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CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy N/A

CHAPTER 503 — Licensed Behavioral Health Centers (LBHC) Coverage Criteria

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Rules and requirements for provision, enrollment, documentation, and reimbursement of Licensed Behavioral Health Center services under West Virginia Medicaid for enrolled providers delivering outpatient behavioral health and rehabilitation services.

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyCHAPTER 503 — Licensed Behavioral Health Centers (LBHC) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 15, 2018

Last ReviewJul 15, 2018

Next Review DateN/A

Key ActionObtain prior authorization from the BMS Utilization Management Contractor before rendering services that require PA and maintain required authorization and service plan documentation (signed Authorization for Services within 72 hours; Initial and Master Service Plans within 7 and 30 days respectively).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

503Chapter

4 / 2H0031 limits (Coordinated/Focused)

7d / 30d / 90dService plan timing (Initial/Master/Review)

16/90dH0032 limit

72hAuthorization form signature window

2018-07-15Effective Date

Coverage Criteria and Medical Necessity

Medical Necessity

Covered when all of the following medical necessity conditions are met:

Medical necessity general: Services and supplies must be appropriate and medically necessary for the symptoms, diagnosis, or treatment of an illness; provided for diagnosis or direct care; within standards of good practice; not primarily for convenience; and the most appropriate level of care that can be safely provided.

Section 503.2

Factors considered: Determination includes: diagnosis (by physician or licensed psychologist), level of functioning, evidence of clinical stability, available support system, and that the service is the appropriate level of care. Consideration of these factors must be documented and re-evaluated at service plan updates; one assessment per calendar year may be performed to update medical necessity (see H0031).

Section 503.2

H0031 Coverage Criteria

H0031 is covered when at least one approved cause for utilization applies and prior authorization is obtained. Limits apply.

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyCHAPTER 503 — Licensed Behavioral Health Centers (LBHC) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 15, 2018

Last ReviewJul 15, 2018

Next Review DateN/A

SourceLink

On This Page

Approved Causes: Any of the following: 1) Intake/Initial evaluation; 2) Alteration in level of care (except stepping down related to functional improvement); 3) Critical treatment juncture (documented meeting and potential revision of service plan); 4) Readmission after an unusual/significant event justifying re-initiation of treatment; 5) Transition from Birth to Three — note: no H0031 for children under age three (refer to Birth to Three).

Provider may request one global assessment per year for medical necessity reinforcement; service unit limits: max 4/year (Coordinated Care) or 2/year (Focused Care).

Coordinated Care Planning Criteria

Coordinated Care services are covered when specific planning and review timelines are met.

Coordinated Care Planning: Development of Initial Service Plan within 7 days of admission AND development of Master Service Plan within 30 days of admission AND review/re-evaluation of the service plan at a minimum of every 90 days or sooner as needed.7 days / 30 days / every 90 days

Sections 503.6 and 503.11

Covered assessments, testing, and service planning

Assessments and diagnostic evaluations are covered when documentation demonstrates medical necessity and required elements are present.

Intake/Initial Evaluation (H0031): Covered for intake/initial evaluation; documentation must include demographic data, a medically necessary purpose statement, presenting problems with frequency/duration/intensity, impact on functioning, history, mental status exam (specified elements), recommended treatment, diagnostic impression signed by licensed clinician, place/date/start-stop times and signature, and SBIRT for ages 10+. H0031 must not be used for children under age 3 or when not intended to provide behavioral health services.

Chunks 36-39

Psychiatric Diagnostic Evaluation (90791): Covered when performed by qualified staff (physician, PA, APRN, LICSW, LPC, WV licensed psychologist, or supervised psychologist); limited to two events per year; prior authorization required; documentation/report must be completed within 15 calendar days and include specified elements (purpose, presenting problem, history, medication efficacy/compliance, SBIRT >=10, mental status exam elements, diagnosis and rationale, prognosis, recommendations, signature with credentials).2 events/year

Chunk 41

Psychiatric Diagnostic Evaluation with Medical Services (90792): Covered when performed by physician/PA/APRN; limited to two events per year; prior authorization required; includes medical evaluation and may include prescribing; documentation completed within 15 calendar days with required elements similar to 90791 plus medical exam elements.2 events/year

Chunk 42

Psychological Testing (96101): Covered when performed by a WV licensed psychologist or supervised psychologist; unit = 60 minutes; prior authorization required; must include scoring, interpretation, and a written report; telehealth not available.60 minutes/unit

Chunk 46

Developmental Testing (96110): Covered when performed by authorized clinicians; event-based with interpretation and report; prior authorization required; cannot be billed if 96101 was billed in the prior six months.Not billable if 96101 billed in last 6 months

Chunk 48

Mental Health Service Plan Development (H0032): Covered for members in Coordinated Care: unit = 15 minutes; limited to 16 units per 90 days; prior authorization required; initial plan within 7 days, master plan within 30 days, master plan updated at least every 90 days; plans must be reviewed/signed by physician/PA/APRN within 72 hours prior to implementing services.16 units/90 days

Chunks 50 and 53

Service planning requirements

Covered when ALL of the following are met

Service plan timing and approval: Initial Service Plan developed within seven days of intake; Master Service Plan developed within 30 days; Master Service Plan updated at least every 90 days; all service plans (including updates) must be reviewed, signed, and approved by a physician, PA, or APRN within 72 hours of the service plan meeting and prior to implementing services; signatures must include start-and-stop times and credentials.7 days / 30 days / every 90 days / 72 hours

Chunks 50 and 54

Required clinician presence during service planning

Physician/PA/APRN or licensed/supervised psychologist must be present (in-person or Telehealth) for members who meet ANY of the following

Presence triggers: Member receives psychotropic medications prescribed by the agency; OR has a diagnosis of major psychosis or major affective disorder; OR has an Intellectual/Developmental Disability (I/DD) diagnosis; OR has an Autism diagnosis; OR has major medical problems in addition to major psychosis and medications; OR physician/PA/APRN presence was specifically requested by the case manager or the member.

Chunk 54

Billing for service planning participation

Billing rules related to service planning meetings

Who may bill for participation: The agency providing services may bill for participation by any of their staff necessary for the service planning process. Participation by staff from other agencies is not billable by the coordinating agency. Participation by family members is not billable. Service planning meetings must be scheduled to facilitate member inclusion and case manager documents justification for presence of each staff person. Service plan signature page must list start/stop times for each participant; missing valid signature page invalidates the plan and services are non-billable.

Chunks 55 and 56

Case consultation coverage rules

Case Consultation coverage constraints

Case consultation rules: Case Consultation (90887) may not be used during service planning; member's case manager cannot be a case consultant; professionals who participated in the current member's service plan within the current 90-day period, or were directed to provide treatment, cannot bill for case consultation; only the consulting professional's time may be billed; one unit per 90 days and prior authorization required.1 unit/90 days

Chunk 60

Supportive counseling criteria

Supportive counseling medical necessity

Supportive counseling conditions: Supportive counseling must augment other coordinated care services; promote application/generalization of age-appropriate skills and/or assist exploration of newly developing skills and barriers related to service plan objectives; must be included in the member's service plan and reviewed at least every 90 days and at each critical treatment juncture; documentation must include date, place, start/stop times, HCPCS code, signature with credentials, reason/purpose, symptoms/functioning, intervention, member response, and plan for continued treatment.

Chunks 66-69

Intensive Outpatient Services criteria

IOS coverage requirements

IOS program and admission: IOS programs must be approved and prior authorized by BMS UMC; members admitted to IOS must meet medical necessity criteria; services must be rendered according to ASAM Level 2.1 when applicable; Master Service Plan with interdisciplinary team present must be completed within seven days of admission; only approved IOS providers may bill and must complete provider application for certification prior to authorization/payment.

Chunks 71-72

Provider Certification Criteria

Covered when ALL of the following are met

Program certification and authorization: Provider must obtain program-specific approval/certification (e.g., IOS application, Day Treatment Program Certification) prior to billing and must submit recertification/changes as required; certification/approval is required for Day Treatment, ACT, Comprehensive Community Support, and IOS.

Chunks 72 and 89; Appendix references

Skills Training Coverage Criteria

Skills Training and Development is covered when ALL of the following are met

Skills Training coverage: Service targets members with basic skill deficits; provided individually or in groups (group must be limited to four members per staff); service must be specified in Initial/Master Service Plan; documentation must include activity note linking service to plan objectives, staff signature/credentials, place/date, start/stop times, and progress toward goals; therapeutic activities only (no recreational/leisure activities).

Chunks 73 and 75

Young children limits: For children under five, staff-to-child ratios and daily/time limits apply (max 1:4; not >4 hours/day or >4 days/week); plan must be developmentally appropriate and support family routines.

Chunks 73 and 75

Medication Services Coverage Criteria

Comprehensive Medication Services (H2010) covered when ALL of the following are met

Medication management requirements: Service must be performed by a Physician, PA, or APRN; includes face-to-face medication monitoring, blood sampling and laboratory review for Clozaril, Lithium, Depakote; physician/PA/APRN must be on site and available for direct service as needed; service includes all physician and nurse oversight so other physician codes (e.g., H0036, E&M) cannot be billed same day; documentation must include written assessment results, lab results, current psychotropic dosage with authorized pharmacy, place/date/start-stop times, and signature with credentials.

