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

CHAPTER 504: Substance Use Disorder (SUD) Waiver Services — Coverage Criteria

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Governs Medicaid coverage, provider enrollment, medical necessity, supervision, and program integrity requirements for SUD Waiver Services provided to West Virginia Medicaid members, including members in managed care and foster care.

Policy Summary

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

PolicyCHAPTER 504: Substance Use Disorder (SUD) Waiver Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes (current revision)

Effective DateJul 1, 2018

Last ReviewJul 1, 2018

Next Review DateN/A

Key ActionObtain prior authorization from the Utilization Management Contractor or authorized MCO before rendering services that require prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6ASAM Dimensions

Age 10+SBIRT required (initial eval)

30 daysProviders must comment on draft exit report within

60 daysRepayment after overpayment notification

15 daysReport for 90791 must be completed within

24 hoursMissed dose must be reported within

Coverage and Medical Necessity Criteria

Medical Necessity

Covered SUD Waiver Services are subject to medical necessity determined by ALL of the following factors:

Medical Necessity Factors: Diagnosis (as determined by a physician or licensed psychologist); Level of functioning; Evidence of clinical stability; Available support system; Service is the appropriate level of care

Level of care is determined by ASAM criteria (6 dimensions). Consideration of these factors must be documented and re-evaluated at regular service plan updates; diagnostic and standardized instruments may be administered at initial evaluation and as clinically indicated.

H0031 Approved Utilization

H0031 is covered when ANY of the following approved causes for utilization are met:

Approved Causes for H0031: Intake/Initial evaluation; Alteration in level of care (except step-downs for function-related reasons); Critical treatment juncture (documented meeting, may revise plan); Readmission after unusual or significant events justifying re-initiation of treatment; Member under age 3 not eligible (refer to Birth to Three); Re-assessment must be specifically documented.

Policy Summary

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

PolicyCHAPTER 504: Substance Use Disorder (SUD) Waiver Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes (current revision)

Effective DateJul 1, 2018

Last ReviewJul 1, 2018

Next Review DateN/A

Key ActionObtain prior authorization from the Utilization Management Contractor or authorized MCO before rendering services that require prior authorization.

SourceLink

On This Page

Provider may request one global assessment per year to reaffirm medical necessity and the need for continued care/services.

Initial Intake/Re-assessment Billing Rules

Billing restrictions for initial intake or re-assessment sessions:

Mutual exclusivity and sequencing: H0031, T1023HE and 90791 or 90792 are not to be billed at the same initial intake or re-assessment unless H0031 is performed first and the evaluator recommends further assessment with 90791 or 90792.

Documentation must justify need for further evaluation using 90791 or 90792; re-assessment documentation elements required (date, reason, changes since prior, MSE, signature/credentials, etc.).

Coverage for Methadone MAT

Covered when provided as part of methadone ASAM-level opioid treatment program and documentation/staffing requirements met.

Bundle inclusion: Services included in the H0020 weekly bundle (medication, treatment services, and laboratory services) must be billed within the bundle; listed component codes may not be billed outside the bundled code.

See H0020 code list for included codes (e.g., G9008, H0004, 90791, 90792, T1023HE, drug screens, therapy codes).

Therapy requirements: Phase 1 (first 12 months): at least 4 hours of therapy per month including a minimum of 1 hour individual professional therapy; Phase 2 (after 12 months with compliance): at least 1 hour of therapy per month. Medical director must revert phase for non-compliance.

Therapy mix (individual/group/family) per service plan; medical director reviews therapeutic component when moving phases.

Urine drug screens: Phase 1: two random urine drug screens per calendar month; Phase 2: one random urine drug screen per calendar month. Medical director monitors alcohol use and assesses for alcohol use disorders as appropriate.

These requirements are in addition to Legislative Rule 69 CSR 11 (OHFLAC) requirements.

Coverage for Psychiatric Diagnostic Evaluations

Covered when diagnostic evaluation documentation requirements are completed and staff credentialing requirements are met.

90791 eligible providers: 90791 must be performed by a West Virginia licensed psychologist in good standing, a physician, physician assistant, APRN, or a supervised psychologist under a Board Approved Supervisor.

Documentation/report must include required elements and be completed within 15 calendar days; completed SBIRT and follow-up required for ages 10+.

90792 eligible providers: 90792 must be completed by a physician, physician assistant, or APRN and includes integrated bio-psychosocial and medical assessment and may include prescribing.

Documentation/report must include required medical elements and be completed within 15 calendar days; completed SBIRT and follow-up required for ages 10+.

Dosing and Missed Dose Criteria

Dose adjustment and missed-dose management rules must be followed for clinical coverage and safe care.

Missed doses - early stabilization: During early stabilization (0–2 weeks): if 24 hours missed — no dose increase; if 48 hours missed — reevaluate member and restart from initial dose; two consecutive missed doses require reassessment and restart at ≤30 mg.24-48 hours

Physician/physician extender reassessment required; clinical in-person assessment and weekly clinician contact expected during early stabilization.

Missed doses - late stabilization/maintenance: Late stabilization (2–6 weeks) and maintenance: 1–2 days missed — if not intoxicated, continue current dose; 3 days missed — reassess including UDS and restart at 50% of prior dose then increase ≤10 mg/day for up to 3 days; 4+ days missed — reassess including UDS and restart at 30 mg or less and titrate per usual.1-2,3,>=4 days

Physician/physician extender reassessment required; missed-dose rules for late stabilization mirror maintenance.

