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CurrentNew Mexico Health Care AuthorityPolicy N/A

Accredited Residential Treatment Centers (ARTC) and Adult Accredited Residential Treatment Centers (AARTC) — Coverage Criteria

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Standards, provider eligibility, member eligibility, covered services, authorization, and billing rules for Accredited Residential Treatment Centers for Youth (ARTC) and Adult Accredited Residential Treatment Centers for Substance Use Disorder (AARTC) under New Mexico Medicaid.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyAccredited Residential Treatment Centers (ARTC) and AARTC coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for ARTC youth admissions and document services in the member's EPSDT health check or diagnostic evaluation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24/7ARTC provides

14 daysTreatment plan timeframe

$50/dayRoom & board supplement

5 daysInitial PA grace period

3.1–3.7WMASAM levels

Coverage and Medical Necessity Criteria

inv-01: ARTC for Youth — Coverage and Admission Criteria

Covered when ALL of the following are met

ARTC admission criteria: (1) Individual is under age 21; (2) Need for the ARTC level is documented in an EPSDT health check (42 CFR 441.57) or other diagnostic evaluation; (3) Less-restrictive settings (e.g., supervised community placement with parent/guardian/relative) have been considered and are inappropriate; (4) Clinical need for this level of care is documented; (5) The admitting facility is accredited, licensed, and certified for ARTC services; (6) Services will be furnished under the direction of a Medicaid board-eligible or -certified psychiatrist; (7) Prior authorization for admission has been obtained as required by policy.

Based on ARTC overview, eligible members, covered services, and authorization sections.

inv-02: AARTC (Adult SUD) — Coverage and Admission Criteria

Covered when ALL of the following are met

AARTC admission criteria: (1) Member meets the ASAM admission criteria for the specific ASAM level of care requested; (2) The facility is accredited and certified to provide that ASAM level; (3) Placement is to the ASAM level appropriate to the most acute problem identified in the assessment; (4) Provider offers medication for opioid use disorder (MOUD) when applicable; (5) Facility meets BHSD certification, life/safety, and site-visit requirements and is approved for the tier/level being billed.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyAccredited Residential Treatment Centers (ARTC) and AARTC coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for ARTC youth admissions and document services in the member's EPSDT health check or diagnostic evaluation.

SourceLink

On This Page

Derived from AARTC overview, provider requirements, eligible providers, and covered services sections.

inv-03: ARTC Covered Services — Required Components

Covered when provided as part of individualized treatment plan

Core ARTC services: Regularly scheduled counseling and therapy (individual, family, group) per the individual's treatment plan; age-appropriate skills development (household management, nutrition, personal care, life skills); assistance with self-administered medication; crisis response, stabilization and referrals; professional consultations; non-medical transportation needed to accomplish treatment objectives; therapeutic services addressing physical, social, cultural, recreational, health maintenance and rehabilitation needs; coordination with the member's educational program; and evaluations/psychological testing when not duplicative.

List drawn from Covered Services and Evaluations sections.

inv-04: ASAM Admission, WM, and Continued Stay Criteria

Covered when the following ASAM-based requirements are met:

ASAM Admission and Placement: Member meets ASAM criteria for the specific ASAM level of care and is admitted only to a facility accredited and enrolled for that ASAM level; level selection is guided by the most acute problem identified in assessment.

ASAM placement logic and facility accreditation requirements.

Withdrawal Management Admission (3.2-WM or 3.7-WM): Member exhibits withdrawal signs/symptoms sufficiently severe to require 24-hour structure and support; assessment includes a substance-use-focused history reviewed with an MD/CNP/PA, a physical exam by MD/CNP/PA within 24 hours, appropriate laboratory/toxicology testing, sufficient biopsychosocial screening, and a treatment plan addressing ASAM dimensions 2–6.

WM-specific assessment and admission elements.

Continued stay/transfer logic: Member continues at the ASAM level until withdrawal or presenting problems resolve to permit transfer to a less intensive level OR signs/symptoms fail to respond and require transfer to a more intensive WM level OR the member cannot complete WM at the level despite adequate trial; continued care beyond initial admission period requires concurrent authorization as specified.

Continued-stay and transfer conditions.

inv-05: LOCUS Tier 5C Criteria

Covered when ALL of the following LOCUS Tier 5C criteria apply:

Tier 5C Criteria: I.4d clear and chronic compromise of ability to care for self or awareness of environment; II.3e chronic and severe interpersonal skill deficits; III.4a chronic medical conditions requiring intensive monitoring; III.4b chronic medical conditions exacerbated by psychiatric/addiction problems requiring structured setting; III.4d substance use uncontrolled outside structured setting destabilizing psychiatric disorder; V.4a-b minimal past response to treatment and inability to maintain gains outside intensive structured setting; V.5a-b persistent symptoms despite extensive/intensive treatment exposure.

Tier 5C itemized criteria from LOCUS Tier 5C section.

inv-06: General LOCUS Level 5-based medical necessity

Covered when ALL of the following are met

LOCUS requirement: Meets criteria for LOCUS Level 5 (Medically Monitored Residential Services).LOCUS Level 5

Applies to Tier 5 residential placements.

Tier-specific additional criteria: Meets at least one tier-specific criterion (examples include chronic inability to care for self, chronic severe interpersonal deficits, chronic medical conditions requiring monitoring, uncontrolled substance use destabilizing psychiatric disorder, minimal past response to treatment, or persistent symptoms despite intensive treatment).at least one

Tier 5A/5B/5C examples documented in corresponding tier sections.

inv-07: Tier 5C (Moderate Intensity Long-Term Residential)

Tier 5C specific criteria (must meet LOCUS Level 5 AND at least one of following):

Tier 5C specific list: I.4d clear and chronic compromise of ability to care for self or awareness of environment; II.3e chronic and severe deficits in interpersonal skills and engagement; III.4a-c chronic medical conditions requiring intensive monitoring or exacerbated by psychiatric/addiction problems; III.4d substance use uncontrolled outside structured setting destabilizing psychiatric disorder; V.4a-b minimal past response to treatment and inability to maintain gains outside intensive structured setting; V.5a-b persistent symptoms despite extensive/intensive treatment exposure; VI items describing chronic inability to understand disability/recovery or relate to others.at least one

Specific Tier 5C items drawn from LOCUS Tier 5C criteria list.

inv-08: Tier 5B (Moderate Intensity Intermediate Stay Residential)

Tier 5B specific criteria (must meet LOCUS Level 5 AND at least one of following):

Tier 5B specific list: Meets LOCUS Level 5 and at least one of: history or low current risk of self/other harm with prior ideation; recent gains/stabilization in structured setting; significant interpersonal disturbance; serious role functioning impairment at work/school/home; active co-occurring substance use and mental health disorders impeding recovery; substance use temporarily arrested in structured setting without initiation of recovery; acute/unstable medical conditions needing monitoring; ongoing life circumstance difficulties exceeding ability to cope; difficulty developing/using supports; prior less-intensive treatments unsuccessful; agreement to participate despite limited insight.at least one

Tier 5B examples assembled from Tier 5B criteria sections.

inv-09: Tier 5A (Intensive Short-Term Residential/Subacute)

Tier 5A specific criteria (must meet LOCUS Level 5 AND at least one of following):

Tier 5A specific list: Meets LOCUS Level 5 and at least one of: current suicidal/homicidal ideation or history with elevated current risk (without means); history of chronic impulsive suicidal/homicidal behavior with current elevation; intoxication with potential for physiologic withdrawal needing monitoring; episodic substance use increasing risk/functional impairment; recent traumatic exposure affecting function; recent deterioration in supports; past treatments with little benefit or repeated inpatient admissions with limited benefit; limited desire/commitment to change.at least one

Tier 5A examples drawn from Tier 5A criteria text.

inv-10: Eligibility for ABA

Covered when ALL of the following apply depending on diagnosis status:

Diagnosed with ASD: Member has a documented medical diagnosis of autism spectrum disorder (ASD) based on the current DSM or ICD at time of diagnosis.

