CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Intermediate behavioral health services (PHP, IOP, IHH, ACT, CCBHC, EOS, OTP, MAT, ECT) coverage criteria

Defines coverage, coding, and reimbursement guidelines for intermediate behavioral health services (partial hospitalization, intensive outpatient, home-based programs, ACT, CCBHC, EOS, OTP, MAT, ECT) for Neighborhood Health Plan of Rhode Island members across Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIntermediate behavioral health services (PHP, IOP, IHH, ACT, CCBHC, EOS, OTP, MAT, ECT) coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date09/01/2025

Next Review DateN/A

Key ActionVerify member eligibility, medical necessity, and obtain required prior authorization per Neighborhood's plan-specific Prior Authorization Reference before rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicaid, INTEGRITY, CommercialLines of business

H0035 / 0912 / 0913PHP codes listed

1/yr90791 limit

T1041 monthlyCCBHC billing

90867-90869

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Coverage Criteria for Intermediate Behavioral Health Services

General coverage criteria for intermediate behavioral health services

Covered when ALL of the following are met:

Medical necessity: Service must be medically necessary as determined using NCD/LCD, InterQual, EOHHS recommendations, Clinical Medical Policies, or ASAM criteria.

From prerequisites

Appropriate level of care selection: Member meets clinical description for the specific intermediate service: PHP (requires daily psychiatric evaluation, 6-9 hours/day, minimum 5 days/week), IOP (structured program with primary group therapy, typically ≥3 hours/day multiple days/week), or EOS (home/community-based intensive services for high-risk children, recommended up to 5 days/week and ~4 hours/day).

From level-of-care definitions

Program enrollment exclusivity: Members cannot be enrolled in IHH/ACT and CCBHC programs within the same month; members may only be enrolled in one specialized program at a time (IHH, ACT, OTP), except OTP may be concurrent with CCBHC where allowed.

From reimbursement requirements and exclusions

Partial Hospitalization Program (PHP)

Covered when services meet program descriptions and provider capabilities

PHP coverage: Member receives daily psychiatric evaluation and treatment comparable to inpatient care; services provided 6–9 hours per day at least 5 days per week; member has a supportive environment to return to in the evening; PHP implements behavior plans, medication management/administration, coordinates transition to community supports, and maintains 24/7 physician availability for emergencies.

From PHP program description

Peer Support

Peer support coverage conditions

Peer support coverage: Services provided by individuals with lived experience to serve as personal guides and mentors, assist recovery, remove barriers, and link members to recovery activities and supports.

Peer support description

TMS and MAT

TMS and MAT program descriptions

TMS: Transcranial Magnetic Stimulation (TMS) is a non‑invasive procedure delivering repetitive magnetic pulses to targeted brain regions to modulate neural activity and treat mental health and certain neurological disorders; initial session includes cortical mapping and motor threshold determination with subsequent sessions billed per session.

From TMS description and coding

MAT: Medication Assisted Treatment (MAT) includes methadone administration and/or related services provided by a licensed program billed using H0020 (and related MAT codes such as H0033 as listed).

From MAT description and coding

Enrollment in specialized behavioral health programs is mutually exclusive in certain combinations. Members cannot be enrolled in IHH/ACT and CCBHC programs within the same month, and only one professional claim line per member per month for CCBHC (T1041) will be reimbursed; additional professional claim lines for that month will receive a global denial. Members also cannot be simultaneously enrolled in ACT, IHH, and OTP Health Home, though OTP may be concurrent with CCBHC in some circumstances. Billing for ACT/IHH and OTP Health Home requires the specified primary HCPC code (e.g., H0040, H0037, H0047) to be submitted with the appropriate shadow direct or indirect codes on the same claim to qualify for bundled payments.

This policy and payment guidance are informational and do not guarantee reimbursement. Coverage and payment remain subject to member eligibility, the member's benefit plan, applicable provider contract agreements, claims payment edits, coding and documentation rules, authorization requirements, and federal/state regulations. Providers are responsible for verifying eligibility, coverage, and prior authorization requirements before rendering services and should consult Neighborhood's plan-specific Prior Authorization Reference page for details.

All services billed under this policy must meet medical necessity as determined by applicable criteria (e.g., NCD/LCD, InterQual, EOHHS recommendations, Clinical Medical Policies, or ASAM criteria). Services that do not meet those medical necessity determinations are not eligible for reimbursement. Providers must ensure documentation in the medical record supports the billed services and medical necessity.