Missed Dose Management

Actions for managing missed methadone doses vary by treatment phase and number of missed days:

Early Stabilization - Missed doses: If member misses 24 hours: no dose increase and no change. If misses 48 hours: reevaluate member and start from initial dose.24-48 hours

Dosing personnel must report missed doses to the OTP medical director, physician or physician extender within 24 hours; reassessment by medical director/physician required for restarts.

Late Stabilization/Maintenance - Missed doses 1-2 days: If missed 1–2 days and member not intoxicated: continue current dose; no change.1-2 days

From policy table; clinician judgment and UDS as indicated.

Late Stabilization/Maintenance - Missed doses 3 days: Reassess member including urine drug screen; restart at 50% of prior dose, then increase by no more than 10 mg daily for up to 3 days.3 days

Prescriber reassessment required; dosing personnel report missed doses within 24 hours.

Late Stabilization/Maintenance - Missed doses 4+ days: Reassess member including urine drug screen; restart at 30 mg or less and titrate per usual.>=4 days

Clinical reassessment and cautious retitration required due to loss of tolerance potential.

Methadone Dose Policy

Methadone dose considerations

Doses below 60 mg: Maintenance doses below 60 mg may be justified for members with no unauthorized opioid use, no significant withdrawal/craving, high risk for methadone toxicity, or those on a tapering protocol.<60 mg

Policy notes evidence that 60–100 mg is more effective, but lower doses acceptable in select cases.

Doses 60-100 mg: Evidence indicates methadone doses of 60–100 mg are more effective than doses below 60 mg for reducing heroin use and retaining members in treatment.60-100 mg

Clinical evidence statement in policy.

Doses above 120 mg: Doses >120 mg are associated with dose-related adverse effects (sedation, overdose risk, sleep apnea, sexual dysfunction) and cardiac risks (prolonged QT, potential Torsades de Pointes); consider tapering and assess for causes of ongoing withdrawal symptoms.>120 mg

Assess risk and consider tapering per clinical judgment.

EMS Naloxone and Referral Criteria

EMS naloxone administration and on-scene referral/brief intervention

Naloxone administration: Naloxone administered by authorized prehospital providers per statewide protocol may be billed using A0998 with modifier HF; it may be billed whether or not the member is transported.N/A

Staff credentials and statewide protocols apply per WV Office of Emergency Medical Services.

Referral to treatment by EMS: When naloxone is administered or a member is identified as having a SUD, prehospital providers should provide WV Helpline informational material and determine interest in treatment; if the member consents, contact the WV Helpline (1-844-HELP4WV) to make a referral. Brief intervention on scene billed as H0050 HF in 15-minute units (max 2 units per calendar day).Max 2 units/day

Billing examples specify combinations of A0998 HF and H0050 HF depending on transport/referral choices.

Peer Recovery Support Coverage Criteria

Peer Recovery Support Services coverage and provider requirements

Eligible recipients: Individuals age 16 years or older with a substance use disorder or co-occurring substance use and mental health disorder are eligible to receive Peer Recovery Support Services (PRSS).>=16 years

PRSS are nonclinical recovery support services delivered by certified peers.

Provider settings and billing: PRSS must be provided by a Comprehensive Behavioral Health Center (CBHC) or Licensed Behavioral Health Center (LBHC), billed with H0038 in 15-minute units, with a service limit of 16 units per calendar day; group RSS is not a covered service and PRSS may not be provided from the PRSS's home. Telehealth is allowed.16 units/day

Prior authorization is required for H0038.

PRSS qualifications and documentation: PRSS must self-identify as having lived experience, be in recovery >=2 years, have HS diploma/GED, be employed by CBHC/LBHC, hold certification (grandfathering allowed for certifications before 7/1/2018), submit application and references, be supervised by a Master's degree clinician employed by the same provider, complete 40 contact hours of volunteer/work prior to billing, maintain CPR/First Aid, pass fingerprint-based background check, and complete required continuing education. Documentation of services must include member name, date/location, start/stop times, activity notes describing activities, staff signature and credentials, facility and affiliation.various

Specific training must be completed within 90 days of employment and prior to billing; activity notes must include reason for service, symptoms/functioning, and member response.

Admission Criteria (general for Residential Adult Services / by level)

Covered when ALL of the following are met:

Core admission criteria: Referral received by a physician, physician extender, or provider; an evaluation/assessment including the six ASAM dimensions showing the member cannot be treated appropriately in an outpatient setting; a current ICD or DSM diagnosis of a substance use disorder; identified functional deficits (e.g., inability to apply recovery skills, lack of personal responsibility, inability to maintain employment/education/relationships, legal involvement).

Level-specific deficits and severity determine appropriate ASAM residential level (3.1, 3.3, 3.5).

Level 3.1 Specific Criteria

Covered when ALL of the following are met:

3.1 admission criteria: Adult (18+) with ICD/DSM diagnosis of a substance use disorder or co-occurring disorder whose treatment needs cannot be met outpatient; functional deficits include inability to apply recovery skills, lack of personal responsibility, or deficits in employment/education/relationships. Evaluation must include ASAM six-dimension assessment.

Program must provide at least 5 clinical service hours per week plus structural supports; prior authorization required; units billed per calendar day (H2036U1HF).