Diagnosed ASD eligibility criteria.

At-risk for ASD (time-limited ABA eligibility): Member is 12–36 months of age AND presents developmental differences/delays on standardized assessments AND demonstrates some ASD characteristics (e.g., social communication impairment, early restricted/repetitive behaviors) AND has at least one genetic risk factor (e.g., older sibling with ASD, Fragile X).All 4 required

At-risk eligibility is time-limited and requires all four characteristics.

inv-11: Treatment model selection and intensity

Choice between focused and comprehensive ABA based on number/complexity of targets and risk:

Focused ABA: Appropriate for limited, targeted functional skills or priority treatment of risky problem behavior; typically 10–25 hours/week of direct treatment (may exceed 25 hours for severe destructive behavior).10-25 hrs/week typical

Focused model intensity guidance.

Comprehensive ABA: Appropriate when multiple targets across most or all developmental domains are affected; often involves 30–40 hours/week of 1:1 direct treatment, with gradual adjustment over time as appropriate.30-40 hrs/week typical

Comprehensive model intensity guidance.

inv-12: Stage-based service criteria

Services are provided in three stages; progression and prerequisites are required:

Stage 1: Evaluation (CDE/Targeted): AEP conducts a comprehensive diagnostic evaluation (CDE) or targeted evaluation after screening positive, develops the Integrated Service Plan (ISP), recommends Stage 2 services, and refers to an approved ABA provider. For previously diagnosed members a CDE/targeted evaluation must be scheduled prior to accessing Stage 2/approved Stage 3 services (grace exception details apply).

Stage 1 prerequisites and role of AEP.

Stage 2: Assessment and Treatment Planning: Behavioral/functional analytic assessment is completed; supervising Behavior Analyst (BA) determines service model, selects/measures goals, and develops the individualized ABA treatment plan in collaboration with family and team.

Stage 2 assessment and BA responsibilities.

Stage 3: Treatment Delivery: Treatment is implemented per the individualized plan; Stage 3 requires clinical management and prior authorization, and BAA/BT implementing treatment receive frequent ongoing supervision from the BA (BACB requires at least 5% of service hours supervised).>=5% supervision

Stage 3 prior authorization and supervision expectations.

inv-13: General coverage prerequisites

Covered when ALL of the following apply

Basic coverage prerequisites: Member must be Medicaid eligible and have an ASD diagnosis (or meet at-risk criteria where applicable); ABA Stage 2 and Stage 3 services require prior authorization with submission of required documentation (CDE/targeted evaluation, ISP, ABA treatment plan) per authorization rules.

General prerequisites and documentation requirements for ABA services.

inv-14: Tier 3 coverage

Tiered services and limits

Tier 3 high-risk intervention access: Adults with destructive or self-injurious behavior or behavior injurious to others, where adaptive coping has become maladaptive and there is risk of ER/inpatient/incarceration, may access Adult ABA Tier 3 services; accessing Tier 3 does not necessarily require prior access to Tier 2. Maximum without prior authorization: Tier 3 up to 30–40 hrs/week for up to 8 weeks (time-limited without prior auth per policy).30-40 hrs/week; up to 8 weeks without prior auth

Tier descriptions and time-limited prior-authorization easements.

inv-15: Concurrent billing and supervision rules

Coverage and billing rules for ABA Stage 3 management, clinical management, and indirect/direct case supervision when delivered via telehealth

Concurrent billing permissions: T1026 UD (ABA Stage 3 management/indirect/direct case supervision) may be billed concurrently with technician-delivered codes such as 97153 and 97154 and, in specified contexts, with 97155 (when not delivered via telemedicine) and family guidance codes (e.g., 97156) when rendered by authorized provider roles; concurrency depends on provider role and telemedicine status as described in billing rules.

Concurrent-billing allowances described across ABA billing sections.

Concurrent billing prohibitions: Do not bill T1026 UD or indirect/direct case supervision concurrently with CPT 0373T in specified contexts; multiple passages reinforce 'Do not bill concurrently with 0373T.'

Prohibition repeated in supervision/billing notes.

inv-16: ASAM Level 1 Admission Criteria (summary)

ASAM Level 1 / 1-WM is covered when patient status meets the ASAM dimensional admission criteria for outpatient low-intensity care.

ASAM Level 1 admission general conditions: Patient has no or only very mild withdrawal manageable in an outpatient/Level 1 setting; biomedical conditions are sufficiently stable for outpatient care; emotional/behavioral/cognitive conditions do not pose imminent risk to self/others and permit participation; patient demonstrates readiness to participate and pursue recovery goals; recovery environment is sufficiently supportive or patient is motivated to obtain supports (Dimension 1–6 assessed at Level 1 descriptors).Dimensions 1–6 consistent with Level 1

Summary of ASAM Level 1 dimensional criteria for adolescents and adults.

inv-16: ASAM Level 1 / 1-WM conjunctive criteria

Covered when ALL of the following are met (repeated phrasing in source):

Primary clinical/social criteria: 1) Patient has a severe and chronic mental, emotional, behavioral, or cognitive condition; AND 2) Patient does not have an adequate family or social support system; AND 3) Patient is chronically impaired but not in imminent danger and has limited ability to establish supports. These three conjunctive elements are repeatedly stated as determinative for outpatient ASAM Level 1 candidacy.

Three-part conjunctive criteria repeated across ASAM Level 1 sections.

inv-17: ASAM Level 1 / 1-WM conjunctive criteria

Covered when ALL of the following are true (supportive recovery environment domain for ASAM Level 1 / 1-WM):

Supportive recovery environment domain criteria: 1) Patient has a severe and chronic mental, emotional, behavioral, or cognitive condition; 2) Patient does not have an adequate family or social support system; 3) Patient is chronically impaired but not in imminent danger and has limited ability to establish a supportive recovery environment.none

This three-part test is presented repeatedly as required for the supportive recovery environment domain.

inv-18: ASAM Level 1 / 1-WM coverage criteria

Covered when ALL of the following are true (criteria repeated throughout the section):

ASAM Level 1/1-WM core criteria: 1) Patient has a severe and chronic mental, emotional, behavioral, or cognitive condition; 2) Patient lacks an adequate family or social support system; 3) Patient is chronically impaired but not in imminent danger and has limited ability to establish a supportive recovery environment. Access to outreach and case management that can provide structure may modify placement and support outpatient care.

Core ASAM Level 1/1-WM criteria with notation that outreach/case management access is a modifying factor.

inv-19: ASAM Level 1 / 1-WM Coverage Criteria

Covered when ALL of the following are present

ASAM Level 1 candidate criteria: 1) Presence of a mental disorder or significant emotional/behavioral/cognitive condition; 2) Lack of an adequate family or social support system; 3) Chronic impairment but not in imminent danger; AND 4) Access to outreach and case management services that can provide structure to support outpatient engagement.

