All services require prior approval unless otherwise noted. Please scroll all the way down this page to view (b)(3) service definitions.

CategoryService Definition
ACT Step-Down H0040 TSAlternative Service Description
Ambulatory DetoxificationClinical Coverage Policy 8A
Assertive Community Treatment Team H0040Clinical Coverage Policy 8A-1
Child and Adolescent Day Treatment H2012:HAClinical Coverage Policy 8A
Child-Parent Interaction TherapyScope of Work
Community Support Team (CST) H2015:HTClinical Coverage Policy 8A

Records Management And Documentation Manual
Community Support Team PlusScope of Work
Dialectical Behavior Therapy (DBT)Scope of Work
Enhanced Therapeutic Foster CareScope of Work
Family Centered TreatmentAlternative Service Description
Inpatient Hospital Psychiatric Treatment (MH) RC100 (Initial Request(s): Pass through of 48 hours for emergency admissions after business hours.Prior authorization required after 48 business hours.)Clinical Coverage Policy 8B
Intensive In-Home Services H2022Clinical Coverage Policy 8A
Level II Group Home Y2363Clinical Coverage Policy 8D-2
Level II Therapeutic Foster Care Y2362Clinical Coverage Policy 8D-2
Medication-Assisted Treatment (Buprenorphine) 99212 22, 99213 22, 99214 22Scope of Work
Mobile Crisis Management H2011
Multisystemic Therapy (MST) H2033Clinical Coverage Policy 8A
Non-Hospital Medical Detoxification H0010Clinical Coverage Policy 8A
Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers (24 unmanaged visits for adults and children. Additional outpatient visits require authorization.)Clinical Coverage Policy 8C
Outpatient OPIOID Treatment H0020Clinical Coverage Policy 8A
Outpatient PlusAlternative Service Description
Partial Hospitalization H0035Clinical Coverage Policy 8A
Professional Treatment Services in Facility-Based Crisis Program S9484-Adult/S9484HA-ChildClinical Coverage Policy 8A
Psychiatric Residential Treatment Facility (PRTF) RC911Clinical Coverage Policy 8D-1
Psychosocial Rehabilitation H2017Clinical Coverage Policy 8A
Rapid ResponseAlternative Service Description
Residential Level III-4 Or Less Beds Y2348Clinical Coverage Policy 8D-2
Residential Level III-5 Or More Beds Y2349Clinical Coverage Policy 8D-2
Residential Level IV-4 Beds Or Less Y2360Clinical Coverage Policy 8D-2
Residential Level IV-5 Beds Or More Y2361Clinical Coverage Policy 8D-2
Substance Abuse Comprehensive Outpatient Treatment Program H2035Clinical Coverage Policy 8A
Substance Abuse Intensive Outpatient Program H0015Clinical Coverage Policy 8A
Substance Abuse Medically Monitored Community Monitored Residential Treatment H0013Clinical Coverage Policy 8A
Substance Abuse Non-Medical Community Residential Treatment H0012HBClinical Coverage Policy 8A

Records Management And Documentation Manual
Targeted Case Management H0032Clinical Policy 8L
Trauma Focused Cognitive Behavioral TherapyScope of Work

Additional MH/SA Resources

Community Guide (b)(3) Service Definition
Individual Support (b)(3) Service Definition
Peer Support (b)(3) Service Definition
Physician Consultation (b)(3) Service Definition
Respite (b)(3) Service Definition
Supported Employment (b)(3) Service Definition


Page last modified: September 8, 2017