Case managers must meet minimum qualifications (bachelor's degree in a human services field or comparable experience; alternative qualified lived/provider experience may be acceptable).
    • State-approval process: initiated through the Addictive and Mental Disorder Division and finalized through the Quality Assurance Division.
    Note

    Action required: verify eligibility and concurrent services before providing SUD TCM

    Ensure SUD TCM is billed only for eligible members and delivered alongside required services; confirm eligibility and documentation before providing services to avoid denials.

    • Verify member meets SUD TCM eligibility (diagnosis of SUD with moderate or severe functional impairment).

    Program Background

    Targeted case management for substance use disorder (SUD TCM) is intended to help members access necessary medical, social, educational, and other community services and to mitigate and improve SUD symptoms. Services are delivered as case management activities — assessment, development and periodic revision of a specific care plan, referral and related activities, and monitoring and follow-up — and are billed in 15-minute units.

    Key Definitions

    SUD Targeted Case Management (TCM) — definition and included services
    DefinitionTargeted case management (TCM) for SUD: services including assessment, determination of need, development and periodic revision of a specific care plan, referral and related activities, and monitoring and follow-up activities.
    Core included servicesAssessment and determination of need
    Care planningDevelopment and periodic revision of a specific care plan
    Care coordinationReferral and related activities to connect members with medical, social, educational, and other services
    Ongoing supportMonitoring and follow-up activities to track progress and service engagement

    Level of Care / Case Management Criteria

    Service Modalities

    Targeted Case Management (TCM)

    Modality: Targeted case management delivered in 15-minute units consisting of assessment, development and periodic revision of a specific care plan, referral and related activities, and monitoring and follow-up15-minute units

    Service modality and billing unit

    Visit Frequency and Unit

    SUD TCM — billing unit and visit limit (15-minute units)
    Billing unitServices are provided and billed in 15-minute units (per service encounter)
    Visit limit descriptorVisit/encounter-level billing measured in 15-minute increments
    Service modalityTCM delivered in repeated 15-minute units as needed for assessment, care planning, referral, monitoring, and follow-up
    Policy Summary
    PayerMontana Department of Public Health & Human Services
    PolicySubstance Use Disorder Targeted Case Management (SUD TCM) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionEnsure SUD TCM is provided by state-approved SUD programs and delivered by qualified case managers with required documentation of assessment, care plan, referrals, monitoring, and follow-up.
    SourceLink
    On This Page
    Coverage and EligibilityRegulatory Citations & Billing CodesProvider Requirements, Documentation, and RiskProgram BackgroundKey DefinitionsLevel of Care / Case Management CriteriaService ModalitiesVisit Frequency and Unit
  1. Confirm the member is receiving at least one other adult mental health or substance use disorder service prior to provision.
    2. Documentation Required

    Required clinical documentation and billing unit

    Document assessment, determination of need, a specific care plan with periodic revisions, referrals and related activities, and monitoring and follow-up; bill services in 15-minute units.

    • Assessment and determination of need for SUD TCM.
    • Development and periodic revision of a specific care plan.
    • Documentation of referrals and related activities, monitoring, and follow-up.
    • Record billing in 15-minute units for each service encounter.
    Denial Risk

    Denial risk: missing SUD diagnosis or concurrent MH/SUD service

    Services lacking a documented SUD diagnosis with moderate or severe functional impairment or not delivered while the member is receiving at least one other MH/SUD service risk denial.

    • Absence of SUD diagnosis with moderate or severe functional impairment may result in services not meeting eligibility criteria.
    • Failure to document concurrent receipt of at least one other adult mental health or substance use disorder service may lead to denial.