Chunks 76-77

Non-Methadone MAT Coverage Criteria

Non-Methadone Medication Assisted Treatment covered when ALL of the following are met

Evaluation and diagnosis: Member must have an appropriate diagnosis for the medication and be evaluated by an enrolled physician (physician/PA/APRN) prior to prescribing; initial evaluation may be completed by non-physician staff but no medication prescribed until physician/PA/APRN evaluation completed.

Chunks 78-79

Provider requirements: Prescribing provider must be MD/DO/PA/APRN licensed in WV, meet DATA 2000 requirements as applicable, and be approved by BMS on the Approved Suboxone Provider Registry; providers must adhere to Coordination of Care Agreement requirements.

Chunk 78

Coordination of Care Agreement must be signed by member, treating provider, and treating therapist and included in the record; member must participate in individual and/or group therapy per agreement; agreement updated annually or when provider/therapist changes.

Chunk 78

Therapy & monitoring: Phase-based therapy frequency and urine drug screening requirements apply: Phase 1 minimum 4 hours professional therapy/month (>=1 hour individual) and at least 2 random urine drug screens/month; Phase 2 minimum 1 hour/month and at least 1 random urine drug screen/month. Non-compliance rules include escalation of treatment frequency, return to earlier phase, or termination per program rules; titration/discontinuation per treating provider order.

Chunks 81-82

Day Treatment Coverage Criteria

Day Treatment (H2012) is covered when ALL of the following are met

Day Treatment program requirements: Service is a structured program of regularly scheduled therapeutic activities; provider/site must be certified; Day Treatment for adults must be available five days/week for a minimum of four hours/day with maximum staff-to-member ratio 1:5; children under five have a maximum ratio 1:4 and not used >4 hours/day or >4 days/week; Day Treatment is all-inclusive and cannot be billed concurrently with other LBHC services; activities must be therapeutic and listed on Master Service Plan.4 hours/day; 5 days/week; ratios 1:5 adults, 1:4 children

Chunks 84-85 and 89

Progress review: Progress on objectives must be reviewed at 90-day intervals; objectives with no progress after two consecutive 90-day intervals must be discontinued or modified; monthly summary notes and 90-day reviews placed in master clinical record.90-day reviews

Chunks 84 and 89

Comprehensive Community Support Coverage Criteria

Comprehensive Community Support (H2015) is covered when ALL of the following are met

Program intent and setting: Member has severe and persistent mental illness requiring structured, ongoing skill maintenance/enhancement to maintain community placement or prevent hospitalization; service must be individualized in the Master Service Plan; provided at a licensed site or in community settings; staff-to-member ratios: 1:12 at licensed site, 1:8 in community; H2015 is all-inclusive and cannot be billed concurrently with other LBHC services.

Chunk 90

Exclusivity vs Day Treatment: Members eligible for Comprehensive Community Support do not meet medical necessity for Day Treatment services; activities that are recreational alone are not billable under H2015.

Chunk 90

Comprehensive Community Support — Coverage Criteria

Covered when ALL of the following are met

Comprehensive Community Support eligibility: Member has severe and persistent mental illness and requires structured, ongoing skill maintenance/enhancement to prevent deterioration or facilitate return to prior functioning; services must be individualized, based on Master Service Plan, community-based, linked to behavioral health condition, and not billable concurrently with other LBHC services.

Chunks 90-91

Community Psychiatric Supportive Treatment — Admission and Continued Stay Criteria

Admission requires meeting criteria in one of three primary areas; continued stay requires meeting specified continued stay conditions

Primary admission domains: Admission/authorization determination organized around: (1) acute psychiatric signs and symptoms, (2) danger to self/others, or (3) medication management/active drug or alcohol withdrawal. Documentation must support the domain-specific need for short-term intensive services.

Chunks 104 and 105

Psychiatric signs and symptoms - Admission: Both must be met: member is experiencing a crisis due to acute psychiatric signs/symptoms causing functional impairment; AND member needs structured, intensive intervention because less restrictive services are inadequate based on documented response to prior treatment; continued stay criteria require one of three specified continued-stay conditions.

Chunk 105

Danger to self/others - Admission: Member needs intensive intervention to prevent hospitalization (e.g., self-injurious or physically aggressive behavior not at inpatient level); continued care criteria mirror psychiatric signs domain with documented progress or modified plans as appropriate.

Chunk 105

Medication management/withdrawal - Admission: Either: member needs a medication regimen requiring intensive monitoring/medical supervision or titration to therapeutic effect; OR evidence of physical dependency with clinically significant withdrawal symptoms requiring medical supervision.

Chunk 109

Crisis Intervention — Coverage and Documentation Requirements

Covered when ALL of the following are met

Crisis Intervention eligibility: Unscheduled, direct, face-to-face intervention for psychiatric crisis with goal to assess, stabilize, and create a plan; not for non-emergency administrative issues (e.g., running out of medication or housing problems); activity note required documenting events leading to crisis, interventions, and outcome; physician/PA/APRN/supervised or licensed psychologist must review documentation within 72 hours and document findings and follow-up recommendations.72 hours for clinical review

Chunk 95

Community Psychiatric Supportive Treatment - Continued Care Criteria

Continued Care Criteria (any one of the following must be met):

Continued Care - Progress observed: Member progress toward crisis resolution and progress directly related to resolving admission factors observed and documented, but symptoms and impairments continue to warrant this level of care.

Chunks 108 and 110

Continued Care - No Progress but Modified Plan: Documented lack of progress toward treatment goals or alternative placement, but care plan has been modified to introduce further evaluation and interventions.

Chunks 108 and 110

Continued Care - New Symptoms: New symptoms or maladaptive behaviors incorporated into care plan that modify discharge date and can be treated safely at this level; less intensive care would not meet needs.

Chunks 108 and 110

Medication Management/Active Drug or Alcohol Withdrawal - Admission Criteria

One of the following must be met for admission:

Medication Regimen Need: Member needs a medication regimen requiring intensive monitoring/medical supervision or evaluation/titration to reach therapeutic effect.

Chunk 109

Physical Dependency/Withdrawal: Evidence of physical dependency with clinically significant withdrawal symptoms requiring medical supervision.

Chunk 109

ACT Member Participation Eligibility

Members must meet one of the following high-utilization criteria or be in specified target populations:

3+ hospitalizations: Three or more psychiatric inpatient hospitalizations in the past 12 months.

Chunk 116

5+ admissions in 24 months: Five or more psychiatric inpatient or Community Psychiatric Supportive Treatment admissions in the past 24 months.

Chunk 116

180 days inpatient: One hundred eighty (180) total days in psychiatric inpatient unit or psychiatric hospital within the past 12 months.

Chunk 116

Other target populations: BMS may authorize ACT for other target populations (e.g., homeless with SPMI, frequent law enforcement contact, co-occurring disorders) demonstrating medical necessity.

Chunk 117

ACT Service Intensity and Inactivity Rules

Service intensity and inactivity conditions:

Minimum contacts per week: Each ACT member must receive a minimum of two face-to-face ACT activities per week and documentation of at least four valid ACT services per week (may include indirect services), with documentation describing multiple services when delivered in one contact.2 face-to-face, 4 valid services/week

Chunk 125

Inactive roster and discharge timing: Team may place member on inactive roster after 30 days of no contact; discharge required if on inactive roster >60 days; provider must document at least weekly attempts to locate member for 30 days before discharge consideration.30 and 60 days

Chunk 126

Billing suspension for 7+ days without services: No billing allowed if member has not received services from ACT Team staff for seven or more days; billing may resume when services resume.7 days

Chunks 125-126

ACT Team Composition, Staffing and Fidelity Requirements

Team staffing, roles, ratios and fidelity indicators required:

Team composition minimum: Team must include at minimum a psychiatrist or board-certified physician with behavioral health experience plus at least five additional staff meeting specified education and experience requirements.Physician + 5 staff

Chunks 119-121

Team leader requirements: One full-time Team Leader/Supervisor with three years behavioral health experience (two in supervisory role), a master's degree and valid WV master's level license; RN may serve if additional RN on team.