Integrates the three core elements with access to outreach/case management as enabling factor.

inv-20: ASAM Level 1 / 1-WM placement considerations

ASAM Level 1 / 1-WM placement considerations center on the following member characteristics:

Core considerations: Assessment must document (1) adequacy of family or social support system; (2) presence of chronic impairment related to substance use disorder but not in imminent danger; and (3) whether the member has access to outreach and case management services that can provide structure to enable participation in outpatient treatment. All three domains are emphasized when considering ASAM Level 1/1-WM placement.

Placement considerations emphasize supports, chronic impairment, and access to outreach/case management.

inv-21: ASAM Level 2-WM Covered Services and Continuation

Covered services for ASAM Level 2-WM include:

ASAM Level 2-WM covered services: Individual assessment; medication or non-medication withdrawal management methods; patient education; non-pharmacological clinical support; involvement of family or significant others; and discharge and transfer planning. Member continues in Level 2-WM until withdrawal signs/symptoms resolve, fail to respond and intensify requiring higher level, or member cannot complete WM at level 2-WM despite adequate trial.

ASAM Level 2-WM service elements and continuation logic.

inv-22: ASAM Level 4 Admission Criteria

ASAM Level 4 admission requirements:

ASAM Level 4 admission: Requires diagnostic criteria for a substance use or substance-induced disorder and meeting required dimensional criteria in at least one of Dimensions 1, 2, or 3; referral from an independent practitioner or transfer from an emergency department; and physician in the hospital or IMD must accept the patient. Prior authorization for Level 4 placement is required.

ASAM Level 4 admission core requirements and authorization requirement.

inv-23: ASAM Level 4 Admission Criteria

Covered when ALL of the following are met:

ASAM Level 4 admission core requirements: Diagnostic criteria for a substance use or substance-induced disorder; required dimensional criteria in at least one of Dimensions 1, 2, or 3; referral from an independent practitioner or ED transfer; and physician acceptance by the hospital/IMD. Only meeting Dimensions 1–3 (not Dimensions 4–6 alone) supports placement in ASAM Level 4.

Includes examples of severe biomedical, withdrawal, and psychiatric conditions that meet Dimension 1–3 thresholds.

Dimension 1 severe conditions (examples): Severe withdrawal, delirium, hallucinosis, seizures, severe agitation, psychosis, unremitting suicide risk, recent serious head trauma, compromised mental status or vital functions due to overdose, or significant acute biomedical disorder posing life-threatening risk during withdrawal.

Dimension 1 examples from Level 4 admission guidance.

Dimension 2 biomedical complications (examples): Biomedical complications requiring medical management and skilled nursing care, concurrent biomedical illness or pregnancy requiring stabilization and daily medical management, recurrent/multiple seizures, or disulfiram-alcohol reaction.

Dimension 2 examples.

Dimension 3 emotional/behavioral/cognitive complications (examples): Dangerousness/lethality (imminent suicidal/homicidal risk or psychosis), interference with recovery due to severe psychiatric problems, uncontrolled behavior posing imminent danger, mental confusion or fluctuating orientation posing imminent danger, severe impairment in social functioning, or concurrent serious emotional/behavioral/cognitive disorder requiring stabilization and daily psychiatric management.

Dimension 3 examples.

inv-24: ASAM Level 4-WM (Withdrawal Management) Criteria

ASAM Level 4-WM specific coverage:

ASAM Level 4-WM eligibility: Withdrawal symptoms severe enough to require primary medical and nursing services in an inpatient acute care hospital; assessment for treatment priorities in ASAM Dimensions 2–6; services delivered by physicians available 24 hours/day and hourly or more frequent nurse monitoring available.

Defines when ASAM Level 4-WM is the appropriate setting.

inv-25: ASAM Level 4-WM medical necessity

Covered when ALL of the following are met

ASAM Level 4-WM admission requirements: Admission approval by a physician; comprehensive nursing assessment; comprehensive history and physical within 12 hours of admission with appropriate laboratory and toxicology testing; substance-use-focused history; sufficient biopsychosocial screening to determine placement; treatment planning including discharge/transfer planning beginning after level identification; and daily interdisciplinary assessment of progress. Prior authorization for ASAM Level 4-WM placement must be approved by a physician.

Admission, documentation, monitoring, and authorization requirements for Level 4-WM.

inv-26: ACT coverage and staffing criteria

Covered when ALL of the following are met

ACT agency and team requirements: Agency has HCA approval prior to providing ACT; agency demonstrates compliance with state administrative, financial, clinical, quality improvement, and information systems requirements and fidelity to the ACT model; team typically comprises 10–12 interdisciplinary staff providing 24/7 services with a staff-to-member ratio around 1:10 (BHSD may approve smaller teams with justification); required team roles include an independently licensed team leader, medical director/prescriber (psychiatrist or other approved prescriber), licensed nursing, MAD-recognized licensed behavioral health professionals (including SUD expertise), employment specialist, certified peer/family peer support worker, and administrative support.

ACT approval, team composition, staffing, and fidelity requirements.

ARTC services cannot be billed in combination with (1) services for which prior approval was not requested and approved; (2) formal educational or vocational services that concern traditional academic subjects or vocational training; and (3) activity therapy, group activities, or other services that are primarily recreational or diversional in nature. Agencies may not bill for days when the Medicaid member is absent from the facility (therapeutic leave or trial community placement) because a vacancy factor is built into reimbursement.

Members must be admitted only to a facility that is accredited and enrolled for the ASAM or LOCUS level of care appropriate to the member’s most acute problem; placement into a non‑accredited or non‑enrolled level is not permitted. The level of service and level of care is determined by the assessment and the most acute problem identified, and transfers to other levels occur based on treatment progress and outcomes rather than predetermined lengths of stay.

Applied Behavior Analysis (ABA) services that are not designed to accomplish objectives in the individualized ABA treatment plan are non‑covered. Examples include activities that are not based on ABA principles, services that are better described as another therapeutic discipline (e.g., speech‑language therapy, occupational therapy, physical therapy, counseling), and activities that are primarily staff training, certification, or licensure supervision rather than ABA case supervision.

Do not bill ABA indirect/direct case supervision or related supervision claims concurrently with CPT 0373T where the document indicates a concurrency prohibition. The policy explicitly repeats the instruction: do not bill concurrently with 0373T in the supervision and telehealth billing guidance.

ASAM Level 1 (outpatient) is not appropriate for patients who are experiencing acute or subacute withdrawal with risk beyond very mild symptoms; Dimension 1 requires that the member is not experiencing acute or subacute withdrawal at risk of acute complications or that any withdrawal present is only very mild and safely manageable in a Level 1 outpatient setting.