Level 3.3 Specific Criteria

Covered when ALL of the following are met:

3.3 admission criteria: Adult (18+) with ICD/DSM diagnosis of a substance use disorder or co-occurring disorder whose treatment needs cannot be met outpatient; impairment is more severe due to cognitive symptomatology, requiring medium-intensity clinical services and a more structured environment. Evaluation must include ASAM six-dimension assessment.

Program must provide at least 10 clinical service hours per week plus structural supports; prior authorization required; units billed per calendar day (H2036U3HF).

Level 3.5 Specific Criteria

Covered when ALL of the following are met:

3.5 admission criteria: Adult (18+) with ICD/DSM diagnosis of a substance use disorder or co-occurring disorder whose treatment needs cannot be met outpatient; significant social and psychological problems, extensive treatment or criminal justice histories, or difficult-to-stabilize behaviors requiring habilitation services addressing education, vocational, and daily living skills.

Program must provide at least 15 clinical service hours per week plus structural supports; prior authorization required; units billed per calendar day (H2036U5HF).

Admission Criteria

Admission Criteria for residential SUD services (applies across described residential levels unless level-specific criteria noted): Covered when ALL of the following are met

Residential admission core criteria: An evaluation/assessment shows the member cannot be treated in an outpatient setting; a current ICD or DSM diagnosis of a substance use disorder; identified deficits (inability to apply recovery skills, lack of personal responsibility, inability to maintain employment/education/relationships, legal involvement, need for more intense structured environment, difficult to stabilize, imminent danger or behaviors requiring intense rehabilitation).

For Level 3.7, additional requirements apply (see Level 3.7 specifics); WM Level 3.2 has specific withdrawal risk factors that must be present for WM admission.

Level 3.7 additional requirement: For Level 3.7 specifically, admission requires meeting specifications in two ASAM Dimensions, at least one in Dimension 1, 2, or 3; individuals have subacute biomedical and emotional/behavioral/cognitive problems requiring residential treatment but not full acute hospital resources.

Level 3.7 program requirements include higher clinical intensity and staffing.

Level 3.2 WM admission risk factors: Withdrawal Management (Level 3.2) requires presence of multiple risk factors such as past seizures or delirium tremens, frequent sleep disturbance, significant autonomic signs (sweating, tremor, pulse >100 with BAL >.10), moderate-severe anxiety or tremor, withdrawal symptoms with fever or BP elevation, moderate-severe co-occurring psychiatric or medical problems, ambivalent commitment, absence of social support or safe housing.

WM Level 3.2 clinical components and documentation requirements apply (comprehensive nursing assessment, H&P within 12 hours, daily progress notes, withdrawal rating scales, physician availability).

Continue Stay and Discharge Criteria

Continuing stay and discharge rules

Continuing stay: Member continues to meet medical necessity for this level of care as documented by the provider of services and the treatment team (level-specific documentation required).

Continuing stay determinations must be documented by the treatment team per level-specific wording.

Discharge criteria: Discharge when goals and objectives are completed and the member can step down to a less intensive level; or when member is unable to complete goals and requires transfer to a different level; when medical issues become unmanageable at this level; member refuses to comply with treatment; or failure to respond to treatment or need to transfer to a higher level.

Documentation of discharge rationale required.

Program Requirements and Clinical Components

Program and clinical operation requirements

Staffing and medical availability: Programs must provide 24/7 structured programming with trained therapists and credentialed interdisciplinary staff; a physician, physician assistant, or APRN must be available to assess the individual in person within 24 hours of admission and thereafter as medically necessary; a registered nurse must conduct an AOD-focused nursing assessment at admission; additional medical/psych specialty, laboratory and toxicology services must be available on-site or by referral; psychiatric services should be available via consultation or referral within specified timeframes.24 hours

Staffing and availability requirements support clinical monitoring and withdrawal management when indicated.

Service intensity: Level 3.7 programs must provide at least 22 clinical service hours per week; other residential programs described require minimum clinical service hours per week (e.g., Level 3.5: 15 hours/week; Level 3.3: 10 hours/week; Level 3.1: 5 hours/week) in addition to structural supports.varies by level

Programs must deliver a comprehensive array of treatment modalities appropriate to the certified service description.

WM Level 3.2 clinical components: Withdrawal Management components include intake, observation, medication services, discharge services, documented progress notes, vital signs, withdrawal rating scales, RN assessment on admission, physician approval and availability, and daily assessment of progress.

Assessment and treatment plan elements must include H&P within 12 hours, biopsychosocial screening, individualized treatment plan addressing all 6 dimensions, and discharge/transfer planning beginning at admission.

Any service, procedure, item, or situation not discussed in the West Virginia Provider Manual is presumed non-covered unless West Virginia Bureau for Medical Services (BMS) notifies otherwise in writing. Providers must assume non-coverage for matters not explicitly addressed in this manual and seek written clarification from BMS before rendering services that fall outside the manual's content.

The Mental Health Assessment by Non‑Physician (H0031) is not to be performed on children under age three. Members younger than three should be referred to the Birth to Three Program; assessments for children transitioning out of that program should be managed to ensure a smooth transition per the Provider Manual.

Residential treatment providers must be approved by BMS and obtain prior authorization before services will be reimbursed. No provider will be reimbursed for residential services unless BMS has approved the provider and the specific services have been prior authorized. Managed Care Organizations (MCOs) may only utilize BMS‑approved residential treatment providers.