Billing Codes and Coding Guidance

IHH / ACT CodesHCPCSCovered

H0037	Community psychiatric supportive treatment program, per diem
H0036	Community psychiatric supportive treatment, face-to-face, per 15 minutes
T1016	Case management, each 15 minutes

CCBHC CodesHCPCS | ModifierCovered

T1041	Medicaid certified community behavioral health clinic services, per month
U3	High Acuity Adult modifier for T1041
U4	High Acuity Children and Youth modifier for T1041
U5	Substance Use Disorder modifier for T1041
U6	Standard Population modifier for T1041

ECT CodesCPTCovered

90870	Electroconvulsive therapy (includes necessary monitoring)
0901	Electroconvulsive therapy (includes necessary monitoring)

Enhanced Outpatient Services CodesCPT | HCPCSCovered

90791	Psychiatric diagnostic evaluation
H0004	Behavioral health counseling and therapy, per 15 minutes
H0036	Community psychiatric supportive treatment, face-to-face, per 15 minutes
H2011	Crisis intervention service, per 15 minutes

IOP CodesCPT | HCPCSCovered

S9480	Intensive outpatient psychiatric services, per diem
0905	Intensive outpatient psychiatric services (alternate numeric variant)
H0015	Alcohol and/or drug services; intensive outpatient
0906	H0015 alternate numeric variant

MAT Codes (Medicaid and Commercial)HCPCSCovered

H0020	Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program).
H0033	H0033

OTP Health Home CodesHCPCSCovered

H0047	Alcohol and/or other drug abuse services, not otherwise specified
H0006	Alcohol and/or drug services; case management
H0036	Community psychiatric supportive treatment, face-to-face, per 15 minutes

MAT Codes (neutral listing)HCPCS

H0020	Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program).
H0033	H0033

PHP CodesHCPCS | mixed

H0035	Mental health partial hospitalization, treatment, less than 24 hours
0912	0912
0913	0913

Peer Support CodesHCPCS

H0038

Self-help/peer services, per 15 minutes

TMS CPT CodesCPT

90867	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management
90868	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session
90869	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management

Partial Hospitalization Program (PHP) - daily minimum hours

Minimum daily program length6-9 hours per day (minimum 5 days per week)

Required clinical activitiesDaily psychiatric evaluation and multidisciplinary treatment comparable to inpatient care

Facility capabilities24/7 physician availability for emergencies; medication management and behavior plans

Intended useAlternative to or step-down from inpatient care to stabilize acute/severe mental illness, SUD, or dual diagnosis

Provider Responsibilities and Billing Expectations

Prior Authorization

Verify eligibility and medical necessity

All services must be medically necessary to qualify for reimbursement. Providers are responsible for verifying member eligibility, coverage and any prior authorization requirements before rendering services. Neighborhood may use National and Local Coverage Determinations (NCD/LCD), InterQual, EOHHS recommendations, Clinical Medical Policies, ASAM criteria, and other industry-accepted criteria when determining medical necessity. For plan-specific prior authorization details, refer to Neighborhood's Prior Authorization Reference page and Behavioral Health Clinical Medical Policies. Contact Provider Services at 1-800-963-1001 with questions.

Verify eligibility and benefits before each service.
Confirm prior authorization requirements and obtain approvals where required.
Apply applicable medical necessity criteria (NCD/LCD, InterQual, CMP, ASAM, EOHHS).

Background

Intermediate behavioral health services bridge inpatient-level care and standard outpatient treatment by providing time-limited, higher-intensity interventions designed to stabilize acute conditions and return members to less intensive settings. Programs in this category include Partial Hospitalization Programs (PHP) — comprehensive multidisciplinary care delivered 6–9 hours per day, minimum 5 days per week with daily psychiatric evaluation and 24/7 physician emergency availability — Intensive Outpatient Programs (IOP) offering structured group-based treatment often at least 3 hours per day across multiple days per week, and Enhanced Outpatient Services (EOS) providing home- and community-based multidisciplinary care for children/youth transitioning from or avoiding inpatient care. These services commonly include medication management, crisis stabilization, individual/group/family therapy, care coordination, and recovery supports to promote stabilization and transition to community-based care.

Definitions

PHP definition

DefinitionPartial Hospitalization Program (PHP): short‑term, comprehensive, multidisciplinary program providing stabilization with daily psychiatric evaluation and treatment comparable to inpatient care

SchedulingAvailable 6-9 hours per day, minimum 5 days per week

SettingMay be hospital‑based or freestanding; intended for members with a supportive environment to return to in the evening

Core servicesBehavior plans, medication management, multidisciplinary therapies, care coordination

IOP definition

DefinitionIntensive Outpatient Program (IOP): structured outpatient program offering intensive treatment (primarily group therapy) for individuals who need more intensity than standard outpatient therapy

Level-of-Care Criteria (PHP, IOP, EOS)

PHP, IOP, EOS level-of-care criteria

Level-of-care criteria for admission, continued stay, and discharge

PHP admission: Member requires stabilization of acute, severe mental illness, substance use disorder, or dual diagnosis and can benefit from a structured program delivering daily psychiatric evaluation and multidisciplinary treatment in a therapeutic milieu while returning to a supportive home environment in the evening.