Procedure, Revenue, and Tracking Codes

Behavioral health facility revenue codesRevenueCovered

revenue code 1001	psychological services (UB claim form)
revenue code 1002	chemical dependency services (UB claim form)

Procedure / HCPCS codes referencedHCPCS

H0002	ASAM level of care assessment
H0019	Procedure code referenced for billing (Tier 1/ASAM Level 3.1 admission)
H0018	Procedure code referenced for billing (Tier 2/ASAM Levels 3.3/3.5)
H0017	Procedure code referenced for billing (Tier 3/ASAM Level 3.7)
H0010	HCPCS/WM tracking code for withdrawal management (added with revenue code 0229)
H0047	Room and board billing code for BHSD supplementary payment

Revenue codesRevenue

Revenue 1003	Revenue code for UB claim billing for AARTC services (used with procedure codes H0019/H0018/H0017)
Revenue 0229	Revenue code to add for withdrawal management tracking (used with H0010)

Room and board add-onHCPCSCovered

H0047

Room and board (used by agencies to bill BHSD $50/day add-on for AARTC)

LOCUS assessment code (forthcoming)mixed

Procedure code to be used for LOCUS level of care assessment (to be provided later)

Service Codes referenced for Adult ABA tiers and Stage 3CPTCovered

97153	Adaptive behavior treatment by protocol
97154	Group adaptive behavior treatment by protocol
97158	Group adaptive behavior treatment (per protocol) — exact description as used in doc
97155	Adaptive behavior treatment with protocol modification (supervised)
97156	Family adaptive behavior treatment guidance
97157	Multiple-family group adaptive behavior treatment guidance
T1026 UD	Unspecified home/community-based waiver or ABA support code (as referenced)

Stage 1 diagnostic and ISP codesHCPCSCovered

T1026 TG	Comprehensive Diagnostic Evaluation (CDE) — one 60-minute unit per day
T1026 HK	Targeted/Risk Evaluation — five 60-minute units per evaluation
T1026 TG/HI	Integrated Service Plan (ISP) — three 60-minute units
T1026 HK/HI	ISP Update — two 60-minute units

ABA Stage 2 and 3 CPT and temporary codesCPT|HCPCS|mixedCovered

97151	Behavior Identification Assessment — unit = 15 minutes; general limit eight units; total units may not exceed 25 units/day
97152	Behavior Identification Supporting Assessment — unit = 15 minutes; total units may not exceed 32 units
0362T	Adaptive (context shows use with adaptive behavior services; 0373T referenced elsewhere for special conditions)
0373T	Code requires prior authorization; used for high-intensity adaptive behavior situations (destructive behavior, QHP on-site, multiple technicians, environment customization)
97153	Adaptive Behavior Treatment by Protocol — individual (15-min unit); administered by technician under direction of QHP
97154	Adaptive Behavior Treatment by Protocol — group (15-min unit)
97155	Adaptive Behavior Treatment with Protocol — QHP-administered (15-min unit); at least four 15-minute units (one hour) required
97156	Family Adaptive Behavior Treatment Guidance — one family (15-min unit)
97157	Family Adaptive Behavior Treatment Guidance — two or more families (15-min unit)
97158	Adaptive Behavior Treatment with Protocol (group) — 15-min units for group

ABA service and supervision codes referencedmixed

97153	Adaptive behavior treatment by protocol (per session)
97154	Group adaptive behavior treatment (per session)
97155	Adaptive behavior treatment with protocol modification
97156	Family adaptive behavior treatment guidance, one family
97157	Family adaptive behavior treatment guidance, two or more families
97158	Group adaptive behavior treatment (other supervisory/mentored contexts referenced)
T1026 UD	Case management/behavioral health intervention code used for indirect/direct supervision/management; flagged UD in this document

Prohibited concurrent codeCPTNot Covered

0373T

Supervisor/mentoring code (not to be billed concurrently as noted)

ABA supervision / applied behavior analysis codes referencedCPT | HCPCS

97153
97154
97155	(without telemedicine) referenced
97156	rendered by a BA to a Mentored BA/BAA
97157	rendered by a BA to a Mentored BA
97158	rendered by a BA to a Mentored BA
0373T

Withdrawal management tracking codeCPTCovered

H0014

Behavioral health procedure code to be used for withdrawal management tracking purposes

Procedure codes for professional services (medical detoxification)CPT | HCPCS | mixedCovered

9922x series	Initial hospital care
9923x series	Subsequent hospital care
99238	Discharge Day management
99239	Discharge Day management
H0009	Withdrawal management tracking (procedure code referenced for tracking purposes)

Revenue codesRevenueCovered

0116	Room and Board - Private room
0126	Room and Board - Semi-Private (Two Beds) Detoxification
136	Room and Board - Semi-Private (Three or Four Beds) Detoxification
156	Room and Board - Ward
250	Pharmacy
260	IV therapy
270	Medical/ Surgical Supplies and Devices
300	Laboratory
320	Radiology - Diagnostic
450	Emergency Room

1–10 of 12

1/2

DRG Codes (acute care hospital billing)DRG

DRG (unspecified list in policy)

DRG codes for medical detox; includes Alcohol/Drug Use Disorder treatment with/without rehabilitation therapy and with/without major complications or comorbidities

Inpatient/revenue and tracking codesRevenue | HCPCS | mixed

0116	Revenue code for private room, Medicaid members age 22-64
0126	Revenue code for semi-private room, Medicaid members age 22-64
0114	Revenue code for private room, Medicaid members age 65 and older
0124	Revenue code for semi-private room, Medicaid members age 65 and older
0229	Revenue code for withdrawal management tracking
H0009	Procedure code to be added for withdrawal management tracking

Out-of-state distance reimbursement rule — ARTC

Out-of-state ARTC reimbursementOut-of-state ARTC providers located more than 100 miles from the New Mexico border are reimbursed at the fee schedule unless a separate rate is negotiated.

UB revenue code for ARTC psychological servicesrevenue code 1001 (used on UB claim form for psychological services in ARTC for Youth).

UB revenue code for ARTC chemical dependency servicesrevenue code 1002 (used on UB claim form for chemical dependency services in ARTC for Youth).

BHSD room & board supplement

BHSD room & board supplement amount$50 per client per day (BHSD State General Fund supplement for AARTC room and board).

Billing procedure code for room & board supplementH0047 (used by agencies to bill BHSD $50/day add-on for AARTC; FFS only).

FFS vs MCO noteSupplement funded by BHSD Star system is available only for AARTCs billing Medicaid fee‑for‑service and is not reimbursed by Medicaid managed care.

Initial prior authorization grace period

Initial prior authorization grace periodUp to 5 days without prior authorization for eligible in‑state Medicaid members who meet LOCUS Level 5; during this period the AARTC must notify HCA and furnish medical necessity documentation.

Concurrent authorization requirement after grace periodConcurrent authorization from MAD or its designee (or relevant MCO) is required for continued care beyond the initial five‑day admission period or prior to moving to a different level of care.

Out‑of‑state AARTC authorizationPrior authorization is required prior to placement for out‑of‑state AARTCs (no 5‑day grace applies).

Adult ABA tier weekly hours

Adult ABA Tier weekly hours (Tier 1)Tier 1: maximum of 10–15 hours per week for combined service codes (97153/97154/97158).

Adult ABA Tier weekly hours (Tier 2)Tier 2: maximum of 20–30 hours per week for combined service codes (97153/97154/97158) for up to 6 weeks without prior authorization.

Adult ABA Tier weekly hours (Tier 3)Tier 3: maximum of 30–40 hours per week for combined service codes (97153/97154/97158) for up to 8 weeks without prior authorization.

Minimum 97155 rendering ratio

Minimum 97155 rendering ratioAt least four 15‑minute units (one hour) of 97155 must be rendered for every eighty 15‑minute units (20 hours) of combined technician‑delivered units (e.g., 97153, 97154, 97156).