The H0020 weekly bundle is a single bundled rate that includes medication, treatment services, and laboratory services. Components listed as included in the H0020 bundle (for example, G9008, H0004, 90791, 90792, drug screens, and listed therapy codes) may not be billed separately or outside of the H0020 bundled code.

Group Recovery Support Services (group RSS) are not a covered service and therefore must not be billed; only individual Peer Recovery Support Specialist (PRSS) services billed under H0038 are allowable when criteria are met.

Peer Recovery Support Specialists may not provide services from their own home. Services should be delivered in appropriate community or telehealth settings as described in the Provider Manual; the PRSS's residence is explicitly excluded as an allowable service location.

Members receiving Residential Adult Services may not concurrently receive Day Treatment or Assertive Community Treatment services. Residential admission requires evaluation showing the member cannot be safely or appropriately treated in an outpatient setting; while in residential care, the member must receive the residential program services and may not be billed concurrently for those other named treatment modalities.

The policy excludes reimbursement for several non‑billable activities, including telephone consultations, meetings held solely to review evaluation results, missed appointments (including cancellations and no‑shows), and any services that do not meet the definition of Medical Necessity. Providers must not bill for these excluded items.

Reimbursement is explicitly not allowed for telephone consultations, meetings solely to review evaluation/results, and missed appointments (including cancelled and not‑kept appointments). These exclusions apply across SUD Waiver Services except where a specific exception is provided (e.g., targeted case management).

Reimbursement is not available for non‑face‑to‑face communications such as telephone conversations, electronic mail (e‑mail), or facsimile transmissions between a provider and a member, except where Targeted Case Management is an allowable exception. Providers should document and bill only permitted, face‑to‑face or telehealth services described in the manual.

Peer Recovery Support may not be provided concurrently at the same time and place with any other direct support Medicaid service; the only exception permitted is Targeted Case Management as an indirect service. PRSS must therefore not be billed for the same encounter that is billed as another direct support Medicaid service.

A service is not medically necessary if the member no longer meets the continuing stay criteria or no longer meets the documented medical necessity for that level of care. Continuing stay requires documentation by the provider and treatment team that the member continues to meet the level's medical necessity; absence of that documentation makes continued reimbursement inappropriate.

Services that do not meet the Provider Manual's definition of Medical Necessity are not reimbursable. Providers must ensure that all billed services satisfy the medical necessity factors and are documented in the clinical record to support payment.

Services failing to meet the definition of Medical Necessity will be denied and are not eligible for reimbursement. Providers must maintain documentation demonstrating that services billed meet the medical necessity criteria described in the manual.

Procedure, CPT and HCPCS Codes

Assessment and SBIRT-related CodesCPT | HCPCS | mixedCovered

90791	Psychiatric Diagnostic Evaluation (No Medical Services)
90792	Psychiatric Diagnostic Evaluation with Medical Services
H0031	Mental Health Assessment by Non-Physician
T1023HE	Referenced in billing restriction note (specific descriptor not provided in this chunk)

Psychiatric Diagnostic EvaluationsCPTCovered

90791

Psychiatric Diagnostic Evaluation (No Medical Services)

Psychiatric Diagnostic Evaluations with Medical ServicesCPTCovered

90792

Psychiatric Diagnostic Evaluation With Medical Services (Includes Prescribing of Medications)

Methadone MAT Bundle and componentsmixedCovered

H0020	Methadone ASAM Level MAT bundle code (weekly)
G9008	Included in H0020 bundle
H0004	Included in H0020 bundle
H0004HO	Included in H0020 bundle
H0004HQ	Included in H0020 bundle
H0004HOHQ	Included in H0020 bundle
H2011	Included in H0020 bundle
H0031	Included in H0020 bundle
H0032	Included in H0020 bundle
H0032AH	Included in H0020 bundle

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Initial OTP administrationHCPCSCovered

T1001

Assessing a Member for OTP Initiation (Modifier HF) - observation of first methadone administration

Naloxone Administration (EMS)HCPCSCovered

A0998

Bundled Code (Includes two 2mg syringes of Naloxone Hydrochloride, administration fee, and atomizers)

EMS Referral/Brief InterventionHCPCSCovered

H0050

Alcohol and/or Drug Services, Brief Intervention (While on the Scene) - 15 Minutes

Peer Recovery Support ServicesHCPCSCovered

H0038

Peer Recovery Support Specialist services - 15 Minutes

Residential Covered Procedure CodesHCPCSCovered

H2036U1HF

Procedure code for Residential Adult Services ASAM Level 3.1

Residential Covered Procedure CodesHCPCSCovered

H2036U3HF

Procedure code for Residential Adult Services ASAM Level 3.3

Residential Covered Procedure CodesHCPCSCovered

H2036U5HF

Procedure code for Residential Adult Services ASAM Level 3.5

Included/Related Codes in Payment BundlemixedCovered

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 Paraprofessional
H2014U4	Skills Training and Development, 1:2-4 by Paraprofessional
H2014HNU1	Skills Training and Development, 1:1 by Professional
H2014HNU4	Skills Training and Development, 1:2-4 by Professional

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Covered procedure and service codesmixedCovered

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

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SBIRT age threshold

SBIRT age thresholdSBIRT required for individuals age 10 and older (required for initial evaluations for codes 90791, 90792, H0031)

Applicable codes90791, 90792, H0031 (SBIRT required for initial evaluations only)

