Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter EIP-20 July 2012 TO: Early Intervention Program Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Early Intervention Program Manual (Revised Service Codes and Descriptions - New Early Intervention Specialty Service) This letter transmits revisions to Subchapter 6, Service Codes and Descriptions, in the Early Intervention Program Manual. Effective for dates of service beginning July 1, 2012, early intervention (EI) providers may bill MassHealth for a new service code and modifier, H2019-SE (therapeutic behavioral services, per 15 minutes; state and federally funded services). This service code and modifier must be used when billing for EI specialty (EIS) services. EI Specialty Services EIS services are provided to children under three years of age who have a diagnosis of autism spectrum disorder (ASD), and meet the clinical eligibility criteria described below. EIS services can be provided only by Department of Public Health (DPH)-approved, EIS service providers (EISSP). EIS services include, but are not limited to, the assessment of the child’s functional skills across domains impacted by ASD, development of an individualized treatment plan to teach new skills, direct child instruction to teach new skills, functional behavioral assessment and support plan to decrease problematic behavior and increase appropriate behavior, family training, and direct supervision to ensure consistency in instructional practice. Eligibility for EIS Services Eligibility for EIS services is determined by the EI provider who bills MassHealth. Members eligible for specialty services must * be enrolled in an EI program (which is responsible for providing traditional EI services as well as billing for EIS services); * have high-intensity service needs that are documented in the child’s Individualized Family Service Plan (IFSP); * have one of the following diagnoses as confirmed by a physician or licensed psychologist: ? autistic disorder, childhood autism (diagnosis code 299.0); ? childhood disintegrative disorder (diagnosis code 299.1); ? other specified pervasive developmental disorders (Asperger’s Syndrome) (diagnosis code 299.8); ? pervasive developmental disorder, not otherwise specified (NOS) (diagnosis code 299.9); or Rett Syndrome (diagnosis code 330.8). MassHealth Transmittal Letter EIP-20 July 2012 Page 2 In addition, the member cannot be participating in the MassHealth 1915c Home and Community Based Services (HCBS) waiver through the Department of Developmental Services (DDS) (the Children’s Autism Spectrum Disorder Waiver), and must receive EIS services from an approved DPH EISSP (see below). Please Note: EI providers must use the appropriate diagnosis code as described above when billing for H2019 SE. Upon determining that the member meets the eligibility criteria for EIS services, the EI provider works with the member’s family to select an EIS service provider. Parents or other legally responsible relatives are given the opportunity to interview EIS service providers before making the selection of a particular treatment model, or EIS service provider. EI providers must comply with all relevant DPH EI operational standards when determining clinical eligibility, and when billing for EIS services, including establishing and monitoring contractual relationships with DPH approved EISSPs. EI Specialty Service Providers EIS services can be delivered only by a DPH-approved EISSP. DPH is responsible for credentialing the EISSPs, who must demonstrate experience in providing applied behavioral analysis (ABA) treatment to children on the Autism spectrum. DPH has shared a list of all approved EISSPs with EI providers. The list of DPH-approved EISS providers can be found in the DPH Early Intervention Directory at www.massfamilyties.org. MassHealth Coverage Members who receive EIS services must have the appropriate MassHealth coverage type for EI services as described in 130 CMR 450.105. Coverage types for early intervention are MassHealth Standard, MassHealth CommonHealth, or MassHealth Family Assistance in accordance with 130 CMR 450.105(H)(1)(c). Members in MCOs If a member has coverage through a MassHealth MCO, EIS services, unlike traditional EI services, are not covered by the MCO and EI providers must submit claims directly to MassHealth. Members with Other Insurance If the member has private insurance, the EI provider must bill the member’s primary insurer before submitting the claim for H2019 SE to MassHealth as a secondary payer. Maximum Payable Units All services billed to MassHealth must be medically necessary in accordance with 130 CMR 450.204. All EI services, including EIS services, must be documented in the member’s individualized family service plan (IFSP). EI providers may bill for up to 24 units (six hours) per day of H2019 SE, provided the services are medically necessary and are documented in the member’s IFSP. MassHealth Transmittal Letter EIP-20 July 2012 Page 3 If an early Intervention provider determines that a member has a medical need for EIS services (H2019 SE) that exceeds the maximum allowable number of units as stated above (and in Subchapter 6), and the member meets the EPSDT criteria as described in 130 CMR 450.140, the EI provider may request prior authorization (PA) from MassHealth before the services are provided. MassHealth will review and approve, deny, or modify the request within 21 days of receipt, and tell the requesting provider and member of its decision, in accordance with 130 CMR 450.303. If MassHealth denies or modifies the PA request, the notification to the member will include the member’s right to appeal MassHealth’s decision. To ensure processing of claims that exceed the maximum allowable number of units for a service code, providers must bill for each date of service on a separate claim line, and indicate the PA number on the claim. Please Note: EI providers must make every effort to accumulate billable time, equivalent to whole units before billing for EI services. if this is not possible, EI providers may round up to the nearest 15-minute unit when billing for EI services. Rates The Division of Health Care Finance and Policy is responsible for establishing rates for early intervention services, including EIS services. If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the paper copy of the publication. The specific regulation title for early intervention program services is Early Intervention Program Services: 114.3 CMR 49.00. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp MassHealth Website This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth. Questions If you have any questions about the information in this transmittal letter, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. MassHealth Transmittal Letter EIP-20 July 2012 Page 4 NEW MATERIAL (The pages listed here contain new or revised language.) Early Intervention Program Manual Pages vi, 6-1, and 6-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Early Intervention Program Manual Pages vi, 6-1, and 6-2 — transmitted by Transmittal Letter EIP-19 And his Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Early Intervention Program Manual Transmittal Letter EIP-20 Date 07/01/12 6. Service Codes and Descriptions Service Codes and Descriptions 6-1 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-1 Appendix U. DPH-Designated Serious Reportable Events That Are Not Provider Preventable Conditions U-1 Appendix V. MassHealth Billing Instructions for Provider Preventable Conditions V-1 Appendix W. EPSDT Services: Medical and Dental Protocols and Periodicity Schedules W-1 Appendix X. Family Assistance Copayments and Deductibles X-1 Appendix Y. EVS Codes/Messages Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-1 Early Intervention Program Manual Transmittal Letter EIP-20 Date 07/01/12 601 Service Codes and Descriptions Unless otherwise specified, one unit = 15 minutes. MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 440.000 and 450.000. An early intervention provider may request prior authorization (PA) for any medically necessary service reimbursable under the federal Medicaid Act, in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a) and 42 U.S.C. 1396d(r)(5), for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Early Intervention Program Manual. For EPSDT-eligible members, the maximum units allowed refers to the maximum number of units payable unless the provider has obtained PA in accordance with 130 CMR 450.144(A)(2). Providers must include the appropriate modifier with each service code when submitting PA requests or when submitting claims for payment. Service Code-Modifier Service Description H2015 Comprehensive community support services, per 15 minutes (use for individual child visits, not center-based). (Maximum units allowed per member equal 16 units per member per day, not to exceed two visits per day) H2015-AH services provided by a clinical psychologist H2015-AJ services provided by a clinical social worker H2015-GN services provided by a speech/language therapist H2015-GO services provided by an occupational therapist H2015-GP services provided by a physical therapist H2015-TD services provided by a registered nurse H2015-TE services provided by a licensed practical nurse LPN/LVN H2015-HN Bachelors degree level (services provided by a developmental specialist) H2019-SE Therapeutic behavioral services, per 15 minutes; state and/or federally-funded programs/services (Use to bill for early intervention specialty services.) (Maximum units allowed = 24 units per member per day) T1015-TL Clinic visit/encounter, all-inclusive (one encounter is defined as one unit) (Use for individual child visits, center-based.) (maximum units allowed = eight units per day). Early intervention/individualized family service plan (IFSP) (Clinical justification for the need for services to be provided at an early intervention center rather than a community site must be documented in the member’s Individual Family Service Plan (IFSP) in accordance with DPH operational standards.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-2 Early Intervention Program Manual Transmittal Letter EIP-20 Date 07/01/12 Service Code-Modifier Service Description T1023 Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project, or treatment protocol, per encounter (use for EI screening/intake); (use the appropriate modifier(s) below to denote who provided the service); (maximum units allowed per member = eight units per 12-month period) T1023-AH services provided by a clinical psychologist T1023-AJ services provided by a clinical social worker T1023-GN services provided by a speech/language therapist T1023-GO services provided by an occupational therapist T1023-GP services provided by a physical therapist T1023-TD services provided by a registered nurse T1023-TE services provided by a licensed practical nurse T1023-HN Bachelors degree level (services provided by a developmental specialist) T1024 Evaluation and treatment by an integrated specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (use for EI assessments); (use the appropriate modifier(s) below to denote who provided the service); (maximum units allowed per member = 40 units per 12-month period) T1024-AH services provided by a clinical psychologist T1024-AJ services provided by a clinical social worker T1024-GN services provided by a speech/language therapist T1024-GO services provided by an occupational therapist T1024-GP services provided by a physical therapist T1024-TD services provided by a registered nurse T1024-TE services provided by a licensed practical nurse T1024-HN Bachelors degree level (services provided by a developmental specialist) T1027-TL Family training and counseling for child development, per 15 minutes Early intervention/individualized family service plan (IFSP) (use for parent-focused group session) (maximum units allowed per member = six units per EI session, one session per week) 96153-U1 Health and behavior assessment, each 15 minutes, face-to-face; individual (two or more members) (use for EI-only child group that includes only those children who are enrolled in EI) (maximum units allowed per child = two sessions per week not to exceed a total of 10 units per week). Clinical justification for the need for EI services to be provided in an early intervention-only, child group rather than an EI community child group (96153-U2) must be documented in the member’s Individual Family Service Plan (IFSP) in accordance with DPH operational standards. 96153-U2 group (two or more patients) (use for EI community child group, for groups of children that include both children enrolled in EI and those not enrolled in EI) (maximum units allowed per member = two EI sessions per week not to exceed a total of 10 units per week)