Scope of 9715597155 (adaptive behavior treatment with protocol modification) is administered by a QHP (BA/BAA/BA Candidate/Supervising BAA) and counts toward the required ratio.

Applies across individual and group contextsThe 97155 minimum-one‑hour requirement applies for individual and group protocol modification contexts (97155/97158 combinations).

Weekly service time limits

Weekly service time limits — adultsAdult ASAM Level 1 program services are provided less than 9 hours per week.

Weekly service time limits — adolescentsAdolescent ASAM Level 1 program services are provided less than 6 hours per week.

Coverage impactExceeding these weekly hour thresholds for ASAM Level 1 services may affect coverage or authorization determinations.

Prior Authorization, Documentation, and Operational Actions

Prior Authorization

ARTC for Youth admissions require prior authorization

Admissions to ARTC for Youth require prior authorization. Services and supporting documentation must be entered into the Medicaid member’s EPSDT (tot to teen) health check screen or other diagnostic evaluations at admission.

Prior Authorization

5‑day in‑state grace period and concurrent‑auth obligations

For eligible in‑state Medicaid members, prior authorization is not required for up to five days from admission; the facility must notify HCA about the admission during that period and obtain concurrent authorization if continued care is necessary. Out‑of‑state AARTCs require prior authorization prior to placement.

Notify HCA about the admission during the five‑day window.
Obtain concurrent authorization from MAD or its designee, or the relevant MCO, if continued care is needed beyond five days.
Secure prior authorization before placing out‑of‑state AARTC members.

Prior Authorization

Initial 5‑day window for LOCUS Level 5 — PA required thereafter

For initial LOCUS Level 5 admissions, prior authorization is not required for up to five days; prior authorization (concurrent authorization) is required before continuing care beyond that initial five‑day admission period.

Notify HCA and furnish medical necessity documentation during the five‑day initial admission window.
Obtain concurrent authorization prior to continuing beyond five days.

Prior Authorization

Prior authorization required for ABA Stage 3 and adult tiered services

Stage 3 ABA services and Adult ABA Tier services require prior authorization. Adult ABA tiers specify maximum authorized hours for combinations of 97153, 97154, and 97158 (codes 97155, 97156, 97157 and T1026 UD are excluded from those maximum hour calculations).

Submit prior authorization for Stage 3 before services are rendered and per renewal rules.
Follow tiered weekly hour maxima when requesting authorization for combinations of 97153, 97154, and 97158.

Prior Authorization

Initial PA periods and reauthorization schedule for ABA

Initial prior authorization periods: three years for members aged 12 months–8 years and six years for members aged 8 years and older. After services begin, prior authorization is required before Stage 3 services and every six months thereafter for renewals.

Initial PA period: 3 years (12 months–8 years) or 6 years (age ≥8).
Reauthorize Stage 3 services every six months after service initiation.

Prior Authorization

No prior authorization required for ASAM Level 1

ASAM Level 1 outpatient services do not require prior authorization.

Prior Authorization

ASAM Level 2‑WM no PA; ASAM Level 4 placement requires PA and physician acceptance

ASAM Level 2‑WM does not require prior authorization. Placement in ASAM Level 4 requires prior authorization and physician acceptance (referral or ED transfer and documented physician acceptance are required).

Do not require PA for ASAM Level 2‑WM admissions.
Obtain prior authorization and document physician acceptance and referral/ED transfer for ASAM Level 4 placement.

Prior Authorization

Physician‑approved prior authorization required for ASAM Level 4‑WM

Prior authorization is required for ASAM Level 4‑WM placement and must be approved by a physician.

Document physician approval on the prior authorization for Level 4‑WM placement.

Note

Place members in ASAM level matching the most acute problem

Place members in the ASAM level of care appropriate to the most acute problem identified in the assessment; transfers between levels are determined by progress/outcomes rather than fixed lengths of stay.

Document the most acute problem identified in the assessment to justify level placement or transfers.

Note

Step Therapy

Stage‑sequencing: confirm diagnosis and ISP before Stage 2/3

Stage 1 (evaluation) must confirm diagnosis/need and produce an Integrated Service Plan (ISP) before accessing Stage 2 or Stage 3 ABA services; for previously diagnosed members a CDE or targeted evaluation must be scheduled prior to Stage 2/approved Stage 3 services.

AEP must perform CDE or targeted evaluation and develop ISP in Stage 1.
Schedule CDE/targeted evaluation before Stage 2/Stage 3 for previously diagnosed members.

Note

Tier 3 access does not require prior Tier 2 access

Accessing Adult ABA Tier 3 services does not necessarily require prior access to Adult ABA Tier 2 services.

Documentation Required

ASAM Level 1‑WM requires specialist consultation, labs, and 24‑hour emergency access

ASAM Level 1‑WM outpatient services depend on access to specialized psychological/psychiatric consultation and supervision; programs must be able to conduct or arrange appropriate laboratory and toxicology testing and have 24‑hour access to emergency medical services when indicated.

Ensure access to specialized psychological/psychiatric consultation and supervision.
Maintain ability to conduct/arrange laboratory and toxicology testing and 24‑hour emergency medical access.

Note

ASAM Level 2‑WM continuation logic — continue until resolved, escalated, or completed

Members in ASAM Level 2‑WM continue in level 2‑WM until withdrawal resolves, fails to respond and requires transfer to a higher level, or the patient completes the program; continued stay decisions follow these clinical criteria.

Billing Rule

Facility billing: UB claim with per‑diem bundled daily rate and professional claims

Facilities must bill all ASAM Level 4 services on a UB claim form using a per‑diem bundled daily rate (depending on bed type) and submit accompanying professional claims as required.

Bill facility services on UB claim with per‑diem bundled daily rate appropriate to bed type.
Submit accompanying professional claims for physician and clinical services.

Note

ASAM Level 4‑WM: daily re‑evaluation and continuation until withdrawal resolves

Members continue ASAM Level 4‑WM until withdrawal signs/symptoms are sufficiently resolved to transfer to a lower level of care; daily interdisciplinary reassessment of progress and treatment changes is required.

Perform daily interdisciplinary assessment of progress and treatment changes.
Continue Level 4‑WM until medically stable for transfer to a lower level.

Documentation Required

Develop treatment plan within 14 days and review monthly

Develop a treatment plan within 14 days of admission by an interdisciplinary team; the plan must include a cultural needs statement and be reviewed at least every 30 days, with all supporting documents available in the member’s file.

Treatment plan developed within 14 days of admission.
Review treatment plan at least every 30 calendar days and keep supporting documents in the member’s file.

Documentation Required

Provide accreditation report, QI plan, and personnel background verification

Facilities must provide recent accreditation reports and any quality improvement plan as part of certification; comply with state background check and employment verification requirements.

Provide most recent accreditation report and QI plan for certification.
Comply with state background check and employment history verification rules.

Documentation Required

Document assessments supporting ASAM placement and WM admission requirements

Assessment documentation at admission must support ASAM placement and for withdrawal management include a substance‑use‑focused history reviewed with MD/CNP/PA, a physical exam by MD/CNP/PA within 24 hours, appropriate laboratory and toxicology tests, and sufficient biopsychosocial screening.

Include substance‑use‑focused history reviewed with MD/CNP/PA.
Perform physical exam by MD/CNP/PA within 24 hours of admission and order appropriate labs/toxicology.
Document biopsychosocial screening to justify level placement.

