Substance Use Disorder (SUD) Services
Overview
Substance use disorder (SUD) services include assessment of needs, treatment planning and interventions to address client needs as a result of substance use.
Eligible Providers
A provider must be enrolled as a Minnesota Health Care Programs (MHCP) provider for Substance Use Disorder (SUD) Services to provide, bill and receive payment for SUD services
Providers must enroll and participate in the Drug and Alcohol Abuse Normative Evaluation System (DAANES) as required by Minnesota Statutes, 254B.05, subdivision 1b, clause 3. All SUD clients, regardless of funding, need to be entered into DAANES for each admission episode. Contact DAANES office by email dhs.daanes@state.mn.us to obtain the documents and training to participate in DAANES.
Eligible providers may include the following:
ASAM Certification
The following MHCP providers of SUD services must certify the ASAM level(s) of care provided:
The following programs do not need to certify ASAM level of care:
To certify for an ASAM level of care, providers must submit an ASAM Certification Checklist (DHS-7325) (PDF) and accompanying documents listed under the ASAM Certification heading on the ASAM resources for Minnesota SUD treatment providers webpage. Providers must meet the requirements listed on these forms and submit the forms to the Minnesota Department of Human Services (DHS) to be eligible to provide, bill and be paid by MHCP for SUD services.
After approval, the effective date of the provider’s participation will be determined by DHS based on when the Approval to Enroll letter was issued. The provider’s MHCP effective date is the date of their Approval to Enroll letter from the Behavioral Health Administration, which the provider is issued upon satisfactory review of the ASAM Certification Checklist (DHS-7325) (PDF).
All DHS licensed residential and nonresidential, including withdrawal management, and all out-of-state programs must enroll with MHCP to provide ASAM levels of care. Enrolled providers must submit the forms found in the SUD Services Enrollment Criteria and Forms section of the MHCP Provider Manual.
Eligible Members
SUD services are available to fee-for-service members with major program code MA, OO (Behavioral Health Fund) and MinnesotaCare. Providers are encouraged to verify member eligibility in MN–ITS on a monthly basis.
If an individual is not already enrolled with Medicaid and has SUD treatment needs, they may be eligible for services through Behavioral Health Fund (BHF) if they meet clinical and financial eligibility requirements:
Refer members enrolled through a managed care organization (MCO) to their MCO health plans for details on coverage and accessing SUD services. Review the exceptions in the SUD Withdrawal Management Services section of the MHCP Provider Manual.
Covered Services
Covered services must be delivered as outlined in the Minnesota Statutes listed under Legal References. Providers must be enrolled with MHCP as an eligible provider of specific services, certified ASAM level(s) of care, specialties or complexity add-ons to receive reimbursement from MHCP. Providers are responsible for knowing and understanding the rules and regulations pertaining to any service they submit for reimbursement. Review the Substance Use Disorder Service Rate Grid with Dollar (DHS-7612) (PDF) for covered services and complexity add-on rates.
Covered SUD services include the following:
When providers are paid the Indian Health Service (IHS) encounter rate, encounter payments are not available for self-administered medication.
* Tobacco Use Disorder cessation provided as counseling by an alcohol and drug counselor and indicated as needed on a treatment plan can be provided in an individual or group counseling session (H2035 or H2035 HQ). Providing coordination to Tobacco Use Disorder cessation resources can fall under the role of a treatment coordination (T1016 HN U8) by assisting in coordination with and follow up for medical services as identified in the treatment plan or facilitating referrals to SUD services as indicated by a client's medical provider, comprehensive assessment, or treatment plan.
Providers may deliver some SUD services via telehealth. Review the Telehealth Delivery of Substance Use Disorder Services section of the MHCP Provider Manual for more information.
Substance Use Disorder treatment with Medications for Opioid Use Disorder (SUD-MOUD) services
Programs providing SUD-MOUD and licensed according to Minnesota Statutes 245G.01 to 245G.17 and 245G.22, must certify their program’s ASAM level(s) of care by submitting a completed ASAM Certification Checklist (DHS-7325-ENG) and accompanying documents listed under the ASAM Certification heading on the ASAM resources for Minnesota SUD treatment providers webpage. Programs with applicable tribal licensure, may certify their program’s ASAM level(s) of care.
Substance Use Disorder treatment services with Medications for Opioid Use Disorder services are reimbursed on a per diem basis and may also be included as an add-on to the residential treatment service per diem. Providers licensed as residential SUD programs must offer SUD-MOUD services on site or facilitate access to SUD-MOUD services off site. SUD-MOUD services may be provided through consultation off-site by a qualified practitioner and reimbursed through the member’s medical benefits. SUD-MOUD may include:
When providers are paid the Indian Health Service (IHS) encounter rate, encounter payments are not available for self-administered medication.
Noncovered Services
The following are not covered:
Billing
Providers are encouraged to verify member eligibility in MN–ITS on a monthly basis.
