Chapter 504 — Substance Use Disorder Services (Coverage Criteria)
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Governance of Medicaid-covered substance use disorder services in West Virginia, including provider enrollment, clinical and administrative requirements, medical necessity, prior authorization, and program structure affecting enrolled providers and Medicaid members.
Prior authorization for behavioral health intensive outpatient, community psychiatric supportive treatment, and Partial Hospital Program services must be obtained from the UMC or MCO and requests submitted within timelines and manner required by the UMC or MCO.
Documentation and record retention requirements mandate providers maintain specified member records for at least five years and retain records through disputes.
Claims must be submitted on BMS-designated forms or electronically, filed within 12 months of date of service, and reflect usual and customary charges.
Multiple SUD policies were moved or updated: Methadone MAT and Naloxone policies transferred to Chapter 519.22; PRSS expanded and split into Community PRSS and PRSS-ED; RAS levels updated to align with ASAM 4th edition and RAS Level 3.3 removed.
Glossary additions and edits including definitions for LPC and PRSS; removal of SBIRT, Methadone, and Naloxone glossary entries.
Coverage and Medical Necessity Criteria
Medical Necessity Criteria
Covered when ALL of the following medical necessity factors are documented and re-evaluated during service planning:
These five factors must be demonstrated throughout provision of services and re-evaluated at regular service plan updates; evidence-based and standardized instruments may be used and results included in the clinical record.
Member Eligibility
Eligibility statement:
The prior authorization process is described in Section 504.22.
Community PRSS Coverage Criteria
Community Peer Recovery Support Specialist (PRSS) services are covered when ALL of the following apply:
PRSS may be provided to eligible individuals ages 16 and older; services for 16- and 17-year-olds must use a family engagement approach.
Community PRSS are delivered through community providers; PRSS-ED delivered only in licensed hospital EDs and must relate to the ED visit reason.
A member may not receive Community PRSS from more than one agency at a time; a primary PRSS is identified and an alternate PRSS may provide services temporarily for documented urgent circumstances.
Group and parent peer support services are not covered; providers must request prior authorization for additional units beyond the daily limit and members with frequent high unit use should be reassessed for a higher level of care.
Community PRSS — Initial Eligibility
Covered when ALL of the following are met
Services must be pursuant to a person-centered service plan with PRSS participation documented; continuing need must be reviewed per plan requirements.
PRSS-ED — Eligibility
Covered when ALL of the following are met
PRSS-ED services must directly relate to the primary reason for the ED visit and the individual must be alert and oriented to benefit; PRSS role limited to scope of training and must facilitate linkages/referrals to community providers.
Residential Adult Services — Medical Necessity
Covered when ALL of the following are met
Prior authorization for RAS admissions and continued stay must be requested through the UMC or MCO; RAS providers must use approved MCO utilization management tools for managed care members.
Admission and Medical Necessity Criteria — Level 3.1
Covered when ALL of the following are met:
Length of stay is individualized and reimbursement is for medically necessary services only.
Weekly service plan review summaries must be documented by the designated case manager.
Services may include medical, nursing, MAT, PRSS, and other supports; PRSS may satisfy no more than 25% of weekly clinically-directed hours.
Initial Admission Criteria — Level 3.1
Covered when ALL of the following are met
A previous assessment may be used if conducted within the past 30 calendar days.
Continuing Stay Criteria — Level 3.1
Covered when ALL of the following are met
Discharge Criteria — Level 3.1
Discharge when ANY of the following are met
Initial Admission Criteria — Level 3.5
Covered when ALL of the following are met
A previous assessment may be used if within 30 calendar days.
Continuing Stay Criteria — Level 3.5
Covered when ALL of the following are met
Discharge Criteria — Level 3.5
Discharge when ANY of the following are met
Initial Admission Criteria — Level 3.7
Covered when ALL of the following are met
Continuing Stay Criteria — Level 3.7
Covered when ALL of the following are met
Discharge Criteria — Level 3.7
Discharge when ANY of the following are met
Any service, procedure, item, or situation not specifically discussed in the West Virginia Provider Manuals must be presumed non‑covered unless BMS provides a written determination otherwise. This presumption applies across the SUD Waiver program and requires providers to verify coverage in the manual or obtain written guidance from the Bureau for Medical Services before billing for novel or undocumented services.