Documentation Required

Notify HCA and provide medical necessity documentation during 5‑day grace period

During the five‑day initial admission window the AARTC must notify HCA about the admission and furnish medical‑necessity documentation based on LOCUS Level 5 or ASAM placement criteria to obtain concurrent authorization if continued care is needed.

Notify HCA within the five‑day initial admission period.
Furnish medical necessity documentation tied to LOCUS Level 5 or ASAM placement criteria to secure concurrent authorization.

Documentation Required

Stage 1 evaluation, ISP, Stage 2 plan, and Stage 3 supervision requirements

For Stage 1, the Autism Evaluation Provider (AEP) must conduct a Comprehensive Diagnostic Evaluation (CDE) or targeted evaluation and develop an Integrated Service Plan (ISP) before Stage 2/3; Stage 2 must produce the ABA treatment plan and Stage 3 requires documented clinical management and supervision.

Stage 1: CDE or targeted evaluation and ISP development by AEP.
Stage 2: Behavior/functional analytic assessment and ABA treatment plan by supervising BA.
Stage 3: Clinical management and supervision with required BACB ≥5% supervision.

Documentation Required

Required documentation to support Stage 3 prior authorization requests

Prior authorization requests for Stage 3 must include the CDE/targeted evaluation and ISP from Stage 1, the ABA treatment plan from Stage 2, the ABA treatment model and requested maximum hours/week, requested case supervision and clinical management hours (if >2 hours per 10 intervention hours), any identified ABA specialty care, and hours allocated to other ISP services.

Attach the CDE/targeted evaluation and ISP.
Include the Stage 2 ABA treatment plan and the ABA treatment model with requested max hours/week.
Document requested case supervision and clinical management hours when >2/10 intervention hours.
List any ABA specialty care needs and hours allocated to other ISP services.

Documentation Required

Document service type, provider role, and T1026 UD usage

Documentation must support service format (one‑family 97156 vs two‑or‑more families 97157), the provider role (BA, BAA, BA Candidate, Supervising BAA, QHP), and whether T1026 UD is billed for guidance/management/indirect supervision contexts.

Specify family format (97156 vs 97157) in documentation.
Document the provider role delivering the service for each billed code.
Support any T1026 UD billing with documentation of guidance/management/indirect supervision.

Documentation Required

Maintain lab/toxicology capability and 24‑hour emergency access

Programs must be able to conduct or arrange appropriate laboratory and toxicology testing and provide 24‑hour access to emergency medical services when indicated for withdrawal management and ASAM services.

Documentation Required

Document severe/chronic condition and family/social support assessment

Documentation should reflect presence of a severe and chronic mental, emotional, behavioral, or cognitive condition and include assessment of family/social support adequacy when justifying ASAM Level 1/1‑WM placement.

Document severe/chronic condition in clinical record.
Document assessment of family/social support adequacy to justify level placement.

Billing Rule

Link professional detox procedure codes to substance‑withdrawal ICD codes

Professional service procedure codes for medical detoxification (initial, subsequent, discharge) must be linked with the relevant ICD code for substance use withdrawal when billing ASAM Level 4/WM professional services.

Link CPT hospital care and discharge procedure codes (9922x, 9923x, 99238/99239) to the appropriate substance‑withdrawal ICD code on claims.

Documentation Required

ASAM Level 4‑WM admission: physician approval, nursing assessment, and H&P within 12 hours

At ASAM Level 4‑WM admission ensure physician admission approval, a comprehensive nursing assessment, and a comprehensive history and physical within 12 hours with appropriate laboratory and toxicology tests and substance‑use focused history.

Obtain physician admission approval at time of admission.
Complete comprehensive nursing assessment and H&P within 12 hours with labs/toxicology and substance‑use history.

Denial Risk

Failure to obtain prior authorization may trigger denial for ARTC Youth admissions

Admissions to ARTC for Youth require prior authorization; failure to obtain required prior authorization may lead to denial of admission‑related claims.

Obtain prior authorization before admission to avoid claim denials.

Billing Rule

Do not bill for member absence days (therapeutic leave/trial community placement)

Days when the Medicaid member is absent from the facility for therapeutic leave or trial community placement cannot be billed; agencies cannot be reimbursed for unbilled absence days.

Do not bill for days the member is absent from the facility (therapeutic leave/trial community placement).

Denial Risk

Risk of denial if HCA not notified and medical necessity not furnished during 5‑day window

Failure to notify HCA about an admission and furnish medical‑necessity documentation based on ASAM placement criteria within the five‑day initial admission period may prevent concurrent authorization for continued care.

Notify HCA and provide ASAM placement medical necessity documentation within five days to preserve ability to obtain concurrent authorization.

Denial Risk

Concurrent authorization required for continued stay — failure may lead to denial

Failure to obtain concurrent authorization from MAD or its designee, or the relevant MCO, for continued care beyond the initial five‑day admission period (or prior authorization for out‑of‑state AARTCs) may result in denial of payment.

Secure concurrent authorization before continuing care beyond five days to avoid denial.
Obtain prior authorization before placing out‑of‑state AARTC members.

Denial Risk

Non‑covered ABA services — risk of denial if billed

Services not designed to accomplish objectives in the ABA treatment plan, not based on ABA principles, better described as another therapeutic service, or primarily staff training/supervision are non‑covered and subject to denial.

Ensure ABA services align with the individualized ABA treatment plan and ABA principles.
Do not bill ABA for services better described as speech, OT, PT, counseling, or staff training.

Denial Risk

PA required for ABA Stage 2 and Stage 3 — failure risks non‑authorization

Prior authorization is required for ABA Stage 2 and Stage 3 services; failure to secure prior authorization before rendering Stage 3 services (and at required renewal intervals) can result in services being non‑authorized.

Obtain initial prior authorization before rendering Stage 3 services.
Submit required documentation and renew Stage 3 authorization every six months as specified.

Denial Risk

Do not bill T1026 UD or supervision codes concurrently with 0373T

Do not bill T1026 UD or indirect/direct case supervision concurrently with CPT 0373T; claims that bill T1026 UD or supervision services concurrently with 0373T may be denied.

Avoid concurrent billing of T1026 UD or supervision services with 0373T to prevent denials.

Denial Risk

ASAM Level 1 weekly service time thresholds (adults <9 hrs; adolescents <6 hrs)

Adult services for ASAM Level 1 programs are provided less than nine hours weekly, and adolescent services less than six hours weekly; exceeding these weekly thresholds may affect coverage.

Limit adult ASAM Level 1 services to under 9 hours/week and adolescent services to under 6 hours/week to align with coverage expectations.

Denial Risk

Risk of denial if documentation does not demonstrate chronic impairment and limited supports

Coverage decisions depend on documentation showing the member is chronically impaired but not in imminent danger and has limited ability to establish a supportive recovery environment; lack of these documented characteristics may risk denial.

Document chronic impairment, lack of adequate family/social support, and lack of imminent danger to support ASAM Level 1 placement.