Direct Access billing
Residential program and room and board
Outpatient Nonresidential program
Outpatient services with the corresponding procedure code and rate enhancement modifiers from Substance Use Disorder Service Rate Grid with Dollar (DHS-7612) (PDF).
Review the MN–ITS User Guides for instructions on how to submit electronic claims.
Revenue and Procedure Codes
Refer to the Substance Use Disorder Service Rate Grid with Dollar (DHS-7612) (PDF) for all modifier combinations.
Service Description | Unit | Revenue Code | HCPCS Procedure Code | Claim Format | Type of Bill | Service Limitations |
Inpatient hospital – bundled room and board and treatment | Day | 0101 | None | 837I | 11X | Per diem |
Inpatient hospital – room-and-board component only | Day | 0118 | None | 837I | 11X | Per diem |
Inpatient hospital – treatment component only | Day | 0944 | None | 837I | 11X | Per diem |
Residential program – room-and-board component only | Day | 1002 | None | 837I | 86X | Per diem |
Residential program – treatment component only | Day | 0944 | None | 837I | 86X | Per diem |
Freestanding room and board | Day | 1003 | None | 837I | 86X | Per diem |
Nonresidential (outpatient) individual treatment | Hour | 0944 | H2035 | 837I | 89X or 13X | Refer to Authorization |
Nonresidential (outpatient) individual treatment | Hour | H2035 | 837P | Refer to Authorization | ||
Nonresidential (outpatient) group treatment | Hour | 0944 | H2035 with modifier HQ | 837I | 89X or 13X | Refer to Authorization |
Nonresidential (outpatient) group treatment | Hour | H2035 HQ | 837P | Refer to Authorization | ||
Nonresidential (outpatient) treatment – SUD-MOUD (Methadone) | Day | H0020 | 837P | Per diem | ||
Nonresidential (outpatient) treatment – SUD-MOUD (Methadone-Plus) | Day | H0020 with modifier UA | 837P | Per diem | ||
Nonresidential (outpatient) treatment – SUD-MOUD (Other) | Day | H0047 | 837P | Per diem | ||
Nonresidential (outpatient) treatment – SUD-MOUD (Other-Plus) | Day | H0047 with modifier UB | 837P | Per diem | ||
Treatment Coordination | 15 minutes | T1016 with modifier U8 HN | 837P | 8 units per day | ||
Peer Recovery Support | 15 minutes | H0038 with modifier U8 | 837P | Max of 16 units (4 hours) per day per individual Max of 56 units (14 hours) per week per individual | ||
Comprehensive Assessment | 1 session | H0001 | 837P |
Billable Units and Time Requirements
Follow HCPCS and CPT guidelines to determine the appropriate units of time to report in the case of time as part of the code definition. Per the guidelines, providers must spend more than half the time of a time-based code performing the service to report the code. If the time spent results in more than half the defined value of the code, and no additional time increment code exists, round up to the next whole number. Refer to the following Unit and measurement table.
Unit and measurement
Units | 15-minute Unit Time Range | 60-minute Unit Time Range |
1 | ≥ 8 min. through 22 min. | ≥ 31 min. through 90 min. |
2 | ≥ 23 min. through 37 min. | ≥ 91 min through 150 min. |
3 | ≥ 38 min. through 52 min. | ≥ 151 min. through 210 min. |
4 | ≥ 53 min. through 67 min. | ≥ 211 min. through 270 min. |
5 | ≥ 68 min. through 82 min. | ≥ 271 min. through 330 min. |
6 | ≥ 83 min. through 97 min. | ≥ 331 min. through 390 min. |
7 | ≥ 98 min. through 112 min. | ≥ 391 min. through 450 min. |
8 | ≥ 113 min. through 127 min. | ≥ 451 min. through 510 min. |
If a provider performs two or more of the same service code for the same member in the same day, the provider must bill based on the total combined number of minutes. Combined time must only account for direct service with members and does not include time for breaks.
Examples:
A provider cannot submit a claim for an individual service and group service for the same encounter. Time should be documented, counted, and billed to reflect the correct service distinct from one another (for example, individual counseling, treatment coordination, etc.).
A claim submission for service provided during the remaining balance of a unit of time is duplicative and ineligible for reimbursement. For example, billing one unit of individual counseling for a session that did not last the entire hour and then starting another different service within the remaining balance of time of that one-hour unit of individual counseling would be considered duplicative and ineligible for payment.
Residential programs
ASAM level 3.1 must provide at least 5 or at least 15 hours of skilled treatment services a week. The hours must be provided based on actual count of continuous minutes of treatment service provided. Breaks may not be included in these continuous minutes.
ASAM levels 3.3 and 3.5 must provide a skilled treatment service seven days a week.
How to determine missed services in residential levels of care
Programs can continue to bill services based on a member’s intensity level when a treatment service is missed when certain conditions are met. The reason for missing a service must be client centered and the program must document both the reason for the member’s absence and the interventions taken.