Group and parent peer support models are explicitly not covered under Community PRSS. A member may not receive Community PRSS billed by more than one agency at the same time; receipt of services from multiple PRSS providers is only permissible in documented crisis or other extenuating circumstances, and the record must identify a primary PRSS responsible for service delivery.
Community PRSS may not be provided in the PRSS' personal residence and must occur in a safe, confidential environment consistent with HIPAA and 42 CFR Part 2. Community PRSS must not be delivered during Alcoholics Anonymous, Narcotics Anonymous, or other mutual‑support meetings, and PRSS may not bill for activities such as waiting with a member for appointments, administering drug screens, leisure/recreational or faith‑based gatherings, oversight of sober living monitoring, or for travel time billed separately. Units are 15‑minute increments with a maximum of 12 units per calendar day and prior authorization is required except as otherwise noted for specified settings.
PRSS‑ED services are billable only when delivered within a hospital Emergency Department licensed under West Virginia law and must directly relate to the primary reason for the ED visit. PRSS‑ED may not be billed during member transportation or during other recovery group services and must not duplicate other direct‑support Medicaid services billed for the same time. PRSS‑ED uses the ED‑specific procedure coding (e.g., H0038 ET) and is limited by the daily unit rules applicable to ED PRSS.
Members receiving Residential Adult Services (RAS) may not concurrently receive day treatment, crisis stabilization, assertive community treatment, comprehensive community support services, or Certified Community Behavioral Health Clinic (CCBHC) services on the same day as RAS services. Providers must ensure scheduling and documentation reflect these service exclusions when a member is enrolled in RAS.
Residential treatment beds at any level of care are prohibited from being flexed with or integrated into a recovery residence or sober living environment. Facilities must maintain clear separation between licensed residential treatment beds and non‑clinical recovery residences.
Reimbursement is not allowed for telephone consultations except where telehealth is expressly permitted under BMS telehealth policy. Other non‑reimbursable items include meetings solely to review evaluation results, missed or cancelled appointments, time spent preparing reports, duplicative medical report copies, experimental services or drugs, leisure/recreational activities, services outside a provider's licensed scope, and similar activities identified in the service exclusions section.
Certain exclusions address the application of telehealth and group psychotherapy; these are detailed in the service exclusions section and updated cross‑references. Providers should consult the service exclusions language for specific telehealth and group psychotherapy limitations when billing or planning services.
Services that are inappropriate, outside standards of good practice, provided primarily for convenience, or not the most appropriate level of care are not medically necessary and are therefore not covered. Medical necessity requires documentation of diagnosis, level of functioning, clinical stability, available supports, and that the service is the appropriate ASAM‑guided level of care.
PRSS‑ED must not be administered where there is an absence of recent problematic substance use or where the individual is sedated, severely psychotic, or delirious; the individual must be alert and oriented and services must directly relate to the ED visit reason as documented in the medical record.
Community PRSS services should be discontinued when the member no longer needs PRSS to make progress on goals in the Person‑Centered Service Plan, is no longer benefiting from the service, no longer wishes to receive it, or no longer meets eligibility criteria. Termination decisions must be documented in the service plan.
Attendance at Alcoholics Anonymous, Narcotics Anonymous, or similar self‑help meetings cannot be counted toward Residential Adult Services (RAS) clinical hours and therefore do not satisfy RAS clinical hour requirements, although participation may be included in the individualized service plan.
Services that do not meet the definition of medical necessity — including those that are not within standards of good practice or are primarily for convenience — are not reimbursable. Providers must document medical necessity per the policy requirements to support reimbursement.
See the service exclusions and related sections for cross‑referenced limits on telehealth and group psychotherapy; these exclusions and the general service exclusions (e.g., telephone consults, experimental services) together define circumstances under which services are not payable.