Chunk 119

Physician involvement: Physician, PA, or APRN must participate in daily ACT meetings (tele-video allowed when necessary), physically attend at least one team meeting per week, participate in annual service planning, and be involved a minimum of 16 hours per week.16 hours/week

Chunk 119

Caseload limits: Maximum 120 members per certified ACT Team; maintain staff/member ratio of at least 1:10 (not counting physician/PA/APRN when >50 members).120 members; 1:10 ratio

Chunk 119

Fidelity indicators: Program meeting occurs daily (except federal holidays); team leader provides services at least 50% of time; program operates at >=95% staffing over 12 months; each member receives an average of two face-to-face valid ACT activities per week and at least four valid activities per week in total; 75% of contacts occur outside clinic.95% staffing; 75% external contacts

Chunks 121-122

Behavior Management — General Medical Necessity

Covered when ALL of the following are met

Behavior Management coverage requirements: Service targets behaviors of a diagnosed behavioral health condition that negatively impact functioning; target behaviors must be identified through assessment and described objectively with baseline data; a Behavior Management Plan is developed only if baseline data justify it; implementation requires trained staff and prior documented implementation training; billing tied to documented plan and activity notes; Development (H2019 HO) and Implementation (H2019) billed in 15-minute units; Behavior Protocol development limited to no more than two units; Maintenance Plan development limited to no more than four units; data analysis/review limited to up to three occasions (one unit each) following maintenance implementation.Unit limits per H2019 HO and H2019 as specified

Chunks 130-136

ACT — Billing and Certification

ACT billing conditions

ACT billing requirements: ACT services may be billed only when active treatment is occurring based on a current service plan; no billing if member has not received ACT services for seven or more days; member may be placed on inactive roster after 30 days of no contact (no billing allowed while inactive); discharge required after 60 days on inactive roster with no contact; provider must notify Contracted Agent within 72 hours of discharge to terminate authorization; ACT Teams must be certified by BMS and certification is team- and individual-specific and valid two years.No billing after 7 days without services; 30/60 day roster rules; 72-hour notification

Chunks 126-129

Transportation Services

Transportation coverage and limits

Community Integration Transportation: Transportation to/from community activities within ACT or CFT programs is covered. Minibus (A0120 DD HE) billed per trip with a limit of six trips daily; per-mile (A0160 DD HE) billed per mile with a 500 miles per month limit. Prior authorization is not required for these transportation services. Documentation must include purpose, vehicle type, departure and arrival locations, date, signature with credentials, and actual time or billable mileage.6 trips/day (minibus); 500 miles/month (per mile)

Chunks 142-145

Coverage and billing unit rules

Covered when services meet Medicaid definitions and program requirements; units must be billed as whole units except where rounding is explicitly allowed.

General coverage conditions: Services must meet WV Medicaid definitions, medical necessity, and program/service-specific requirements; providers must follow prior authorization and program approval rules in Chapters 300 and 503.

Chunk 147

Rounding allowed for specific services: The following services are eligible for rounding to whole units when documented minutes are totaled and divided by minutes per unit: H0032, H0032AH, G9008, 90887, H2010, H2011, H2019 HO, and H2019. Billing period cannot overlap calendar months and only whole units may be billed.

Chunks 148-149

Any service, procedure, item, or situation not addressed in this manual is presumed non-covered unless the West Virginia Bureau for Medical Services (BMS) provides written notice to the contrary. Covered LBHC services must be rendered by enrolled providers within their licensed scope and in accordance with State and Federal regulations; reimbursement follows the program rules described in this chapter.

The procedure code H0031 (Mental Health Assessment by Non‑Physician) is covered only when one of the approved causes for utilization is met (for example, intake/initial evaluation, alteration in level of care, a critical treatment juncture, readmission for an unusual/significant event) and when prior authorization is obtained. H0031 must not be used for services that are not behavioral‑health in nature (e.g., solely to document E&M or 1915(c) waiver activities), and providers may request additional units only for documented critical treatment junctures or one global assessment per year to reaffirm medical necessity.

Do not perform H0031 on children under age three; those members should be referred to the Birth‑to‑Three program unless preparing a documented transition assessment. The psychologist screening code T1023HE is limited to one event every six months and must not be used routinely (for example, to co‑sign H0031 or to substitute for a full diagnostic evaluation) or for involuntary hospitalization procedures.

The case consultation code 90887 may not be used during service planning activities. Consultants must not be professionals who participated in the current member's service plan within the current 90‑day period or the member's case manager; only the consulting professional may bill for the consultation and documentation must relate the consultation to specific service‑plan objectives.

Activities that are recreational, leisure, or social in nature (for example, recreational trips, mall visits, social events, or reinforcement activities for behavioral programs) are explicitly excluded and are not billable as Skills Training and Development or other LBHC therapeutic services.

Recreational or leisure events and social outings are not therapeutic interventions and cannot be billed under Skills Training and Development codes (H2014 series) or Comprehensive Community Support (H2015); services billed under these codes must be therapeutic, tied to Master/Service Plan objectives, and documented as such.

Day Treatment (procedure code H2012) is an all‑inclusive service and cannot be billed concurrently with any other LBHC service. Day Treatment programs must meet program requirements (site on behavioral health license, staffing ratios, availability) and document activities on the daily attendance/clinical records.

When billing H2010 (Comprehensive Medication Services), the service includes all physician and nurse oversight; therefore Community Psychiatric Supportive Treatment (H0036), Pharmacologic Management (E&M codes), or any other physician codes cannot be billed on the same day as H2010.

Comprehensive Community Support (H2015) is an all‑inclusive program and recreational activities alone are not billable under that code. H2015 is not billable concurrently with other LBHC services; services under H2015 must be individualized, tied to the Individual Master Service Plan, and documented accordingly.

No payment is made for Assertive Community Treatment (H0040) while the member is hospitalized for a psychiatric condition or is receiving Community Psychiatric Supportive Services, except up to 84 hours per year. ACT requires team certification and prior authorization and payment is all‑inclusive with limited concurrent billing exceptions.

General observation or monitoring performed by non‑staff persons is not a billable implementation activity. Behavior Management Implementation must be delivered by trained, qualified staff and must be supported by a documented Behavior Management Plan; implementations by Behavior Management Assistants must be reviewed and signed by the Behavior Management Specialist per documentation rules.

BMS will not pay for telephone consultations, meetings solely to review evaluation results, missed appointments (including cancellations and no‑shows), time spent preparing reports, copies of reports when the agency paid for the original, experimental services or drugs, any activity provided for leisure or recreation, or services rendered outside a provider's licensed scope.

Providers may not bill for a Service Plan and/or Treatment Plan for members designated as Focused Care. Focused Care is intended for low‑frequency professional contacts and does not require the 72‑hour Authorization form; Service Plan billing is reserved for Coordinated Care and other levels that require formal service‑planning timelines.

Procedure Codes, Units, and Limits

Assessment CPT/HCPCSHCPCSCovered

H0031

Mental Health Assessment by Non-Physician

ModifierModifier

GT	Telehealth modifier - services provided via interactive audio/video

Covered assessment codesCPTCovered

H0031

Intake/initial assessment — service must not be used for children under age three or when not intended to provide behavioral health services

Psychiatric Diagnostic Evaluation (no medical services)CPTCovered

90791

Psychiatric diagnostic evaluation (no medical services)

Psychiatric Diagnostic Evaluation (with medical services)CPTCovered

90792

Psychiatric diagnostic evaluation with medical services (includes prescribing of medications)

Psychologist screeningHCPCSCovered

T1023HE

Screening by licensed psychologist

Psychological testingCPTCovered

96101

Psychological testing with interpretation and report (60 minutes)

Developmental testingCPTCovered

96110

Developmental testing: limited (interpretation and report)

Service planningCPTCovered

H0032

Mental Health Service Plan Development (15-minute unit)

Service Plan Development codesHCPCSCovered

H0032 AH

Mental Health Service Plan Development by Psychologist

Physician oversight codesHCPCSCovered

G9008

Physician Coordinated Care Oversight Services

Consultation codesCPTCovered

90887

Case Consultation

Behavioral health counseling/supportive codesHCPCSCovered

H0004 HO	Behavioral Health Counseling, Professional, Individual
H0004 HO HQ	Behavioral Health Counseling, Professional, Group
H0004	Behavioral Health Counseling, Supportive, Individual
H0004 HQ	Behavioral Health Counseling, Supportive, Group
H0004 HO IS	Behavioral Health Counseling, Professional, Individual - Intensive Outpatient Services
H0004 HO HQ IS	Behavioral Health Counseling, Professional, Group - Intensive Outpatient Services
H0004 IS	Behavioral Health Counseling, Supportive, Individual - Intensive Outpatient Services
H0004 HQ IS	Behavioral Health Counseling, Supportive, Group - Intensive Outpatient Services

Skills Training and Development codesHCPCSCovered

H2014 U4	Skills Training 1:1 by Paraprofessional
H2014 U1	Skills Training 1:2-4 by Paraprofessional
H2014 HN U4	Skills Training 1:1 by Professional
H2014 HN U1	Skills Training 1:2-4 by Professional

Skills Training and DevelopmentCPTCovered

H2014 U4	Skills Training 1:1 by Paraprofessional
H2014 U1	Skills Training 1:2-4 by Paraprofessional
H2014 HN U4	Skills Training 1:1 by Professional
H2014 HN U1	Skills Training 1:2-4 by Professional

Comprehensive Medication ServicesCPTCovered

H2010

Comprehensive Medication Services; Mental Health

Day TreatmentCPTCovered

H2012

Day Treatment

Comprehensive Community SupportCPTCovered

H2015

Comprehensive Community Support Services

Comprehensive Community SupportCPTCovered

H2015

Comprehensive Community Support Services

Crisis InterventionCPTCovered

H2011

Crisis Intervention

Community Psychiatric Supportive Treatment and relatedCPTCovered

H0036	Community Psychiatric Supportive Treatment
T1017	Targeted Case Management (allowed concurrently with H0036 only)