DocumentationCompleted SBIRT and appropriate follow-up must be included in the initial evaluation record for ages 10+

90791 documentation completion

90791 report timeframeDocumentation/Report for 90791 must be completed within 15 calendar days from the date of service

Required elements (examples)Date/location/purpose, clinician signature with credentials, presenting problem, history, duration/frequency of symptoms, medication history, mental status exam

SBIRT inclusionCompleted SBIRT and appropriate follow-up required for individuals age 10 and older

Initial dose parameters

Recent abstinenceStart at 10 mg or less

Higher risk for methadone toxicityStart at 20 mg or less

No risk factors with recent abstinenceStart at 30 mg or less

Dose increase rates

Early/late stabilization incrementsIncrease by 5-15 mg depending on risk every 3-5 days (specific: recent abstinence 5 mg or less every 5 days; higher risk 5-10 mg every 3-5 days; no risk factors 10-15 mg every 3-5 days)

Maintenance phase (>=80 mg)Increase no more than 5-10 mg every 5-7 days with in-person physician assessment

Clinical monitoringAssess weekly during ongoing dose adjustments; medical director involvement for maintenance increases

Methadone dosing thresholds

Optimal maintenance range60-120 mg is identified as the optimal maintenance range for most OTP members

Below 60 mgDoses below 60 mg may be justified for members with no unauthorized opioid use, no significant withdrawal/craving, high toxicity risk, or on taper

Above 120 mgDoses >120 mg are high dose — assess for dose-related adverse effects (sedation, QT prolongation) and consider tapering

Clinical service hours per week (Level 3.1)

Clinical service hours (Level 3.1)Program must provide at least 5 clinical service hours per week

Service unitResidential Level 3.1 is a structured 24-hour setting (service unit: 24 hours)

Prior authorizationPrior authorization required; units billed one per calendar day and must be prior authorized

Clinical service hours per week (Level 3.3)

Clinical service hours (Level 3.3)Program must provide at least 10 clinical service hours per week

Service unitResidential Level 3.3 is a structured 24-hour setting (service unit: 24 hours)

Prior authorizationPrior authorization required; units billed one per calendar day and must be prior authorized

Clinical service hours per week (Level 3.5)

Clinical service hours (Level 3.5)Program must provide at least 15 clinical service hours per week

Service unitResidential Level 3.5 is a structured 24-hour setting (service unit: 24 hours)

Prior authorizationPrior authorization required; units billed one per calendar day and must be prior authorized

Service Unit

Service unit definitionResidential service procedure codes use a service unit of 24 hours (one unit per calendar day)

Reimbursement timingReimbursement begins on the day of admission (regardless of time before midnight) and continues per calendar day except day of discharge

Prior authorization requirementAll residential units must be prior authorized through the Utilization Management Contractor

Authorization, Documentation, and Operational Requirements

Prior Authorization

Obtain Prior Authorization Before Rendering PA-Required Services

Providers must obtain prior authorization from the Utilization Management Contractor (UMC) or the Managed Care Organization (MCO) authorized by BMS before rendering any services that require prior authorization; prior authorization does not guarantee payment.

Prior Authorization

Prior Authorization Required for H0031, 90791, 90792

Prior authorization is required for Mental Health Assessment by Non‑Physician (H0031) and psychiatric diagnostic evaluations (90791 and 90792); each of these services lists prior authorization as a service limit.

Prior Authorization

BMS Approval and Prior Authorization Required for Residential Treatment

Residential services must be approved by BMS and prior authorized before reimbursement; no provider will be reimbursed for residential services unless approved by BMS and the services have been prior authorized.

Complete Appendix B Application for Residential Adult Services and submit to BMSSUDWaiver@wv.gov; await BMS certification prior to providing services.
BMS will notify the provider of approval/disapproval within 30 days of receipt.

Prior Authorization

Prior Authorization Required for Psychiatric Diagnostic Evaluations

90791 and 90792 both require prior authorization and must follow the service limits listed for Psychiatric Diagnostic Evaluations.

Note

H0020 Methadone Bundle — No Prior Authorization; Components Are Bundled

The methadone MAT weekly bundle (H0020) is not subject to prior authorization; component codes listed as included in the H0020 bundle may not be billed separately outside the bundle.

H0020 is billed per calendar week and includes listed component codes (e.g., 90791/90792, H0031, T1023HE) which cannot be billed separately.

Prior Authorization

Prior Authorization Required for Peer Recovery Support (H0038)

Peer Recovery Support Specialist services (H0038) require prior authorization; providers must ensure H0038 is prior authorized before billing.

H0038 is a 15‑minute unit with a service limit of 16 units per calendar day.

Prior Authorization

Prior Authorization Required for Residential Adult Services (All Units)

Prior authorization is required for Residential Adult Services (H2036U1HF, H2036U3HF, H2036U5HF); all units billed (one per calendar day) must be prior authorized and reimbursement begins on the day of admission.

Service unit = 24 hours; one unit per calendar day must be prior authorized.
Reimbursement begins on day of admission (regardless of time prior to midnight) and continues for each calendar day except the day of discharge.

Prior Authorization

Prior Authorization Required for H2036U7HF (Level 3.7)

Prior authorization is required for H2036U7HF (Residential ASAM Level 3.7); all units must be prior authorized and reimbursement begins on the day of admission (paid per calendar day except day of discharge).