From PHP admission criteria

IOP admission: Member requires intensity greater than standard outpatient therapy but can be safely treated outside a partial hospital or inpatient setting; needs structured group therapy and the higher frequency/intensity offered by IOP.

From IOP description

EOS admission: Child or youth at high risk who needs home/community-based intensive clinical services to transition from inpatient/residential care or to avoid admission; program recommended up to 5 days/week with approximately 4 hours/day by a multidisciplinary team.

Treatment Modalities and Program Descriptions

IOP, PHP, ACT, IHH, EOS, OTP, MAT — treatment modality overview

Treatment modalities overview — services typically included

Modalities described: Services include individual, group, and family therapy; medication management and administration; crisis stabilization; recovery/rehabilitation skills; substance use treatment (for ACT participants and OTP/MAT programs); supported employment/schooling; peer support; care coordination; and other multidisciplinary interventions as required by the program.

From treatment modality descriptions across programs

TMS

TMS treatment and coding linkage

TMS sessions: Initial TMS includes cortical mapping and motor threshold determination (90867); subsequent treatment sessions billed per session (90868); motor threshold re-determination with treatment billed using 90869 when performed.

From TMS coding guidance

Visit Limits and Unit Constraints

Behavioral health counseling and therapy, per 15 minutes (H0004)

ServiceBehavioral health counseling and therapy, per 15 minutes

Max allowed unitsH0004 Max Allowed Units = 16 per day

Coding contextListed under Enhanced Outpatient Services coding limits

Community psychiatric supportive treatment, per 15 minutes (H0036)

ServiceCommunity psychiatric supportive treatment, face‑to‑face, per 15 minutes

Max allowed unitsH0036 Max Allowed Units = 24 per day

Modifier

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIntermediate behavioral health services (PHP, IOP, IHH, ACT, CCBHC, EOS, OTP, MAT, ECT) coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date09/01/2025

Next Review DateN/A

Key ActionVerify member eligibility, medical necessity, and obtain required prior authorization per Neighborhood's plan-specific Prior Authorization Reference before rendering services.

SourceLink

On This Page

EOS H0004 max units

H0004 max unitsH0004 Max Allowed Units = 16 per day

Procedure descriptionBehavioral health counseling and therapy, per 15 minutes

ApplicabilityApplies to Enhanced Outpatient Services (EOS) coding limits

EOS 90791 limit

90791 limit90791 Max Allowed Units = 1 per year or new episode of care

Procedure descriptionPsychiatric diagnostic evaluation

ContextUsed in Enhanced Outpatient Services (EOS) with per‑episode/year limit

EOS H0036 max units

H0036 max unitsH0036 Max Allowed Units = 24 per day

Procedure descriptionCommunity psychiatric supportive treatment, face-to-face, per 15 minutes

Modifier notedH0036 Modifier = HN (per coding table)

Billing Rule

CCBHC billing and enrollment conflicts

CCBHC providers must follow CCBHC enrollment and billing rules to avoid conflicts with other programs. Members cannot be enrolled in IHH/ACT and CCBHC within the same month; billing conflicts will result in denials. CCBHC claims should be submitted as one professional claim per member per month with T1041 (with the appropriate population modifier) on the first line covering the service span for the month; other lines should list services with the actual date rendered. Only one line per monthly claim will receive reimbursement; other lines on that claim will be globally denied. Refer to the EOHHS CCBHC Billing Manual and Shadow Billing codes list for full guidance.

One professional claim per member per month with T1041 first line (appropriate population modifier).
Other lines: list service-specific codes with actual dates of service; one rendering provider per month.
Members cannot be enrolled in IHH/ACT and CCBHC programs within the same month — enrollment conflict causes denials.

Documentation Required

Medical record support

Neighborhood reserves the right to request medical records for any billed service. Medical record documentation must support the service(s) billed and demonstrate medical necessity. Providers should follow CMS standards for documentation, maintain legible and contemporaneous records, include progress notes, treatment plans, signed orders, medication records, and any authorization letters. Ensure documentation is retained and available for audit or upon request to avoid denials or recoupment.

Documentation must support billed codes and medical necessity.
Maintain progress notes, treatment plans, signed orders, medication administration records, and prior authorization evidence.
Produce records promptly when requested to prevent claim denials or audit adjustments.