ACT Procedure CodesHCPCSCovered

H0040

Assertive Community Treatment, 24 hours

Allowed concurrent psychiatric service codesCPTCovered

90887

Interpretation or explanation of results of psychiatric, other medical and mental health assessments (listed here as allowable psychiatric service)

Personal Care Services (may be billed concurrently with ACT in specified limits)HCPCSCovered

T1001	Personal care services
T1002	Nursing services
T1019	Personal care services, unspecified

Community Psychiatric Supportive Services (limited concurrent billing)HCPCSCovered

H0036

Community Psychiatric Supportive Services

Therapeutic Behavioral ServicesHCPCSCovered

H2019 HO	Therapeutic Behavioral Services - Development
H2019	Therapeutic Behavioral Services - Implementation

Transportation — MinibusHCPCSCovered

A0120 DD HE

Transportation by minibus (per trip)

Transportation — Per mileHCPCSCovered

A0160 DD HE

Transportation: Per Mile

Procedure codes mentionedmixed

A0160	Community Integration Transportation: Per Mile
A0120	Transportation Services (procedure code referenced as exception to prior authorization)
H0032	Mental Health Service Plan Development
H0032AH	Mental Health Service Plan Development by Psychologist
G9008	Physician Coordinated Care Oversight Services
90887	Case Consultation
H2010	Comprehensive Medication Services; Mental Health
H2011	Crisis Intervention
H2019HO	Therapeutic Behavioral Services -Development
H2019	Therapeutic Behavioral Services -Implementation

inv-78: H0031 service unit limits

H0031 — Coordinated Care limitMaximum of 4 events per year for members in Coordinated Care; provider may request additional units only after current authorizations are expired/used

H0031 — Focused Care limitMaximum of 2 events per year for members in Focused Care

Authorization requirementPrior authorization required through Utilization Management Guidelines

inv-79: Psychiatric diagnostic evaluation limit

Allowed eventsTwo psychiatric diagnostic evaluation events (90791 or 90792) per member per year

Prior authorizationPrior authorization required per Utilization Management Guidelines

Provider credentialing90791: physician/PA/APRN/LICSW/LPC/WV psychologist or supervised psychologist; 90792: physician/PA/APRN only

inv-80: T1023HE frequency

FrequencyOne T1023HE screening event every 6 months

ProviderMust be performed by WV licensed psychologist or supervised psychologist

Use limitationNot to substitute for more in-depth assessments (use 96101 or 90791 when indicated)

inv-81: 96101 unit length

Unit length96101 unit = 60 minutes (psychological testing with interpretation and report)

TelehealthTelehealth not available for 96101

Prior authorizationPrior authorization required per Utilization Management Guidelines

inv-82: H0032 service limit

Service unit limitH0032 limited to 16 units per 90-day period (15-minute units)

H0032 by psychologistH0032 AH: one unit per month when provided by a licensed or supervised psychologist (15-minute unit)

Prior authorizationPrior authorization required per Utilization Management Guidelines; cannot bill H0032 for Focused Care members

inv-83: Miscellaneous service unit/limits

Key service limits summaryVarious code-specific limits: H0004 HO Individual 60 units/year; H0004 HO HQ Group 50 units/year; G9008 (physician oversight) 2 units/90 days; 90887 case consultation 1 unit/90 days

Rounding/unitsMany services billed in 15-minute units; follow rounding and billing rules where allowed

Prior authorizationMost listed services require prior authorization per Utilization Management Guidelines

inv-84: Drug screen frequency

Drug screen frequency — Phase 1Minimum of 2 random urine drug screens per month for Phase 1 MAT members

Drug screen frequency — Phase 2Minimum of 1 random urine drug screen per month for Phase 2 MAT members

Required substancesScreens must include at minimum opiates, oxycodone, methadone, buprenorphine, benzodiazepines, cocaine, amphetamine, methamphetamine

inv-85: Therapy frequency for MAT phases

Phase 1 therapy frequencyMinimum 4 hours professional therapeutic services per month, including at least 1 hour individual therapy

Phase 2 therapy frequencyMinimum 1 hour professional therapeutic services per month (individual, family, or group)

Non-compliance handlingFrequency may increase based on medical necessity; non-compliance may trigger escalation or termination per program rules

inv-86: Unit and time limits (H2011, H0036)

H2011 (Crisis Intervention)Billed in 15-minute units; maximum 16 units per 30 days

H0036 (Community Psychiatric Supportive Treatment)Billed in 15-minute units; 288 units per six months; billing cannot exceed 48 units in a 24-hour period and must be on consecutive days

H2015Billed in 15-minute units and is all-inclusive (see policy for concurrency rules)

inv-87: Hospitalizations criteria for ACT eligibility

Hospitalization threshold — ACT eligibilityThree or more psychiatric inpatient hospitalizations in the past 12 months qualifies as high-utilizer for ACT consideration

Alternate hospitalization criteriaFive or more psychiatric inpatient or Community Psychiatric Supportive Treatment admissions in past 24 months, or 180 total inpatient days in past 12 months

Other target populationsBMS may authorize ACT for other high-need groups (e.g., homeless with SPMI, frequent law enforcement contact, co-occurring disorders)

inv-88: Minibus trips per day

Minibus trips per dayMaximum of 6 trips daily per A0120 DD HE

Prior authorizationNot required for minibus trips (A0120 DD HE)

DocumentationActivity note required for each transport including purpose, vehicle type, departure/arrival, date, staff signature, and start/stop times

inv-89: Mileage limit

Per-mile mileage limit500 miles per month for A0160 DD HE (per-mile transportation)

Prior authorizationNot required for per-mile transportation

Service unitService unit = one mile billed as A0160 DD HE

inv-90: Transportation per-month mileage limit

Monthly mileage cap500 miles per month for Community Integration Transportation per-mile billing (A0160)

Prior authorizationNot required for A0160 or A0120 transportation services

Documentation requiredProviders must document actual billable mileage and maintain activity notes per trip

Prior Authorization, Documentation, and Billing Actions

Prior Authorization

Obtain prior authorization from BMS' UMC

Providers must register with BMS' Utilization Management Contractor (UMC) and obtain prior authorization from the UMC before rendering any LBHC service that requires PA. Prior authorization requests must be submitted within timelines and in the manner specified by BMS' UMC; note that PA does not guarantee payment.

Register with BMS' UMC before requesting PA
Submit PA requests per UMC timelines and procedures
PA does not guarantee payment

Prior Authorization

Prior authorization required for H0031

H0031 (Mental Health Assessment by Non‑Physician) requires prior authorization through the BMS UMC before use; providers may request additional units for critical treatment junctures and may request one global assessment per year to reaffirm medical necessity.

H0031 is prior‑authorization required
Providers may request extra units for critical treatment junctures
One global assessment per year may be authorized to reaffirm medical necessity

Prior Authorization

Authorization required for evaluations and testing

Prior authorization is required for psychiatric diagnostic evaluations and testing: procedure codes 90791 and 90792, psychological testing (96101), developmental testing (96110), and Mental Health Service Plan Development (H0032).

90791 and 90792 require PA and are limited to two events per year
96101 and 96110 require PA; 96101 units = 60 minutes; 96110 payment limited if 96101 billed in last 6 months
H0032 (service plan development) requires PA and is limited to 16 units per 90 days

Prior Authorization

Obtain PA for listed LBHC services per UMC guidance

Multiple services across the chapter require prior authorization; providers must refer to the Utilization Management Guidelines and obtain UMC authorization before billing for these services.

Includes H0032, G9008, 90887, H0004 variants, H2014 codes, H2012, H2010, H2015, H2011, H0036, etc.
IOS programs require program approval and PA from the BMS UMC

Prior Authorization

Prior authorization required for Skills Training (H2014)

Skills Training and Development (H2014 family of codes) requires prior authorization from the BMS UMC before services are provided and billed.

H2014 codes: prior authorization required
Telehealth is not available for skills training (document per service rules)

Prior Authorization

PA required for Comprehensive Medication Services (H2010)

Comprehensive Medication Services (H2010) requires prior authorization through the UMC before billing; this physician‑directed medication management service must be authorized in advance.

H2010 requires PA
When H2010 is billed, certain physician codes (e.g., H0036, E&M) cannot be billed same day per payment limits

Prior Authorization

Obtain PA for Day Treatment (H2012)

Day Treatment (H2012) requires prior authorization from the BMS UMC prior to providing and billing Day Treatment services.

H2012 is PA required
Day Treatment is all‑inclusive and cannot be billed concurrently with other LBHC services

Prior Authorization

PA required for Comprehensive Community Support (H2015)

Comprehensive Community Support (H2015) must be prior authorized by BMS' UMC before services are delivered and billed.

H2015 requires PA
H2015 is all‑inclusive and cannot be billed concurrently with other LBHC services

Prior Authorization

PA required for H2015, H2011, H0036

Prior authorization is required for H2015 (Comprehensive Community Support), H2011 (Crisis Intervention), and H0036 (Community Psychiatric Supportive Treatment); providers must follow Utilization Management Guidelines for authorization.