Prior Authorization

Providers must register and obtain prior authorization from BMS' UMC for Behavioral Health IOS, Community Psychiatric Supportive Treatment (CPST), and Partial Hospitalization Program (PHP) services; requests must be submitted within the timelines and in the manner required by BMS' UMC.

Note

Billing Rule

Sequencing Rule for H0031, T1023HE and 90791/90792 at Intake/Reassessment

H0031, T1023HE and 90791/90792 must not be billed together at the same initial intake or re-assessment unless H0031 is performed first and documentation justifies further evaluation with 90791 or 90792.

If 90791/90792 are used after H0031, documentation must explicitly justify the need for a more detailed medical or psychological assessment.

Step Therapy

Follow Phase‑Dependent Missed‑Dose Management for Methadone

Dose re‑initiation and adjustments after missed methadone doses depend on stabilization phase and number of missed days; follow the phase‑dependent clinical rules to avoid unsafe dosing.

Early stabilization: after two consecutive missed doses cancel prescription until reassessment and restart at ≤30 mg.
Late stabilization/maintenance: 1‑2 days missed — continue current dose if not intoxicated; 3 days — reassess and restart at 50% of prior dose then increase ≤10 mg/day (max 3 days); ≥4 days — restart at ≤30 mg and titrate per usual.

Documentation Required

Execute Stepwise Clinical Actions After Missed Methadone Doses

For missed methadone doses the policy prescribes stepwise clinical actions by stabilization phase and number of missed days; do not increase dose after a 24‑hour miss in early stabilization and perform required reassessments before reinitiation.

Dosing personnel must report missed doses to the OTP medical director, physician, or physician extender within 24 hours.
A clinically significant loss of opioid tolerance may occur within 3 days; reduce dose accordingly and reassess.

Note

Maintain Level‑of‑Care Coordination and Affiliations

Programs must have direct affiliations or close coordination with other levels of care so members can be stepped up or down as clinically indicated.

Note

Documentation Required

Maintain Staff Credentials, Contracts, and Personnel Documentation

Maintain documentation of staff credentials (licenses, transcripts, certifications), contracts/agreements for prescriptive authority, and personnel records on file at the service location; these records may be reviewed by BMS, contractors, or auditors.

Keep college transcripts, certifications, background checks, and training records in personnel files for review.

Documentation Required

Include Diagnostic Instruments and Results in Clinical Record

Diagnostic and standardized instrument results used to justify level and type of service must be part of the clinical record and documented during the initial evaluation and as clinically indicated.

Documentation Required

Maintain Complete, Legible Member Records and Provide Timely Access

Providers must maintain complete, legible member records (electronic or written) including identifying information, individualized service plan with goals/objectives derived from a comprehensive assessment, signatures and credentials, discharge reports, and copies of consents/releases; requested records must be presented for retrospective review and copies provided within one business day if requested.

Documentation for initial intake/reassessment must include place/date/time, start/stop times, evaluator signature/credentials, and a diagnostic impression signed by a licensed clinician.
Electronic signatures are acceptable if time/date stamped.

Documentation Required

Complete and Document SBIRT for Individuals Age 10+ on Initial Evaluations

SBIRT must be completed for individuals age 10 and older as part of initial evaluations for 90791, 90792, and H0031; include completed SBIRT and appropriate follow‑up in the documentation.

SBIRT is required ONLY for initial evaluations under these codes.

Documentation Required

Document Required Elements and Timeline for 90791

90791 documentation must include date/location/purpose, clinician signature with credentials, presenting problem, history, duration/frequency of symptoms, medication history, psychiatric and medical history, full Mental Status Exam elements, DSM/ICD diagnosis with rationale, prognosis, recommendations, completed SBIRT for ages 10+, and the report must be completed within 15 calendar days of service.

Mental Status Exam elements must include appearance, behavior, attitude, level of consciousness, orientation, speech, mood/affect, thought process/content, suicidality/homicidality, insight and judgment.

Documentation Required

Document Required Elements and Timeline for 90792 (Includes Medical Evaluation)

90792 documentation must include date/location/purpose, clinician signature with credentials, confirmation the member was present and that a medical evaluation was completed, presenting problem, history, medication history, psychiatric and medical history, full Mental Status Exam elements, DSM/ICD diagnosis with rationale, prognosis, recommendations, completed SBIRT for ages 10+, and the report must be completed within 15 calendar days of service.

90792 must be completed by a physician, physician assistant, or APRN.

Note

Documentation Required

Document T1001 HF Observation and Complete Admission Documentation for First Methadone Dose

T1001 HF observation for first‑time methadone administration requires documentation of date, start/end times, member response, side/adverse effects including changes to level of consciousness, and signature with credentials; include completion of applicable documentation elements from H0031, 90791, and 90792.

Documentation Required

Peer Recovery Support — Required Documentation Elements

Peer Recovery Support Service documentation must include member name, date of service, location, start/stop time, activity note describing each activity, type of service, signature and credentials of staff, facility and affiliation; activity notes must state reason for service, symptoms/functioning, and member response.

Meetings are not allowed by phone only; PRSS may not provide services from their own home.
If a Master Service Plan exists, interventions should reflect goals/objectives on the plan.

Billing Rule

EMS Naloxone and On‑Scene Referral — Billing and Documentation Rules

When naloxone is administered by EMS, billing may use A0998 HF; brief on‑scene referral/intervention is billed as H0050 HF (15‑minute units, max 2 per calendar day); follow provided billing examples to determine correct code combinations.