Level-of-Care and Residential Tier Criteria

Applied Behavior Analysis Eligibility and Operational Rules

Available Treatments and Service Modalities

Service Duration, Units, and Visit Limits

Therapeutic leave / trial community placement (vacancy factor)

Vacancy factorA vacancy factor of 24 days annually per Medicaid member is built in for therapeutic leave and trial community placement (these days are not billable)

Billing prohibitionAgencies cannot bill or be reimbursed for days when the Medicaid member is absent from the facility

PurposeCaptures therapeutic leave and trial community placement allowances in cost/reimbursement calculations

ASAM Level 3.1 minimum weekly hours

Minimum weekly hoursASAM Level 3.1 provides a minimum of five hours of low-intensity SUD treatment per week

Service typesIncludes individual, group, and family therapy, medication management, psychoeducation and recovery skills

Residential componentResidential stability at Level 3.1 supports relapse prevention and may combine with IOP if dimensional criteria met

Initial admission without prior authorization (days)

Initial admission without prior authorization (days)5

ApplicabilityApplies to eligible in-state Medicaid members meeting LOCUS Level 5 criteria to facilitate immediate admission

Concurrent authorization requirementConcurrent authorization required for continued care beyond the initial period

Combination codes and tier weekly maxima

Combined-code maximaTier-specific weekly hour maxima apply to combinations of 97153, 97154, and 97158 (service codes for adult ABA tiers)

Exclusions from maximaCodes 97155, 97156, 97157 and T1026 UD are not included in the maximum-hour calculations

Tier referencesTier 1/2/3 weekly maximums defined elsewhere in policy (10–15; 20–30; 30–40 hrs/week respectively)

97151 Behavior Identification Assessment limits

97151 daily limitBehavior Identification Assessment units may not exceed 25 units per day

Unit definitionUnit = 15 minutes for 97151

AdministrationAdministered by a qualified health professional (BA/QHP) and must be in process to bill certain supporting assessments

97152 Behavior Identification Supporting Assessment limits

97152 total units limitBehavior Identification Supporting Assessment total units may not exceed 32 units

Unit definitionUnit = 15 minutes for 97152

PrerequisiteA Behavior Identification Assessment must be in process to bill the Supporting Assessment

Combined technician-delivered units daily limit

Combined technician-delivered daily limitCombined technician-delivered units (97153, 97154) may not exceed 32 units per day (equivalent to 8 hours)

Unit definitionOne unit equals 15 minutes for technician-delivered ABA services

ContextLimit applies to combined daily total of these technician codes to cap technician time per day

ASAM Level 1 program weekly service limits

ASAM Level 1 adult weekly capAdults: services provided less than 9 hours per week

ASAM Level 1 adolescent weekly capAdolescents: services provided less than 6 hours per week

ImplicationExceeding these thresholds may affect authorization or coverage decisions for outpatient SUD services

Facility inpatient ASAM Level 4 billing format

Facility billing formatFacilities must bill all ASAM Level 4 services on a UB claim form using a per diem bundled daily rate

Withdrawal tracking codesAdd revenue code 0229 and procedure code H0009 (or H0009/H0010 depending on context) for withdrawal management tracking when billing per diem revenue codes

Accompanying professional servicesPer diem facility billing is accompanied by separately billed professional services as applicable

ACT visit limits (not specified)

ACT visit limitsNo specific visit limits stated for ACT in this excerpt

Team modelACT is delivered by an interdisciplinary team providing 24/7 services; team size typically 10–12 with staff-to-member ratio consideration

Approval requirementACT agency must be approved by HCA prior to providing services

Policy Background and Definitions

Accredited Residential Treatment Centers for Youth (ARTC) provide individualized, trauma‑informed, interdisciplinary psychotherapeutic treatment delivered on a 24‑hour basis for individuals under age 21 with severe behavioral, psychological, neurobiological, or emotional problems when less restrictive settings are inappropriate.

ARTC for Youth / AARTC — definitions

ARTC for Youth (definition)Accredited Residential Treatment Center (ARTC) for Youth: 24-hour accredited residential program for individuals under age 21 with severe behavioral/psychological/neurobiological/emotional problems when less restrictive settings are inappropriate

AARTC (definition)Adult Accredited Residential Treatment Center for SUD: residential/inpatient SUD treatment organized by ASAM levels into three reimbursement tiers

EPSDT linkageARTC/ABA services are part of EPSDT for eligible youth (12 months–21 years) as applicable

ASAM levels / tiers (AARTC)

ASAM tiers in AARTCAARTC uses ASAM levels organized into three reimbursement tiers (Tier 1 = 3.1; Tier 2 = 3.3; Tier 3 = 3.5/3.7 etc.)

Tier–reimbursement linkEach tier is tied to a separate reimbursement level

Placement ruleMembers must be placed in the ASAM level appropriate to the most acute problem identified in assessment

ASAM 3.2-WM / 3.7-WM — withdrawal management

3.2-WM and 3.7-WM definitionsASAM 3.2-WM and 3.7-WM: medically monitored/ clinically managed withdrawal management levels providing 24-hour supervision, nursing and physician oversight for withdrawal requiring inpatient-level support

StaffingRequires 24-hour nursing care and physician availability as needed; facilities must arrange appropriate labs/toxicology

Continuation logicMember remains until withdrawal resolves, worsens requiring higher level, or cannot complete WM despite adequate trial

ASAM 3.5 / LOCUS Tier 5C

ASAM 3.5 / Tier 5C descriptionClinically managed high-intensity residential services; Tier 5C = moderate intensity long-term residential treatment for persons with long-term persistent disabilities requiring extended rehabilitation and skill building

Typical stayLength of stay for Tier 5C varies from two months to a year

Target populationIndividuals with multiple limitations including severe/chronic mental disorders and impaired functioning

Tier 5C — definition

Tier 5C definitionModerate intensity long-term residential treatment for persons with long-term persistent disabilities requiring extended rehabilitation and skill building

CapacityIncludes long-term nursing and rehabilitation facilities providing intensive Level 5 programming

Length of stayTypically ranges from two months up to a year

Tier 5B — definition

Tier 5B definitionModerate intensity intermediate-stay residential treatment following stabilization or to prevent deterioration; length of stay usually does not exceed 60 days

FunctionProvides intensive treatment environment for rehabilitation and skill building after crisis stabilization

Criteria linkAdmission requires meeting LOCUS Level 5 and at least one Tier 5B-specific criterion

Tier 5A — definition

Tier 5A definitionIntensive short-term residential/subacute services for members stepping down from inpatient care or in crisis without need for locked facility; length of stay usually does not exceed 7–10 days

PurposeProvides intensive short-term programming (subacute/respite) to stabilize and transition members

Admission triggersMeets LOCUS Level 5 and at least one Tier 5A-specific clinical criterion

At-risk for ASD — definition and eligibility

At-risk for ASD — age rangeEligible age range: 12–36 months for time-limited ABA services for 'at-risk' members

At-risk required characteristicsMust meet all four characteristics including developmental differences on standardized assessments, some ASD characteristics, and at least one genetic risk factor

EPSDT contextABA services for at-risk and diagnosed ASD members are part of EPSDT for Medicaid members 12 months–21 years

Diagnosed with ASD — definition

Diagnosed with ASDA documented medical diagnosis of ASD based on the current DSM or ICD at time of diagnosis

Coverage implicationDiagnosis supports eligibility for ABA services under Medicaid

DocumentationDiagnosis must be recorded in member's clinical record per policy requirements

Tier 3 — definition (High-Risk Intervention Services)

Tier 3 (High-Risk Intervention)Tier 3: High-Risk Intervention Services for adults with destructive/self-injurious behavior or risk of ER/inpatient/incarceration