H2011 (Crisis Intervention) requires PA and is limited to 16 units per 30 days
H0036 requires PA and has unit limits (288 units/6 months; max 48 units per 24‑hour period)
H2015 requires PA and is exclusive of other LBHC services

Prior Authorization

Prior authorization required to provide ACT (H0040)

Assertive Community Treatment (ACT, H0040) requires prior authorization from BMS; programs must have a valid BMS authorization to bill for ACT and must document a comprehensive assessment and initial service plan at entry.

H0040 requires PA
Program must have valid authorization from BMS to bill ACT services
Initial comprehensive assessment and initial service plan required within seven days of admission

Prior Authorization

PA required for Therapeutic Behavioral Services (H2019/H2019 HO)

Therapeutic Behavioral Services—both Development (H2019 HO) and Implementation (H2019)—require prior authorization from the BMS UMC prior to billing.

H2019 HO and H2019 require PA
Telehealth is unavailable for these services

Prior Authorization

Providers must register and prior authorize all LBHC services with BMS' UMC except Transportation Services (A0120 DD HE and A0160 DD HE), which do not require PA.

Register and obtain PA for LBHC services via BMS' UMC
Transportation codes A0120 DD HE and A0160 DD HE are exceptions and do not require PA

Step Therapy

Sequence additional H0031 authorizations only after current PA is used/expired

H0031 authorizations may be extended for critical treatment junctures, but additional H0031 units may only be requested after the current authorization is used or expired; a change of payer does not justify a separate new H0031 authorization.

Additional H0031 units permitted for critical treatment junctures with PA
Providers may request one global assessment per year to reaffirm medical necessity
New authorization cannot be requested solely because payer changed

Step Therapy

Follow provider orders for Non‑Methadone MAT titration; Vivitrol noncompliance rule

For Non‑Methadone MAT, titration and discontinuation actions must follow the treating provider's orders; Vivitrol must be discontinued immediately for noncompliance, and providers must have a coverage plan in place to cover medication responsibilities when unavailable or risk a hold on prescription authorizations.

Titration per treating provider order
Vivitrol discontinued immediately for noncompliance
Providers must have back‑up prescriber coverage (DEA‑X) or prescription authorizations may be placed on hold

Documentation Required

Obtain signed Authorization form and timely service plans

Providers must obtain and retain the signed 'Authorization for Services' form within 72 hours of admission (unless an Initial Service Plan is created at intake) and develop Initial and Master Service Plans within required timeframes (Initial within 7 days; Master within 30 days). Diagnostic and standardized instrument results must be in the clinical record to justify services.

Signed Authorization for Services form within 72 hours of admission (unless Initial Service Plan created at intake)
Initial Service Plan developed within 7 days; Master Service Plan within 30 days
Assessment results and standardized instruments must be maintained in the clinical record

Documentation Required

Maintain organized, retrievable clinical records and provide copies on request

Maintain organized, legible clinical records including release/consent forms, member identifiers, service goals/objectives derived from assessments, and discharge reports; provide copies of records within one business day if requested. Documentation must show only one staff person's time billed per specific activity.

Uniform case record organization and legible documentation required
Provide copies within one business day upon request
Only one staff person's time may be billed for any specific activity

Documentation Required

Document Telehealth use and bill with GT modifier

When services are provided via Telehealth, document the modality and bill the service code with the 'GT' modifier; telehealth services must align with Chapter 519.17.

Document Telehealth modality in the record
Bill Telehealth services with the GT modifier
Ensure Telehealth delivery complies with Chapter 519.17

Documentation Required

Document required elements for H0031 assessments

H0031 documentation must include demographic data, a medically necessary purpose statement, presenting problems with frequency/duration/intensity, impact on functioning, history, mental status exam, recommendations, diagnostic impression signed by licensed clinician, place/date/times and signature.

Include Demographic data and Medically Necessary Purpose Statement
Presenting problems must specify frequency, duration, intensity and impact on functioning
MSE elements, recommendations, diagnostic impression and licensed clinician signature required

Documentation Required

Complete specified assessment documentation and timelines

Assessments and evaluations must include date/location, purpose, presenting problem, history, medications and efficacy, detailed mental status exam, diagnosis with rationale, recommendations, and signature/credentials; many reports must be completed within 15 calendar days of service.

Complete required documentation within 15 calendar days where specified
Include MSE elements, medication history and efficacy, and diagnostic rationale
Signature with credentials required on reports

Documentation Required

Ensure service plans contain required signatures, times, and timelines

Service plans (initial and master) must include signatures with credentials, start/stop times of participation, and specified content; Initial Service Plan within seven days and Master Service Plan within 30 days, with master plans updated at least every 90 days.

Signature page must list participants, credentials, and actual start/stop times
Initial plan within 7 days; Master plan within 30 days; updates at least every 90 days
Physician/PA/APRN must review/sign plans within 72 hours

Documentation Required

Include detailed activity notes with times and signatures

Activity notes and service activities must include dated signatures with credentials, start‑and‑stop times, purpose/relation to the treatment plan, symptoms/functioning, interventions, member response, and plan for continued treatment; group notes must include group topic.

Activity notes must show start/stop times and staff signature/credentials
Explain relationship of activity to service plan objectives
Document member response and next steps

Documentation Required

Document absent member reason and obtain signature within 7 days

If a member or guardian is absent from a service planning meeting, document the reason; the service plan must be reviewed and signed by the member or guardian within seven calendar days.

Document reason for absence in the clinical record
Member/guardian must sign the plan within seven calendar days if absent

Documentation Required

Document cross‑agency participants and maintain separate records

If staff from another agency participates in service planning, list their agency on the signature page and include separate documentation in that agency's record: purpose, signature/credentials, location, date, and start/stop times.

List external agency on signature page
Obtain separate activity note in participating agency's record with purpose and times

Documentation Required

Document Skills Training activity notes and attendance roster

Skills Training documentation must include an activity note linking the service to plan objectives, staff signature and credentials, place/date, start/stop times, progress toward goals, and an attendance roster for 1:2–1:4 group ratios signed and dated by staff (roster maintained for review, not in main clinical record).

Activity note linking service to plan objectives
Staff signature/credentials and start/stop times
Attendance roster for group ratios (signed, kept available for review)

Documentation Required

Keep detailed medication management records for H2010

Comprehensive Medication Services documentation must include written assessment results, laboratory results, current psychotropic dosage with authorized pharmacy, place of service, start/stop time, date, and signature with credentials of qualified staff.

Document assessment and lab results
Record current psychotropic dosage and authorized pharmacy
Include place, start/stop times, date, and signature/credentials

Documentation Required

Maintain Day Treatment daily summaries and progress reviews

Day Treatment documentation must include a daily summary with start/stop times, place of service, staff signature/credentials, activity notes linking each service to Master Service Plan objectives, a daily attendance roster (kept for review), monthly progress notes, and 90‑day reviews in the master clinical record.

Daily summary with start/stop times and staff signature/credentials
Activity notes tied to Master Service Plan objectives
Monthly progress notes and 90‑day reviews placed in master clinical record

Documentation Required

Document H2015 objectives, daily activities, rosters and progress

Comprehensive Community Support documentation must include all treatment objectives on the Individual Master Service Plan and daily episode documentation describing activities, start/stop times, staff credentials and ratios, and progress toward objectives; daily attendance rosters must be maintained for review.

All program objectives reflected on the Individual Master Service Plan
Daily documentation of activities with start/stop times and staff credentials
Maintain daily attendance roster with staff/member ratios for review

Documentation Required

Keep master clinical file with program‑specific documents and timely reviews

Maintain a master clinical file with required documentation and reviews: for H2015 include Individual Master Service Plan objectives, daily attendance roster with start/stop times, staff credentials and ratios, activity descriptions linked to service plan objectives, progress notes and staff signatures; for H2011 include activity notes and physician/PA/APRN/supervised psychologist review within 72 hours; for H0036 include progress notes, treatment plan implementation and response.

Master clinical file must hold program‑specific documentation for H2015, H2011, H0036
H2011 requires clinical review by physician/PA/APRN/supervised or licensed psychologist within 72 hours

Documentation Required

Maintain permanent clinical records and required timelines

Maintain permanent clinical records including written orders for each crisis episode, medication orders and administration records, individualized service plans, comprehensive assessment at entry, initial service plan within seven days, master plan within 30 days, daily logs, weekly intensive summaries, 90‑day reviews, and documentation of each staff contact with date, place, purpose, content, outcome, start/stop times and signature with credentials.

Permanent clinical record must include orders, medication records, and individualized plans
Document daily logs, weekly summaries, and 90‑day reviews
Record each staff contact with full details and signatures

Documentation Required

Capture daily treatment hours and clinical status in notes

Daily documentation must include number of treatment hours per day, a summary of the member's status and need for continued care, participation, crisis symptoms, vitals and withdrawal protocol if admitted for detox, and service notes meeting respective service‑section requirements.

Record treatment hours per day and summary of member's status
Include crisis symptoms and withdrawal protocol details if applicable
Ensure therapy notes meet service section documentation standards

Documentation Required

Document ACT team certification, roster and qualifications

Records for ACT must identify the Qualified Team, include team certification and roster, and document staff qualifications; certification is specific to individuals and qualifications and requires BMS/BBHHF approval.