A0998 HF can be billed whether or not the member is transported.
H0050 HF is limited to 2 units per calendar day.

Documentation Required

Report Missed Methadone Doses to OTP Medical Director Within 24 Hours

Dosing personnel must report missed methadone doses to the OTP medical director, physician or physician extender within 24 hours.

Documentation Required

Required Clinical Documentation at Admission and During Residential Stay

Activity notes or intervention documentation must include the reason for service, symptoms and functioning, member response, signature and credentials of staff, facility and affiliation; residential records must also include physician/physician extender order authorizing services, individualized service plan, daily participation summary signed by attending staff, medication administration records, urine drug screen records, sign‑in/sign‑out sheet, and a service plan developed within 72 hours and reviewed at least every 7 calendar days.

Service plan must be developed within 72 hours of admission and reviewed at least every 7 calendar days.
Sign‑in/sign‑out sheets must record actual departure/return times, reasons, and staff signatures.

Note

Documentation Required

Maintain and Retain Required Service Documentation (Minimum 5 Years)

Providers must maintain required service documentation for each member (identifying info, diagnostic info, current service plan signed by provider, staff signature/credentials, service designation, dates, start/stop times) and retain all required documentation for at least five years (or until resolution of any dispute).

Denial Risk

Respond to Provider Review Findings — Comment Period and Repayment Options

Provider review findings that identify potential disallowances can result in repayment demands, placement of liens, or a recovery schedule; providers have 30 calendar days to comment on the draft exit report and must repay BMS within 60 days if payment to BMS is selected.

Options to effectuate repayment include payment within 60 days, placement of a lien to recover within 60 days, or a recovery schedule up to 12 months.

Denial Risk

Submit Plan of Correction Timely to Avoid Pay Hold

BMS may place a pay hold on claims if an approved Plan of Correction (POC) is not submitted to the contracted agent within 30 calendar days of receipt of the draft POC; submit a POC that addresses how the deficiency will be corrected, prevention systems, monitoring, completion date, and training needs.

POC must be submitted electronically to the contracted agent for approval within 30 calendar days.

Note

Denial Risk

Certification Termination Risk for Non‑Compliance or Adverse Findings

BMS may terminate certification for non‑compliance with policy, state licensing revocation, or reports of abuse, fraud or other indicators of improper practice; providers must maintain compliance to avoid termination.

Billing Rule

Do Not Provide/ Bill Day Treatment or ACT Concurrently with Residential Adult Services

Medicaid members in Residential Adult Services may not receive Day Treatment or Assertive Community Treatment Services concurrently; providers must not bill or provide these services simultaneously.

Denial Risk

Service‑Level Denial Triggers — Non‑Medical Necessity and Exclusions

Reimbursement is not allowed for services that do not meet the definition of Medical Necessity and for listed exclusions (telephone consultations, meetings solely to review results, missed appointments, experimental services, services outside scope of license, time spent preparing reports, and similar items).

Ensure services meet Medical Necessity and are documented accordingly to avoid denial.

Denial Risk

Documentation Failures May Trigger Recoupment by BMS

Failure to maintain all required documentation may result in disallowance and recovery by BMS of any amounts paid to the provider for which required documentation is not maintained or provided upon request.

Providers must present records requested for retrospective review and provide copies within one business day if requested.

Denial Risk

Do Not Bill for Excluded Services That Trigger Denial

Reimbursement is not allowed for telephone consultations, meetings solely to review evaluation/results, missed appointments (including cancellations/no‑shows), services not meeting Medical Necessity, experimental services, and services outside the provider's license; these exclusions will trigger denials.

Key Terms and Definitions

Medical necessity definition

General definitionServices and supplies that are appropriate and medically necessary for the symptoms, diagnosis, or treatment of an illness

Additional criteriaProvided for diagnosis or direct care; within standards of good practice; not primarily for convenience; most appropriate safe level of care

DocumentationMedical necessity must be demonstrated and re-evaluated throughout provision of services; ASAM six-dimension assessment used for level of care

SBIRT

DefinitionSBIRT is a comprehensive, evidence-based public health approach composed of Screening, Brief Intervention, and Referral to Treatment for early identification and intervention of risky alcohol/drug use

Required useSBIRT is required as a documentation component for initial evaluations for codes 90791, 90792, and H0031 for individuals age 10+

ComponentsScreening (brief questions), Brief Intervention (education/motivation), Referral to Treatment (facilitate access)

H0031 definition

Code descriptionH0031: Mental Health Assessment by Non-Physician — initial or reassessment evaluation to determine needs, functioning, mental status and social history

Service unit & PAService unit: Event; Prior authorization required

Staff credentialsStaff must have at minimum master's degree, bachelor's in human services, or RN; supervision by master's-level individual required

90791 definition

Code description90791: Psychiatric Diagnostic Evaluation (No Medical Services) — integrated bio-psychosocial assessment including history, mental status exam, and recommendations

Providers who may performWest Virginia licensed psychologist, physician, physician assistant, APRN, or supervised psychologist

Documentation timingReport must be completed within 15 calendar days of the date of service and include full MSE and SBIRT for ages 10+

H0020 bundle

H0020 bundle descriptionH0020 is a weekly bundled rate that includes medication, treatment services, and laboratory services; listed component codes may not be billed separately