Procedure Codes, Units, and Limits
| H0038 | Community PRSS service procedure code |
| HB | Modifier added for FQHCs (billed outside the FQHC encounter rate on CMS 1500 Form) |
| H0038 | Peer Recovery Support Specialist services — Community PRSS |
| H0038 ET | Peer Recovery Support Specialist — Emergency Department services (PRSS-ED) |
| H0038 with modifier HB | H0038 with modifier HB added for FQHCs (billed outside the FQHC encounter rate on CMS 1500 Form) |
| H2036U1HF | Residential Adult Services — 24 hours (bundled rate) |
| 90791 | Psychiatric Diagnostic Evaluation without medical services |
| 90792 | Psychiatric Diagnostic Evaluation with medical services |
| H0031 | Mental Health Assessment by a Non-Physician |
| H0032 | Mental Health Service Plan Development by a Non-Physician |
| H0032AH | Mental Health Service Plan Development by a Psychologist |
| T1017 | Targeted Case Management |
| H2014U1 | Skills Training and Development, 1:1 by a Paraprofessional |
| H2014U4 | Skills Training and Development, 1:2-4 by a Paraprofessional |
| H2014HNU1 | Skills Training and Development, 1:1 by a Professional |
| H2014HNU4 | Skills Training and Development, 1:2-4 by a Professional |
| 90791 | Psychiatric Diagnostic Evaluation without medical services |
| 90792 | Psychiatric Diagnostic Evaluation with medical service |
| H0031 | Mental Health Assessment by a Non-Physician |
| H0032 | Mental Health Service Plan Development by a Non-Physician |
| H0032AH | Mental Health Service Plan Development by a Psychologist |
| T1017 | Targeted Case Management |
| H2014U1 | Skills Training and Development 1:1 by a Paraprofessional |
| H2014U4 | Skills Training and Development 1:2-4 by a Paraprofessional |
| H2014HNU1 | Skills Training and Development 1:1 by a Professional |
| H2014HNU4 | Skills Training and Development 1:2-4 by a Professional |
| experimental | Experimental services or drugs |
Provider Obligations, Prior Authorization, and Documentation
Obtain PA for SUD Waiver level-of-care determinations
If prior authorization is required, each member's level of services will be determined when prior authorization for SUD Waiver services is requested through the utilization management contractor (UMC) or the MCO authorized by BMS; providers must obtain authorization prior to rendering services though authorization does not guarantee payment.
- Level of care determination occurs at PA request through the UMC or MCO.
- Authorization must be obtained before rendering services that require PA, but PA does not guarantee payment.
Prior authorization required for H0038 (Community PRSS)
Community PRSS delivered and billed using procedure code H0038 require prior authorization before services are rendered.
- Procedure code H0038 (Community PRSS) is subject to prior authorization.
- FQHCs use modifier HB for billing exceptions but PA still required for the service.
PA rules for H0038 and PRSS-ED exceptions
Prior authorization is required for Community PRSS (H0038); PRSS-ED (H0038 ET) is exempt from prior authorization, and any additional Community PRSS units beyond the 12-unit daily limit require PA with documentation of medical necessity.
- PRSS-ED (H0038 ET) does not require prior authorization.
- Providers must request PA for units beyond the 12-unit per calendar day limit and document medical necessity.
- Members requiring consistent high daily units must be reassessed for a higher level of care.
Prior authorization required for H2036U1HF (RAS 24-hour unit)
Procedure code H2036U1HF (RAS 24-hour unit) must be prior authorized; service limits restrict to one unit per calendar day and all units must be prior authorized.
- H2036U1HF is a 24-hour bundled rate and requires PA.
- Only one unit permitted per calendar day; all units require prior authorization.
PA required for H2036U5HF (RAS Level 3.5 bundle)
Prior authorization is required for H2036U5HF (RAS Level 3.5); one unit equals 24 hours, all units must be prior authorized, and reimbursement begins on the day of admission and continues each calendar day except the day of discharge.
- H2036U5HF is billed per 24-hour unit and requires PA for every unit.
- Reimbursement starts on admission day (regardless of admission time) and excludes the discharge day.
PA required for H2036U7HF (RAS Level 3.7 bundle)
Prior authorization is required for H2036U7HF (RAS Level 3.7); one unit equals 24 hours, all units must be prior authorized, and reimbursement begins on the day of admission and continues each calendar day except the day of discharge.
- H2036U7HF is a 24-hour bundled rate and requires PA for every unit.
- Reimbursement begins on the day of admission and excludes the discharge day.
Register and obtain PA from UMC/MCO for intensive SUD programs
Providers must register and obtain prior authorization from the UMC or MCO for behavioral health intensive outpatient, community psychiatric supportive treatment, and Partial Hospital Program services; requests must be submitted within timelines and manner required by the UMC or MCO.
- PA for these intensive programs must be obtained from the UMC or the member's MCO.
- Requests must follow UMC/MCO submission timelines and processes.
Document ASAM-guided level-of-care determination in service planning
The level of care must be the most appropriate level that can be safely provided and is guided by the ASAM Criteria; service planning must document consideration of medical necessity factors and rationale for selected level of care.