Include Qualified Team identification and certification packet
Maintain roster of members assigned to ACT Team
Certification is team‑ and individual‑specific and valid two years

Documentation Required

Follow Behavior Management documentation requirements

Behavior Management documentation must include activity notes with start/stop times, place, component performed, signature with credentials; a separate Behavior Management Plan with target behaviors, baseline data, intervention methods, data collection and responsible person signature; Behavior Protocol and Maintenance Plan content and time entries are required.

Activity notes must state start/stop times, place, component, and staff signature/credentials
Behavior Management Plan must include target behaviors, baseline data, criteria for success, methods, data collection and responsible person
Behavior Protocol and Maintenance Plan must include dates, time spent, and signatures

Documentation Required

Document all transportation trips with purpose, times or mileage

Transportation documentation must include purpose, vehicle type, departure and arrival locations, date, signature with credentials, and either actual time (minibus trips) or actual billable mileage (per‑mile transports).

Document purpose and vehicle type for each trip
Record place of departure and arrival, date, and staff signature/credentials
For per‑mile billing, record actual billable mileage

Documentation Required

Document Implementation activities with measurements and signatures

Implementation activity notes must document the intervention used, methods, measurements, outcomes, place/date, implementing staff signature with credential initials, and start/stop times; general observation/monitoring alone is not billable.

Document specific intervention, methods and measurable outcomes
Include implementing staff signature with credential initials and start/stop times
Observation/monitoring alone is non‑billable

Documentation Required

Retain clinical documentation at least five years and supply on request

Providers must retain required documentation for at least five years (or until dispute resolution) including member identifiers, signed current service plan, staff signatures and credentials, dates and start/stop times; failure to maintain documentation may result in disallowance and recovery by BMS.

Retain all required records for at least five years
Maintain identifying information, signed service plan, staff signatures and times
Failure to maintain documentation may trigger recovery of payments

Denial Risk

Rendering PA‑required services without PA risks denial

Services that require prior authorization but are rendered without that authorization, or services provided outside the scope of the authorization/documentation forms, are not billable and may be denied.

Do not render PA‑required services without an approved authorization
Services provided outside authorized documentation requirements are non‑billable
Claims may be denied for lack of PA or proper authorization forms

Denial Risk

Services outside authorized documentation are non‑billable

Any services rendered outside the documentation requirements of the authorization forms that authorize services are not billable to WV Medicaid.

Ensure services are documented per the authorization form and service plan
Do not bill for services provided outside those documented authorizations

Denial Risk

Submit approved POC timely to avoid pay hold

Failure to submit an approved Plan of Correction (POC) within 30 calendar days of receipt may result in a pay hold on claims; incomplete, illegible, copied/boilerplate, or missing documentation may result in disallowance.

Submit POC electronically within 30 calendar days of draft POC receipt
Avoid copied/boilerplate language and illegible records to prevent disallowance
BMS may place a pay hold if approved POC not received

Denial Risk

Do not perform H0031 on children under age three or for non‑behavioral purposes

H0031 must not be conducted for children under age three and must not be used when the assessment is not intended to provide behavioral health services (e.g., for 1915 C Waiver or E&M codes only); providers must refer children under three to Birth to Three.

No H0031 for members under age three; refer to Birth to Three Program
Do not use H0031 for non‑behavioral health purposes

Denial Risk

Obtain PA and monitor unit/event limits to avoid denials

Prior authorization and adherence to service limits are required for 90791, 90792, 96101, 96110, and H0032; exceeding event/unit limits or lacking PA may trigger denial of claims.

90791/90792 limited to two events/year and require PA
96101 and 96110 require PA and have billing restrictions (e.g., 96110 cannot be billed if 96101 billed in prior 6 months)
H0032 limited to 16 units/90 days and requires PA

Denial Risk

Invalid or missing signature page makes services non‑billable

A service plan without a valid signature page (including required signatures and documented start/stop times) renders the plan invalid and services provided under it non‑billable.

Ensure signature page includes original dated signatures with credentials and start/stop times
If member/guardian absent, document reason and obtain signature within seven days
Invalid signature page = services non‑billable

Note

Billing Rule

Hold required program certification before billing

Providers must obtain required certification or program approval (e.g., IOS approval, Day Treatment certification, ACT team certification) prior to billing; lack of required certification prevents authorization and payment.

IOS providers must complete Appendix 503 G application and be approved before billing
Day Treatment and ACT require program certification prior to billing
ACT Teams must be certified by BMS before billing H0040

Note

Prior Authorization

PA and concurrency/unit limits for H2015 and H0036

Comprehensive Community Support (H2015) and Community Psychiatric Supportive Treatment (H0036) require prior authorization and have concurrency and unit limits; H0036 billing cannot exceed specified unit limits and is all‑inclusive (only T1017 may be billed concurrently).

H2015 and H0036 require PA
H0036: 288 units per six months; max 48 units per 24‑hour period; no other LBHC services reimbursed concurrently except T1017
H2015 cannot be billed concurrently with other LBHC services

Prior Authorization

PA and unit limit (16 units/30 days) for Crisis Intervention

Crisis Intervention (H2011) requires prior authorization and is limited to a maximum of 16 units per 30 days; providers must obtain PA and track unit usage to avoid overbilling.

H2011 requires PA
Service limit: 16 units per 30 days

Billing Rule

Suspend billing when ACT member inactive or without contact ≥7 days

Do not submit billing for ACT services for members on an inactive roster or for members who have not received services from ACT Team staff for seven or more days; billing may resume only when services resume.

No billing while member on inactive roster
No billing if no ACT staff contact for ≥7 days; billing resumes when services resume
Provider must document attempts to locate member prior to discharge

Denial Risk

ACT payment excluded during hospitalization or concurrent H0036 (except 84 hrs/yr)

No payment will be made for ACT services when the member is hospitalized for a psychiatric condition or is receiving Community Psychiatric Supportive Services (except for up to 84 hours per year); ACT Team must still participate in discharge planning.

ACT payment excluded during psychiatric hospitalization or concurrent H0036 beyond allowed 84 hours/year
ACT Team must remain involved in hospital discharge efforts

Billing Rule

ACT billing requires BMS team certification

No ACT services may be billed for a member unless the ACT Team has written certification from BMS; teams must complete the certification process and receive approval before billing.

Obtain BMS written certification for each ACT Team before billing
Certification is valid for two years and is team‑ and individual‑specific

Prior Authorization

Secure PA for Therapeutic Behavioral Services prior to delivery

Therapeutic Behavioral Services (H2019 HO and H2019) require prior authorization per Utilization Management Guidelines; providers must secure PA before providing development or implementation services.

H2019 HO and H2019 require PA
Development and Implementation are distinct services with specific documentation requirements

Denial Risk

Implementation must be supported by documented Behavior Management Plan

Implementation activities that are not supported by an appropriately documented Behavior Management Plan will be considered non‑reimbursable; ensure the Plan meets detailed documentation requirements before billing for implementation.

Behavior Management Implementation is non‑reimbursable without a compliant Behavior Management Plan
Ensure Behavior Management Plan contains required baseline data, methods, data collection, responsible person and signatures

Denial Risk

Documentation noncompliance may lead to payment recovery by BMS

Failure to maintain required documentation (clinical records, service plans, signatures, start/stop times) may result in disallowance and recovery by BMS of any amounts paid for which documentation is not maintained or provided upon request.

Maintain required records for at least five years or until dispute resolution
Provide documentation to BMS upon request to avoid recovery actions

Key Definitions and Service Descriptions

inv-151: Behavioral Health Clinic Services definition

Behavioral Health Clinic ServicesOutpatient services that are preventative, diagnostic, therapeutic, or palliative provided under direction of a physician/PA/APRN at a non-hospital facility

Behavioral Health Rehabilitation ServicesMedical or remedial services recommended by physician/PA/APRN or licensed psychologist to reduce disability and restore function; may be provided in home, community, or residential settings (not inpatient)

Coverage presumptionAny service not discussed in the manual is presumed non-covered unless BMS informs otherwise in writing

inv-152: Behavioral Health Rehabilitation Services definition

Definition summaryBehavioral Health Rehabilitation Services: medical/remedial services recommended by an authorized clinician to reduce physical or mental disability and restore function; provided in home, community, or residential settings (not inpatient)

SettingsMay be provided in home, community, or residential program; not inpatient

PurposeDesigned for members with mental illness, substance abuse, and/or dependence to restore functioning

inv-153: Focused Care definition

Exclusion — H0031H0031 is excluded from Focused Care providers (Focused Care excludes Mental Health Assessment by Non-Physician)

inv-154: Coordinated Care definition

Coordinated Care definitionFor severe/chronic behavioral conditions requiring a multidisciplinary team, case manager, comprehensive service plan with Initial Service Plan within 7 days and Master Service Plan within 30 days

IntensityTreatment usually provided several times per week up to daily; team coordinates varied services

Service inclusionMay include ACT, professional therapy, crisis stabilization, TCM, comprehensive community support, day treatment, and others

inv-155: H0031 definition

H0031 (definition)Mental Health Assessment by Non-Physician: initial or reassessment evaluation to determine needs, strengths, functioning, mental status, and social history; includes administration/scoring of functional assessment instruments; event-based unit