Access noteAccessing Tier 3 does not always require prior access to Tier 2

Duration/limitsTier 3 may be authorized up to 30–40 hrs/week for up to 8 weeks without prior authorization

Eligible provider roles

Eligible provider roles (summary)Includes Autism Evaluation Provider (AEP), Behavior Analyst (BA/BCBA), BA Candidate, Behavior Analyst Assistant (BAA/BCaBA), Behavioral Technician (BT), BCAT, RBT, and Stage 3 Specialty Care Provider

Supervision requirementsBAs supervise BA Candidates, BAAs, BTs and must meet BACB and policy attestation requirements; BA Candidate must obtain BCBA within one year or stop delivering Stage 2/3 services

Background checksAll ABA providers must complete criminal background and registry checks before rendering services

Family Adaptive / Family Adaptive Behavior Treatment guidance

Family adaptive treatment formatsFamily Adaptive Behavior Treatment Guidance is delivered as one-family (97156) or two-or-more-families (97157) formats

Provider rolesThese family services may be administered by BA, BA Candidate, Supervising BAA, or QHP depending on service and supervision

Concurrent billingT1026 UD may be billed in some Stage 3 contexts alongside family treatment codes per billing rules

ASAM Level 1-WM — definition

ASAM Level 1-WM definitionASAM Level 1-WM without extended on-site monitoring: organized outpatient service deliverable in office, crisis center, or medical/behavioral health setting; depends on support systems and access to labs/24-hour emergency services

Services includedMay include medication-assisted treatment, medication oversight, and disease management services

Support requirementDepends on specialized psychological/psychiatric consultation and supervision when biomedical, emotional, behavioral, or cognitive problems encountered

Chronically impaired but not in imminent danger — definition

Chronically impaired (not imminent danger)A recurrent patient state of long-standing impairment without immediate safety risk; used to determine appropriateness for outpatient ASAM Level 1/1-WM

Coverage implicationPatients in imminent danger are not appropriate for outpatient Level 1 — chronic impairment without imminent danger is required

DocumentationClinical record should document chronic impairment and lack of imminent danger to support placement

Inadequate family or social support system — definition

Inadequate family/social supportPatient lacks sufficient family or community support, influencing level-of-care decisions for outpatient SUD services

Role in ASAM criteriaOne of the three conjunctive criteria (severe/chronic disorder; inadequate support; chronically impaired but not in imminent danger) for Level 1 placement

Documentation expectationProviders should document the inadequacy of family/social supports and access to outreach/case management if present

Supportive recovery environment — ASAM domain

Supportive recovery environment (ASAM domain)Condition where patient has severe/chronic disorder, lacks adequate family/social support, and is chronically impaired but not in imminent danger with limited ability to establish supports

Use in placement decisionsThis three-part test is repeatedly applied to determine appropriateness for ASAM Level 1/1-WM outpatient services

Modifier roleAccess to outreach/case management may modify service planning but does not replace core criteria

ASAM Level 1 / 1-WM patient criteria (three-part)

ASAM Level 1 / 1-WM patient criteria (concise)1) Severe and chronic mental/emotional/behavioral/cognitive condition; AND 2) inadequate family or social support; AND 3) chronically impaired but not in imminent danger

DocumentationProviders must document these three elements and note access to outreach/case management if applicable

Placement implicationMeeting all three elements supports outpatient Level 1/1-WM placement; lack of these elements may risk denial

ASAM Level 1 / 1-WM candidate

ASAM Level 1 / 1-WM candidateAn individual with a mental disorder or emotional/behavioral/cognitive condition who lacks adequate family/social support, is chronically impaired but not in imminent danger, and has access to outreach and case management that can provide structure

Support roleOutreach and case management services may enable outpatient placement even when family supports are limited

Eligibility nuancePresence of these supports is a modifying factor in placement decisions described across multiple chunks

Supportive recovery environment — member support/resources

Supportive recovery environment — member support/resourcesAn environment where the member has sufficient family/social support or access to outreach and case management to engage in outpatient treatment

Effect on careAccess to outreach/case management that can provide structure allows member to work toward stabilizing substance use while in outpatient care

DocumentationProviders should document access to these services and how they will support outpatient treatment planning

Chronically impaired (not imminent danger) — definition

Chronically impaired (not imminent danger) — restatementMember has ongoing impairment related to SUD but is not in immediate risk of harm; may be appropriate for outpatient services if supports or outreach are available

Contrast to imminent dangerImminent danger excludes outpatient Level 1 candidacy; documentation must reflect absence of imminent danger

Assessment implicationClinical assessment should record chronicity, risk level, and support availability

ASAM Level 2-WM — definition

ASAM Level 2-WM definitionAmbulatory withdrawal management with extended on-site monitoring; outpatient services providing safe withdrawal under physician/NP-monitored protocols

StaffingProvided by medical and nursing professionals under physician or nurse practitioner monitored procedures

Continuation logicContinue Level 2-WM until withdrawal resolves or requires higher level, or cannot complete despite adequate trial

ASAM Level 4 — definition

ASAM Level 4 definitionMedically managed intensive inpatient services delivered in an acute care inpatient setting for individuals requiring primary medical and nursing care

Admission prerequisitesRequires diagnostic criteria for substance use disorder and dimensional criteria in at least one of Dimensions 1, 2, or 3; referral/ED transfer and physician acceptance required

Physician responsibilityPhysician manages diagnosis, treatment and treatment plan decisions as part of interdisciplinary team

ASAM Level 4-WM — definition and admission requirements

ASAM Level 4-WM definitionMedically managed intensive inpatient withdrawal management in an acute care hospital with 24-hour physician availability and hourly or more frequent nurse monitoring

Admission requirementsPhysician admission approval, comprehensive nursing assessment, history and physical within 12 hours with labs/toxicology, substance-use focused history, and biopsychosocial screening

Continued stayDaily interdisciplinary team assessment; member continues until withdrawal signs/symptoms sufficiently resolved to transfer to lower level

ASAM Level 4-WM — physician availability

ASAM Level 4-WM — physician availabilityProvided in inpatient acute care hospital with physicians available 24 hours/day and frequent nursing monitoring

SettingDelivered in inpatient acute care hospitals (UB billing) with per diem facility rates and accompanying professional services

MonitoringHourly or more frequent nurse monitoring as required by clinical condition

Assertive Community Treatment (ACT) — definition

ACT definitionAssertive Community Treatment (ACT): voluntary, 24/7 psychiatric, comprehensive case management and psychosocial intervention program delivered by a transdisciplinary team

Team functionProvides individualized treatment, rehabilitation, support, crisis services and community integration to reduce recurrent acute episodes and improve functioning

Team compositionTypical interdisciplinary team of 10–12 staff, approved by HCA, providing 24/7 coverage and fidelity to ACT model

AARTC Residential Levels (ASAM) — high-level mapping

AARTC residential levels mappingAARTC residential programming is organized by ASAM levels (3.1, 3.2-WM, 3.3, 3.5, 3.7, 3.7-WM) and grouped into three reimbursement tiers

Placement ruleMembers must be placed into facilities accredited and enrolled for the specific ASAM level of care

Reimbursement tieEach tier corresponds to a separate reimbursement level per policy billing rules

Policy Revision History

2025-04-01policy_publicationLatest

Behavioral Health Policy and Billing Manual effective date published for New Mexico Health Care Authority Medicaid behavioral health services.