- Document the ASAM-guided assessment and rationale in the service plan.
- Re-evaluate and document medical necessity factors at regular service plan updates.
No action specified
No specific provider action specified in this section.
Ensure screening and facilitation of access to FDA‑approved MAT
If the RAS provider does not provide MAT directly, the program must screen for, ensure, and facilitate access to all FDA‑approved MAT for members, and ensure continuation of MAT for individuals already receiving it.
- Programs must describe how they screen for and facilitate access to FDA‑approved MAT.
- Ensure coordination to continue MAT for members admitted who are already receiving these services.
Register and request PA for intensive outpatient and PHP services
Providers must register and obtain prior authorization from the UMC or MCO for behavioral health intensive outpatient, community psychiatric supportive treatment, and Partial Hospital Program services per UMC/MCO timelines and processes.
- Registration and PA must follow UMC/MCO required timelines and submission methods.
- Contact the UMC or MCO for general PA requirements and contact information.
Document medical necessity factors in the clinical record and service plan
Maintain documentation of diagnosis, level of functioning, evidence of clinical stability, available support system, and justification for the level and type of service in the clinical record; use standardized instruments as appropriate and update during service planning.
- Include results of evidence-based diagnostic and standardized instruments in the clinical record.
- Re-evaluate and document these medical necessity factors at regular service plan updates.
Maintain staff credentials and supporting documentation on file
Keep practitioner credentials, licenses, certifications, training records, contracts or collaborative agreements, college transcripts, and background checks on file at the service location and available for review.
- Personnel files must contain required licenses, certifications, proof of training completion, and background checks.
- Documentation must be available for BMS, contractors, or state/federal auditors upon request.
Adhere to documentation rules and federal confidentiality/HIPAA requirements
Follow Chapter 503 Section 503.13 documentation requirements and maintain confidentiality per 42 U.S.C. §290dd‑2, 42 CFR Part 2, and HIPAA; obtain appropriate releases before sharing records and provide evidence of HIPAA compliance to BMS upon request.
- Obtain an appropriate release of information prior to sharing records except as permitted by law.
- Provide timely evidence of HIPAA compliance to BMS when requested.
Provide and document Community PRSS per the member's Person‑Centered Service Plan
Deliver Community PRSS services pursuant to the member's Person-Centered Service Plan and document each service in the individual's current record, including a specific recovery plan that aligns with the service plan.
- PRSS activities must be included in and support goals in the person-centered service plan.
- A specific recovery plan must be developed and documented as part of the service plan.
Include required elements in medical record entries for each service
Maintain medical record entries that include member name; date, location, and start/stop time; signature and credentials of staff; employing facility; and an activity note describing goals, how PRSS supports them, specific activity types, and the member's response.
- Activity notes must tie to the individual's approved person-centered service plan goals.
- Boilerplate or non‑individualized summaries will not be accepted as valid documentation.
Document PRSS‑ED services with specified member and service details
PRSS-ED documentation must include member name, date of birth, contact information; date, location, and start/stop time of service; signature and credentials of staff; employing facility; activity note describing services and member response; and documentation of referrals or next steps.
- Document referrals, linkages, or next steps identified as a result of the PRSS‑ED intervention.
- Do not use boilerplate language; documentation must clearly pertain to the individual.
Keep comprehensive clinical documentation for RAS admissions
Maintain a clinical record including a physician/physician extender order authorizing RAS at the specified level of care within 24 hours of admission, diagnoses, medical clearance, physical exam per ASAM timeframe, medication administration records, urine drug screen records, sign‑in/sign‑out sheets, and weekly service plan review summaries signed by the supervising clinician.
- Physician/physician extender order must be completed within 24 hours of admission.
- Include medication administration and urine drug screen records and weekly service plan review summaries signed by supervising clinician.
Obtain and document physician/physician extender orders and ASAM assessment within required timelines
A physician or physician extender must complete, sign, and date a physician order form specifying the level of care within 24 hours of admission; medical clearance and a documented SUD diagnosis within the last 12 months are required, and a comprehensive ASAM assessment must be completed within one business day.
- Physician/physician extender order specifying level of care must be on file within 24 hours.
- ASAM assessment documenting medical necessity must be completed within one business day (or a prior assessment within 30 days).
Complete physical exam within ASAM-specified timelines
Complete physical exams within required timelines: within 72 hours of admission for Level 3.5 programs and within 24 hours of admission for Level 3.7 programs.