Service timingShould be completed prior to rendering behavioral health services

Prior authorization and limitsPrior authorization required; maximum 4/year (Coordinated Care), 2/year (Focused Care); providers may request a global assessment once/year

inv-156: Psychiatric Diagnostic Evaluation (90791 / 90792) definition

90791 definitionPsychiatric diagnostic evaluation (no medical services): integrated bio-psychosocial assessment including history, mental status, recommendations; event-based

90792 definitionPsychiatric diagnostic evaluation with medical services: integrated bio-psychosocial and medical assessment; may include medication prescribing and medical evaluation; event-based

Service limitsBoth limited to two events per year and require prior authorization; documentation completed within 15 calendar days

inv-157: T1023HE Screening by Licensed Psychologist

T1023HE definitionScreening by licensed psychologist to determine appropriateness for program participation; event-based; limited to one event every 6 months

Use limitationsMust demonstrate need for psychologist-level differential diagnosis; not routine co-sign of H0031 or used for involuntary hospitalization processes

Prior authorizationPrior authorization required

inv-158: Psychological and Developmental Testing definitions (96101, 96110)

96101 definitionPsychological testing with interpretation and report performed by a licensed psychologist; service unit = 60 minutes; telehealth not available

96110 definitionDevelopmental testing: limited, event-based with interpretation and report; cannot be billed if 96101 billed in last 6 months

Prior authorizationPrior authorization required for both codes

inv-159: H0032 Mental Health Service Plan Development

H0032 definitionMental Health Service Plan Development: individual service plan development activities for Coordinated Care; unit = 15 minutes; limited to 16 units per 90 days

Use restrictionCannot be billed for Focused Care members

Prior authorizationPrior authorization required

inv-160: H0032 by Psychologist

H0032 AH definitionH0032 AH: Mental Health Service Plan Development by psychologist; unit = 15 minutes; limit: one unit per month; supervising psychologist must sign when performed by supervised psychologist

DocumentationDated signature with credentials and start/stop times required; supervising signature within 7 days if applicable

Prior authorizationPrior authorization required

inv-161: G9008 Physician Coordinated Care Oversight Services

G9008 definitionPhysician Coordinated Care Oversight Services: 15-minute unit for physician/PA/APRN participation in service planning; telehealth allowed

Service limitTwo units per 90 days

DocumentationDated signature with credentials and start/stop times required

inv-162: Case Consultation (90887) definition

90887 definitionCase Consultation: event-based interpretation/explanation by consulting professional; one unit per 90 days; cannot be used during service planning

Billing restrictionOnly consulting professional may bill; professionals who participated in current service plan within 90 days cannot bill; case manager cannot be consultant

DocumentationConsultation summary with purpose, recommendations, relation to service plan, and start/stop times required

inv-163: Skills Training and Development definition

Skills Training definitionStructured individual and group activities for members with basic skill deficits; focuses on daily living skills and social appropriateness; group max 4 members per staff

Service unit15-minute units; telehealth not available

Prior authorizationPrior authorization required

inv-164: Comprehensive Medication Services; Mental Health

Comprehensive Medication Services definitionPhysician-directed medication management for Clozaril, Lithium, Depakote including face-to-face assessment, blood sampling/interpretation, and onsite physician/PA/APRN availability

Billing restrictionIncludes all physician and nurse oversight so other physician codes cannot be billed same day as H2010

Prior authorizationPrior authorization required

inv-165: Day Treatment / Comprehensive Community Support definition

Day Treatment (H2012)Structured ongoing therapeutic activities to increase skills and adaptive functioning; service unit = 60 minutes; all-inclusive (cannot bill other LBHC services concurrently)

Comprehensive Community Support (H2015)Long-term, preventive, rehabilitative structured program for severe and persistent mental illness; unit = 15 minutes; all-inclusive

Setting and ratiosDay Treatment: adult ratio 1:5, children <5 ratio 1:4; H2015: licensed site and community ratios specified in policy

inv-166: Comprehensive Community Support (H2015) definition

H2015 definitionComprehensive Community Support: long-term, preventive, rehabilitative program to maintain functioning and prevent deterioration for members with severe and persistent mental illness

Payment limitsAll-inclusive; cannot be billed concurrently with other LBHC services

Prior authorizationPrior authorization required

inv-167: Crisis Intervention (H2011) definition

H2011 definitionCrisis Intervention: unscheduled, direct, face-to-face intervention to resolve psychiatric crisis; billed in 15-minute units; max 16 units per 30 days

Not intended usesNot for non-emergency administrative issues (e.g., running out of medication, housing problems)

Prior authorizationPrior authorization required

inv-168: Community Psychiatric Supportive Treatment (H0036) definition

H0036 definitionCommunity Psychiatric Supportive Treatment: short-term, intensive, physician-driven services to stabilize after a crisis episode; unit = 15 minutes

Service limits288 units per six months; billing cannot exceed 48 units in a 24-hour period; no other LBHC services reimbursed concurrently except T1017

Prior authorizationPrior authorization required

inv-169: ACT definition

ACT definitionAssertive Community Treatment (ACT): intensive, integrated community-based rehabilitative services for members with serious and persistent mental illness and high utilization of psychiatric hospitalization/crisis stabilization

Service modelMultidisciplinary team provides direct services in community; set caseload limits and fidelity requirements apply

Prior authorization and certificationTeam certification by BBHHF/BMS and prior authorization required to bill H0040

inv-170: Service Unit for ACT (H0040)

H0040 service unitACT service billed per 24-hour unit (one per day)

Payment limitsPayment for ACT services is all-inclusive; certain codes (e.g., 90887, T1001/T1002/T1019, H0036 up to 84 hours/year) allowed under limited circumstances

Prior authorizationPrior authorization required; team certification required

inv-171: H2019 HO definition

H2019 HO definitionTherapeutic Behavioral Services - Development: includes behavior assessment, plan development, implementation training, and data analysis/review; billed in 15-minute units; telehealth unavailable

Billing limits for protocols/maintenanceBehavior Protocol development: max 2 units; Maintenance Plan development: max 4 units; data analysis/review: up to 3 occasions (max 1 unit each)

Prior authorizationPrior authorization required; Behavior Management Assistant must use HO modifier and documentation reviewed/signed by specialist

inv-172: H2019 definition

H2019 definitionTherapeutic Behavioral Services - Implementation: one staff to one member, face-to-face hands-on delivery of behavioral interventions defined in Behavior Management Plan; billed in 15-minute units; telehealth unavailable

Billing restrictionNon-staff implementation activities are not billable; implementation must be supported by a valid Behavior Management Plan

DocumentationActivity notes must include intervention, methods, measurements, outcomes, start/stop times, place, and implementing staff signature with credentials

inv-173: Community Integration Transportation definition

Community Integration Transportation definitionTransportation to/from community activities within ACT/CFT programs; billed per trip (A0120) or per mile (A0160)

Minibus specificsA0120 DD HE billed per trip; max 6 trips daily; prior authorization not required

Per-mile specificsA0160 DD HE billed per mile; 500 miles per month limit; prior authorization not required

inv-174: Assertive Community Treatment (ACT) definition (duplicate)

ACT (glossary) summaryAssertive Community Treatment: intensive, highly integrated community mental health approach serving outpatients with serious functional difficulties

Behavioral Health Rehabilitation Services (glossary)Medical/remedial services to reduce disability and restore function; may be provided in home, community or residential programs (not inpatient)

ApplicabilityDefinitions apply to services described throughout Chapter 503

Level-of-Care Definitions and Admission/Continued Stay Rules

Available Treatment Modalities and Service Elements

Focused Care / Coordinated Care

Focused Care / Coordinated Care distinctions rely on level-of-care determination and service planning requirements.

Focused vs Coordinated Care: If a member is in Focused Care, providers cannot bill for a Service Plan or Treatment Plan and no 72-hour Authorization is required; Coordinated Care requires Initial and Master Service Plans and team-based documentation.72 hours / 7 days / 30 days

Chunks 18 and 11

Various Coordinated Care services

Coordinated Care includes a range of services that must be integrated into the Master Service Plan and coordinated across providers.

Included Coordinated Care Services: May include: Assertive Community Treatment; Professional Individual/Group Therapy; Crisis Stabilization and Detoxification; Targeted Case Management; Comprehensive Community Support Services; Basic Living Skills; Intensive Service Programs; Supportive Counseling; Professional Therapy and Medication Management within Coordinated Care; Residential Care for Children/Youth; Emergency Shelter Care; Day Treatment.

Chunk 30

Assessments, Testing, Service Planning

Assessments, testing, and service planning modalities require specified credentials, limits, and documentation.

Assessment modalities: 90791/90792, 96101, 96110, and H0032 have specific staff credential requirements, prior authorization and event/unit limits, and comprehensive documentation obligations completed within designated timelines.2 events/year for 90791/90792; 60 minutes/unit for 96101; 16 units/90 days for H0032

Chunks 41,42,46,48,53

Therapy and skills training

Therapy and skills training modalities require credentialed staff, service limits, and documentation linked to the Master Service Plan.