Holiday scheduling flexibility
Treatment week services hours in outpatient treatment and ASAM level 3.1 residential treatment may be reduced to accommodate federally recognized holidays. ASAM levels 3.3 and 3.5 must continue to provide a skilled treatment service daily.
Authorization
SUD authorization request for Nonresidential (outpatient) group and individual treatment for more than six hours a day or 30 hours a week.
Outpatient or nonresidential substance use disorder services are provided based on the identified individual need and client preference. Authorizations are required when an individual receives more than six hours/units a day or 30 hours/units a week of any combination of individual (H2035) or group (H2035 HQ) treatment services. This authorization process is only applicable for SUD nonresidential licensed programs.
The 30 hours/units a week is calculated based on a rolling seven-day time span. Authorization is required if at any point during a rolling seven-day time span more than 30 hours/units of H2035 and/or H2035 HQ of service is provided. A rolling seven-day time span includes the hours of service on the date of service and the six calendar days counting forward OR the six calendar days counting backwards from the date of service. For example, if the date of service is on July 1, the rolling seven-day time span would be from June 25 to July 1 or from July 1 to July 7.
Providers must submit an authorization request and required documentation when it is determined that the client needs more than six hours/units per day or 30 hours/units per week. Refer to the “Substance Use Disorder Authorization Criteria” document in the Substance Use Authorization section of the medical review agent’s Training webpage for a description of documentation required to be submitted in order to determine medical necessity for the additional services.
Authorizations to exceed six hours/units a day or 30 hours/units a week cover up to 28 calendar days. After the 28-day authorization period, if it is determined the member continues to meet medical necessity for more than six hours/units a day or 30 hours/units a week, the provider needs to request another authorization.
Refer to information under Substance Use Disorder Request for Nonresidential (outpatient) Group and Individual Treatment in the Authorization section of the MHCP Provider Manual for information on how to submit an authorization request for SUD nonresidential (outpatient) group and individual treatment to the medical review agent.
Billing Authorization for H2035 and H2035 HQ
Providers must submit additional hours/units of service which require authorization separately from services which do not require authorization. The separate claim for additional services may be submitted once authorized by the medical review agent.
Review the Outpatient Substance Use Disorder (SUD) Services section of the MN–ITS user guide for instructions on how to submit the authorization number received from the medical review agent for services that have been authorized by the medical review agent.
Managed Care Organization (MCO) Enrollees
Bill treatment and room and board services for MinnesotaCare members enrolled in an MCO to the appropriate plan.
MA members enrolled in MCOs
Bill room-and-board services that are authorized by the MCO directly to MHCP. Report the following information in the “Value Code” field:
Billing for Member Services in Institution for Mental Disease (IMD) facilities
Notify the county by submitting the County Notice of IMD Status (DHS-4145) (PDF) when a member is receiving services from an IMD facility.
Interim Billing
Bill residential and inpatient hospital claims that span multiple months using interim billing method. Include the date of discharge on the final treatment claim along with appropriate patient status code.
Nonresidential (Outpatient) Substance Use Disorder with Medications for Opioid Use Disorder (SUD-MOUD) billing
Bill all nonresidential (outpatient) SUD-MOUD using the professional (837P) claim format. Report the appropriate place of service to distinguish on-site dosages from take-home dosages. Itemize dosages by listing each date of service on a separate service line.
Medicare
Certified Medicare facilities serving Medicare-eligible clients must follow the MHCP Medicare policy found in the MHCP Provider Manual; review Medicare and Other Insurance under Billing Policy.
Third-Party Liability (TPL)
Individuals with private insurance may qualify for behavioral health fund if their insurance does not cover 100 percent of their treatment. MHCP TPL policy applies to all SUD treatment providers. When a member has private commercial insurance, you must first bill the private commercial insurance before billing MHCP. Bill doing the following:
Utilization Management
Providers are subject to participation in utilization reviews as defined in Minnesota Statutes sections 256B.04, subdivision 15, and 254A.03, subdivision 3, paragraph b. Procedures are embedded in the medical review agent's webpage.
Legal References
Minnesota Statutes, 245F (Withdrawal Management Programs)
Minnesota Statutes, 245G (Substance Use Disorder Licensed Treatment Facilities)
Minnesota Statutes, 254A.03 (Alcohol and Drug Abuse)
Minnesota Statutes, 254B (Substance Use Disorder Treatment)
Minnesota Statutes, 254B.05, subdivision 1b (3)
Minnesota Statutes, 254B.05, subdivision 5(h)
Minnesota Statutes, 254B.06, subdivision 5 (Prohibition of duplicative claim submission)
Minnesota Statutes, 256B.031 (Prepaid Health Plans)
Minnesota Statutes, 256B.0759 (Substance Use Disorder Demonstration)
Minnesota Statutes, 256L (MinnesotaCare)
Minnesota Rules, 9530.6800 to 9530.7030 (Rule 24)
Minnesota Rules, 9530.6510 to 9530.6590 (Rule 32)
Code of Federal Regulations title 42, section 440.130(d)
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