Minimum intensityOperates at least 3 hours per day and multiple days per week (per H0015 description for SUD IOP)

Primary modalityGroup therapy within a therapeutic milieu to support recovery

IHH / ACT definition

DefinitionIntegrated Home Health (IHH) / Assertive Community Treatment (ACT): community‑based multidisciplinary teams providing coordinated care, 24/7 crisis stabilization, medication management, therapy, rehabilitation, and supports to persons with serious mental illness

Team functionsCare coordination, outreach, housing and tenancy supports, supported employment/schooling, peer support, and linkage to medical and social services

AvailabilityACT teams are mobile and available 24/7, 365 days per year

EOS definition

DefinitionEnhanced Outpatient Services (EOS): home/community‑based clinical services by a specialized multidisciplinary team to transition children from inpatient care or to prevent admission

Recommended frequencyRecommended up to 5 days per week

Recommended daily durationApproximately 4 hours per day by a multidisciplinary clinical team

ECT definition

DefinitionElectroconvulsive Therapy (ECT): medical treatment involving brief electrical stimulation of the brain under anesthesia delivered by a trained medical team for severe, treatment‑resistant depression or bipolar disorder

Setting and staffAdministered in inpatient or outpatient settings by a psychiatrist, anesthesiologist, and nurse or physician assistant

PHP (alternate) definition

Alternate PHP definitionShort‑term, comprehensive, multidisciplinary behavioral health program providing stabilization and daily psychiatric evaluation with services similar to inpatient care

Use caseAlternative to or step‑down from inpatient care for acute/severe mental illness, SUD, or dual diagnosis

Program features6-9 hours per day, minimum 5 days/week; medication management and 24/7 physician emergency availability

Peer Support definition

DefinitionPeer Support: services provided by individuals with lived experience who assist and mentor people in recovery and link them to supports

CodingH0038 - Self‑help/peer services, per 15 minutes

RoleRemove barriers, provide recovery coaching, and connect members to recovery activities and supports

Medication Assisted Treatment (MAT) definition

DefinitionMedication Assisted Treatment (MAT): program involving administration of medications (e.g., methadone) by a licensed program for treatment of substance use disorders

CodingH0020 - Methadone administration and/or service; H0033 also listed

SettingProvided by licensed MAT programs and billed using HCPCS codes

Transcranial Magnetic Stimulation (TMS) definition

DefinitionTranscranial Magnetic Stimulation (TMS): non‑invasive procedure delivering repetitive magnetic pulses to targeted brain regions to modulate neural activity and treat disorders such as depression

CPT codes90867 (initial w/ mapping and motor threshold), 90868 (subsequent per session), 90869 (motor threshold re‑determination)

Procedure detailsUses a magnetic coil placed over the scalp to activate neurons in targeted regions

From EOS description

PHP continued stay: Ongoing need for daily psychiatric evaluation, multidisciplinary services, medication administration/management, physician availability for emergencies, and documented progress toward transition back to community supports.

From PHP continued stay criteria

IOP continued stay: Continued need for intensive structured therapy that cannot be met in standard outpatient settings.

From IOP continued stay criteria

EOS continued involvement: Ongoing need for home/community-based multidisciplinary interventions to support child/family functioning and prevent inpatient admission.

From EOS continued stay criteria

Partial Hospitalization Program (PHP) level-of-care criteria

Admission criteria: Member requires stabilization of acute/severe mental illness, substance use disorder, or dual diagnosis and can benefit from daily psychiatric evaluation and treatment comparable to inpatient care while returning to a supportive environment in the evening.

From PHP program description

Continued stay criteria: Member's symptoms require ongoing daily psychiatric monitoring and management; medication is administered/managed as needed; progress toward transition to community supports is documented; facility maintains 24/7 physician availability for emergencies.

From PHP continued stay description

Medication Assisted Treatment (MAT)

Medication Assisted Treatment (MAT) program coverage and coding notes

MAT services: MAT includes methadone administration and/or services provided by a licensed program billed with H0020; related MAT service codes such as H0033 may also apply.

From MAT description and coding

H0036 Modifier = HN (per coding table)

Psychiatric diagnostic evaluation (90791)

ServicePsychiatric diagnostic evaluation

Max allowed units90791 Max Allowed Units = 1 per year or new episode of care

ContextApplied within Enhanced Outpatient Services (EOS) coding limits

IOP minimum hours/days per H0015 description

IOP minimum intensityAt least 3 hours per day and at least 3 days per week (per H0015 description)

Program componentsAssessment, counseling, crisis intervention, activity therapies or education

Primary treatment modalityGroup therapy in a structured therapeutic milieu

Partial Hospitalization Program (PHP) — 6-9 hours per day

Daily duration6-9 hours per day

Program frequencyMinimum 5 days per week

Program purposeStabilization of acute/severe mental illness with daily psychiatric evaluation and transition planning