Therapy and skills training: Professional individual and group therapy (H0004 HO/HQ) require master's-level clinicians, have annual unit limits (60 individual, 50 group), and documentation must link interventions to Master Service Plan goals. Skills Training (H2014 codes) targets basic daily living skills, group size limited to 4 per staff, telehealth not available, and prior authorization required.60 units/year individual; 50 units/year group

Chunks 61-73

Medication management (Clozaril, Lithium, Depakote)

Comprehensive Medication Services are physician-directed and include monitoring for high-risk psychotropic medications with onsite medical availability.

Clozaril/Lithium/Depakote management: Comprehensive Medication Services include face-to-face assessment, blood sampling/interpretation, and physician/PA/APRN availability on-site; when billed, other physician codes for pharmacologic management cannot be billed the same day.

Chunk 76

MAT (buprenorphine, naltrexone)

MAT modalities require enrolled prescribers, Coordination of Care, and therapy participation.

Non-Methadone MAT modality: MAT with Suboxone/Subutex or Vivitrol requires an enrolled prescriber evaluation prior to prescribing, adherence to Coordination of Care Agreement, approval on BMS Approved Suboxone Provider Registry, and member participation in required therapy; program supervision and monitoring requirements apply.

Chunks 78-79

Crisis stabilization and supportive outpatient treatment

Crisis stabilization and supportive outpatient treatment include comprehensive evaluation, medication management, and therapeutic activities aimed at stabilizing the crisis episode.

Components: Includes comprehensive psychiatric evaluation, ongoing psychotropic medication evaluation/administration, individual and small group problem solving/support, intensive one-on-one supervision when ordered, and therapeutic activities consistent with the service plan. Documentation and physician review timelines apply per crisis intervention and Community Psychiatric Supportive Treatment rules.

Chunks 96, 99, 102

ACT service elements

ACT service elements define outreach, engagement, assessment, crisis response, and medication management responsibilities.

Outreach and engagement: Assertive outreach to identify and engage eligible individuals; sustained effort to engage member in treatment and medication education.

Chunk 120

Comprehensive assessment of medical, environmental and social needs and maintenance of ongoing involvement during institutional stays to assist transition back to community placement.

Chunk 120

Crisis response: 24-hour crisis response for ACT members and transportation facilitation as needed.

Chunks 120 and 121

Medication management and substance abuse treatment: Psychiatric services, medication management, and substance abuse treatment provided directly by team members as needed.

Therapeutic Behavioral Services

Therapeutic Behavioral Services include Development (assessment/plan/training/data review) and Implementation (one-to-one delivery) with required documentation and unit rules.

Behavior Management modality rules: Development (H2019 HO) performed by Behavior Management Specialist includes assessment, plan development, implementation training, and data analysis/review; Assistants' work must be supervised and signed by specialist; Implementation (H2019) is one-to-one hands-on delivery and is nonreimbursable without a valid Behavior Management Plan meeting documentation requirements; telehealth not available; prior authorization required.Unit limits apply for Protocol (<=2 units), Maintenance Plan (<=4 units), data review (<=3 occasions),

Chunks 130-140

Service Visit Limits, Units, and Frequency Caps

inv-200: H0031 for complex needs (Coordinated Care) - units

H0031 units — Coordinated Care4 per year (maximum) for Coordinated Care members

H0031 units — Focused Care2 per year (maximum) for Focused Care members

Authorization sequencingProvider may request additional H0031 only after current authorizations are expired/used; change of payer does not justify new H0031

inv-201: H0031 for simpler needs (Focused Care) - units

H0031 units for Focused Care2 per year maximum

Billing noteH0031 should not be used for Focused Care as primary ongoing service; Focused Care uses treatment strategy instead

Prior authorizationRequired per Utilization Management Guidelines

inv-202: 90791 / 90792 psychiatric diagnostic evaluations - events/year

Psych diagnostic evaluations per year90791 and 90792 are each limited to 2 events per year

Documentation timingReports must be completed within 15 calendar days of service

Prior authorizationPrior authorization required per Utilization Management Guidelines

inv-203: T1023HE (psychologist screening) - events

T1023HE frequencyOne event every 6 months

PerformerWV licensed psychologist or supervised psychologist

Do not use for certain processesNot for involuntary hospitalization or routine co-signing of H0031

inv-204: 96101 unit length

96101 unit length60 minutes per unit

TelehealthNot available for 96101

Prior authorizationPrior authorization required

inv-205: H0032 service limit (units)

H0032 units16 units per 90 days (15-minute units)

Cannot bill in Focused CareH0032 cannot be billed for Focused Care members

Prior authorizationPrior authorization required

inv-206: H0004 HO Individual annual limit

H0004 HO Individual annual limit60 units per year

Prior authorizationPrior authorization required

inv-207: H0004 HO Group annual limit

H0004 HO HQ Group annual limit50 units per year

Group size limitMaximum of 12 persons per group session regardless of payer

inv-208: G9008 physician oversight units

G9008 unitsTwo units per 90 days (15-minute units) for physician/PA/APRN oversight

TelehealthTelehealth allowed with GT modifier

Prior authorizationPrior authorization required

inv-209: 90887 case consultation units

90887 unitsOne unit per 90 days (event-based)

Use restrictionMay not be used during service planning; consultant must be enrolled WV Medicaid provider if external

DocumentationConsultation summary with relation to service plan required

inv-210: Non-Methadone MAT therapeutic services frequency

Non-Methadone MAT Phase 1 therapyMinimum 4 hours professional therapy per month including >=1 hour individual

Non-Methadone MAT Phase 2 therapyMinimum 1 hour professional therapy per month

Therapy may increaseFrequency may increase based on medical necessity

inv-211: Urine drug screens for MAT

Urine drug screens — Phase 1Minimum 2 random urine drug screens per month

Urine drug screens — Phase 2Minimum 1 random urine drug screen per month

Required panelMust include opiates, oxycodone, methadone, buprenorphine, benzodiazepines, cocaine, amphetamine, methamphetamine

inv-212: Day Treatment attendance minimums

Day Treatment attendanceMinimum 4 hours per day, 5 days per week availability for adults

Staff-to-member ratiosAdults max 1:5; children <5 max 1:4; Day Treatment is all-inclusive and cannot be billed concurrently with other LBHC services

Prior authorizationPrior authorization required for Day Treatment (H2012)

inv-213: H2011 Crisis Intervention unit limit

H2011 unit limit16 units per 30 days (15-minute units)

Prior authorizationPrior authorization required per Utilization Management Guidelines

TelehealthNot available for H2011

inv-214: H0036 Community Psychiatric Supportive Treatment limits

H0036 limits288 units per six months; maximum 48 units in any 24-hour period; 15-minute units

ConcurrencyNo other LBHC services reimbursed during H0036 except T1017 Targeted Case Management

Prior authorizationPrior authorization required

inv-215: ACT service unit (H0040) billing frequency

ACT service unit billingH0040 billed as one 24-hour unit per day (one per day)

Payment inclusivityACT payment is all-inclusive; limited concurrent codes allowed as specified in policy

Prior authorization and certificationPrior authorization required and team must be certified by BBHHF/BMS to bill

inv-216: ACT billing prohibition after 7+ days inactivity

ACT inactivity billing prohibitionNo billing may be submitted for a member who has not received ACT services for seven or more days; member may be placed on inactive roster after 30 days and discharged after 60 days

ResumptionBilling may resume once active services are provided again with documentation

NotificationProvider must notify Contracted Agent within 72 hours of discharge to terminate authorization

inv-217: H2019 HO (Behavior Protocol development) limit

H2019 HO — Behavior Protocol developmentNo more than two units (H2019 HO) may be billed for development of a Behavior Protocol

H2019 HO — Maintenance Plan developmentNo more than four units for development of Behavior Management Maintenance Plan

Data analysis/reviewFollowing implementation, up to three occasions of data analysis/review (maximum one unit each) may be billed

inv-218: H2019 HO (Maintenance Plan development) limit

Maintenance Plan unitsMaximum of four H2019 HO units billed for Behavior Management Maintenance Plan development

Implementation periodMaintenance Plan implementation period not to exceed 90 days

Prior authorizationPrior authorization required for therapeutic behavioral services

inv-219: Data analysis and review units (H2019 HO)

Data analysis & review unitsUp to three occasions of data analysis/review may be billed, maximum one unit each occasion

PurposeTo assure behavior levels are maintained following Maintenance Plan implementation

DocumentationAnalysis must compare baseline and implementation data and support continuation/modification/termination decisions

inv-220: Transportation (per mile) monthly mileage limit

Transportation per-mile monthly limit500 miles per month (A0160 DD HE)

Prior authorizationNot required for per-mile transportation

DocumentationProviders must record actual billable mileage and include purpose and trip details in activity note

Background and Scope

West Virginia Medicaid distinguishes LBHC outpatient clinic services from Behavioral Health Rehabilitation Services. Covered LBHC services must be medically necessary, provided by enrolled providers within their licensed scope, and documented to meet program requirements. If a service is not described in this manual it is presumed non‑covered unless BMS states otherwise in writing.

Policy Dates and Revision History

2018-07-15policy_effectiveLatest

Chapter 503 Licensed Behavioral Health Centers (LBHC) policy became effective.

2018-07-15policy_review

Document header indicates review date matching effective date (last review recorded as 2018-07-15).