- Level 3.5: physical exam within 72 hours of admission.
- Level 3.7: physical exam within 24 hours of admission.
Retain complete member records for at least five years and through disputes
Maintain required member records for all services including name, address, birth date, Medicaid ID, pertinent diagnostic information, current service plan signed by provider, staff signatures and credentials, documentation of services/dates, and actual start‑and‑stop times; retain all documentation for at least five years or through any dispute.
- Retain records at least five years; if dispute occurs, retain until dispute end or five years, whichever is longer.
- Failure to maintain required documentation may result in disallowance and recovery of payments.
Obtain required prior authorization before rendering PA‑mandated services
Providers must obtain prior authorization before rendering services that require it; prior authorization does not guarantee payment and failure to obtain required PA may result in denial or non‑payment.
- Obtain required PA from the UMC or MCO prior to service delivery.
- PA approval is not a guarantee of payment; failure to obtain PA risks denial.
Prepare for BMS/contractor reviews and utilization management audits
Enrollment, service provision, and utilization are subject to review by BMS and contracted agents; services may be reviewed under utilization management and are subject to state and federal audit which can trigger denial or recoupment if requirements are not met.
- Keep documentation available for BMS and contracted agents' review.
- Noncompliance discovered in audits may lead to denial or recovery of payments.
Risk of denial if PA not obtained for Community PRSS or extra units
Failure to obtain required prior authorization for Community PRSS services may result in claim denial; providers must request prior authorization for any additional units over the 12‑unit daily limit.
- Community PRSS has a 12‑unit per calendar day limit; PA required for any units beyond this limit.
- Failure to secure PA for additional units may result in denial of those units.
PA and medical necessity required for RAS reimbursement
Prior authorization is required for RAS services through the UMC or MCO and reimbursement is only for medically necessary services documented per ASAM assessment; H2036U1HF requires PA and all units must be prior authorized.
- Reimbursement limited to medically necessary services documented by ASAM assessment.
- H2036U1HF and other RAS codes require PA for each unit.
Failure to PA bundled RAS codes risks denial
Prior authorization is required for the bundled RAS procedure codes H2036U5HF and H2036U7HF and all units must be prior authorized; failure to obtain PA for bundled codes may result in denial.
- H2036U5HF and H2036U7HF are 24‑hour bundled units requiring PA for every unit.
- Failure to PA these bundled codes can cause claim denial.
Do not bill for services excluded or not medically necessary
Services that do not meet medical necessity definitions or listed service exclusions (for example, telephone consultations except permissible telehealth) are not reimbursable and may be denied.
- Verify services meet medical necessity and are not listed in exclusions before billing.
- Telephone consultations are excluded except where telehealth is expressly permitted.
Timely PA submission and claim filing required to avoid denial or non‑payment
Failure to obtain required prior authorization from the UMC or MCO, or to submit PA requests within the timelines and manner required, may result in denial of services; claims must be filed within 12 months from the date of service to avoid untimely filing risk.
- Submit PA requests per UMC/MCO timelines and methods.
- File claims within 12 months from date of service to avoid non‑payment.
Background and Policy Scope
West Virginia Medicaid provides a comprehensive scope of medically necessary substance use disorder services under a CMS Section 1115 waiver. Covered SUD Waiver services follow the ASAM Criteria continuum of care, must be delivered by enrolled providers within their licensed scope, and require documentation of medical necessity for coverage.
Definitions and Glossary
Policy Changes and Effective Dates
Chapter 504 SUD Services policy becomes effective
PRSS policy split into Community PRSS (504.15.1) and PRSS-ED (504.15.2); Methadone MAT and Naloxone policies moved to Chapter 519.22; RAS sections updated and RAS Level 3.3 removed to align with ASAM 4th edition
Chapter-level reorganizations: updates to RAS coding in bundled rates, added detail about medical necessity and MAT references, and exclusions updated regarding telehealth and group psychotherapy
Moved administrative prior authorization direction for behavioral health intensive outpatient, community psychiatric supportive treatment, and PHP services into Chapter 504 referencing Chapter 300 and requiring PA be obtained from the UMC or MCO
Specified required member record fields and retention period of at least five years and described consequences for failure to maintain documentation
Added requirement that claims be submitted on BMS-designated forms or electronically, certify claim accuracy via Provider Enrollment Agreement, and filed within 12 months of date of service
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