Example included codesIncludes codes such as 90791, 90792, H0031, H2011, drug screens (80305-80307), psychotherapy codes, and others as listed in policy

Prior authorizationH0020 bundle is not subject to prior authorization

Induction phase

Induction phase overviewInitial dosing period where starting dose is chosen based on risk factors (recent abstinence, toxicity risk, tolerance) with conservative initiation to avoid overdose

Toxicity risk factorsConsider sedating meds, benzodiazepines, antipsychotics, and drugs of abuse that increase methadone toxicity risk; check initial drug screen

Clinical cautionOpioid tolerance is difficult to establish — safer to initiate at lower doses and titrate per protocol

Naloxone (A0998 HF)

Definition and useNaloxone is a pure opioid antagonist (Narcan®) used by authorized prehospital providers to prevent or reverse opioid effects including respiratory depression; billed with A0998 HF

Billing pointThis code may be billed regardless of whether the member is transported to the hospital

ComponentsA0998 bundled code includes two 2 mg syringes, administration fee, and atomizers

Peer Recovery Support Specialist (PRSS)

DefinitionPeer Recovery Support Specialist (PRSS) is a certified individual with lived experience who delivers nonclinical recovery support services to eligible individuals

Eligibility and settingPRSS may serve individuals age 16+ with SUD or co-occurring disorders and must be employed by CBHC or LBHC; group RSS not covered

Certification and requirementsPRSS must meet BMS education, certification, supervision and training requirements (documentation retained in personnel files)

ASAM Level 3.1

DefinitionASAM Level 3.1: Structured 24-hour residential treatment for adults with SUD or co-occurring disorder whose needs cannot be met outpatient

Program focusApplying recovery skills, preventing relapse, improving emotional functioning, and reintegration supports

Service/unit specificsService unit 24 hours; at least 5 clinical service hours per week; prior authorization required

ASAM Level 3.3

DefinitionASAM Level 3.3: Structured 24-hour residential setting providing medium intensity clinical services for clients with cognitive impairments or more severe needs

Program focusSlower pace, repetitive services to address cognitive/mental health impairments

Service/unit specificsService unit 24 hours; at least 10 clinical service hours per week; prior authorization required

ASAM Level 3.5

DefinitionASAM Level 3.5: Structured 24-hour residential treatment for clients with significant social and psychological problems and habilitation needs

Program focusHabilitation services addressing education, vocational, and daily living skills for severely impaired members

Service/unit specificsService unit 24 hours; at least 15 clinical service hours per week; prior authorization required

Withdrawal Management Level 3.2

DefinitionWithdrawal Management Level 3.2: Clinically managed residential withdrawal management providing 24-hour supervision, observation, medication services, intake and discharge services

Therapies and servicesIncludes cognitive, behavioral, medical and other therapies, interdisciplinary assessment, health education, family services, and discharge planning

Nursing and medical componentsRN assessment on admission, physician approval/availability, documented progress notes and withdrawal rating scales

Residential ASAM® Level 3.7

DefinitionResidential ASAM® Level 3.7: Structured 24-hour professionally directed residential programs in permanent facilities for individuals with subacute biomedical and severe behavioral or cognitive problems

Admission requirementMeet specifications in two Dimensions, at least one in Dimension 1, 2, or 3; interdisciplinary credentialed staff including addiction credentialed physicians

Service/unit specificsService unit 24 hours; prior authorization required; reimbursement begins on day of admission

Medication Assisted Treatment (MAT)

DefinitionMedication Assisted Treatment (MAT): Use of FDA‑approved medications in combination with evidence‑based behavioral therapies to provide a whole‑member approach to treating SUDs

Example medicationMethadone is a commonly used synthetic opiate in MAT as a substitute for heroin in treatment programs

Bundle referenceMethadone MAT services are provided under the H0020 weekly bundle which includes medication, treatment, and lab services

Naloxone

Naloxone definitionNaloxone is an opioid antagonist that prevents or reverses opioid effects including respiratory depression (sold as Narcan®)

EMS billingBilled using bundled code A0998 HF which includes two 2 mg syringes, administration fee and atomizers

Provider scopeAdministered by authorized prehospital providers per statewide protocol; may be billed regardless of transport

Methadone

Methadone descriptionMethadone is a synthetic opiate commonly used as a legal substitute for heroin in addiction treatment programs

Clinical considerationsInitiate conservatively during induction and monitor for toxicity; titrate per stabilization/maintenance guidance in policy

Dose-related risksBe aware of dose-related adverse effects (sedation, overdose risk, QT prolongation) particularly at high doses

Policy Background

West Virginia's Section 1115 waiver established a continuum of medically necessary SUD treatment benefits to address individuals' physical, mental, and social needs and to promote long‑term recovery. The SUD Waiver Services are organized using the ASAM® Criteria continuum of care and are available to all Medicaid members, including those in managed care; covered services must be rendered by enrolled providers within the scope of their license and in accordance with State and Federal regulations.

Policy Revision History

2018-07-01policy_effective_date

Chapter 504 SUD services policy effective date recorded as 2018-07-01 in policy metadata.

2018-07-01documentation_retention_specified

Providers must retain all required service documentation for at least five years (or until resolution of dispute if longer).

2018-07-01timely_claim_filing_limit_specifiedLatest

Claims must be filed within 12 months from date of service; claims must include required information and represent usual and customary charges.