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.
1115 Substance Use Disorder System Reform Demonstration
Minnesota is implementing a Substance Use Disorder (SUD) System Reform Demonstration that incorporates the American Society of Addiction Medicine (ASAM) criteria to establish specific residential and outpatient levels of care for SUD treatment services for Medical Assistance (MA) under the authority of section 1115(a) of the Social Security Act. The demonstration, through the implementation of ASAM criteria, seeks to enhance evidence-based assessment and placement criteria for the purpose of matching individual risk with the appropriate ASAM level of care. The demonstration also increases standards for treatment coordination to ensure transitions to needed services across a comprehensive continuum of care.
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). You will not receive reimbursment as a SUD treatment provider unless you have complied with the DAANES requirements for each Behavioral Health Fund (BHF) recipient. 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:
1115 Substance Use Disorder System Reform Demonstration
Providers must enroll, meet the requirements and submit the forms listed under the 1115 SUD System Reform Demonstration heading on the Substance Use Disorder (SUD) Services Enrollment Criteria and Forms provider enrollment webpage to be eligible to provide, bill and be paid by MHCP for SUD services within the 1115 SUD System Reform Demonstration.
After approval, the effective date of the provider’s participation will be determined by MHCP Provider Eligibility and Compliance based on when the assurance statement was received, and will be communicated to providers in a letter.
Eligible Members
SUD services are available to fee-for-service members with major program code MA, OO (Behavorial 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. See exceptions in the SUD Withdrawal Management Services section of the MHCP Provider Manual.
1115 Substance Use Disorder System Reform Demonstration
All MHCP members are eligible for SUD services delivered by MHCP-enrolled 1115 SUD System Reform Demonstration providers. Only members in major program MA qualify for the enhanced rate.
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, specialties or complexity add-ons to receive reimbursement from MHCP. Providers are responsible for knowing and understanding the rules and regulations pertaining to any services they submit for reimbursement. See the BHF Service Rate Grid with Dollar Amounts (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 when 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.
1115 Substance Use Disorder System Reform Demonstration
All SUD services provided by MHCP-enrolled 1115 SUD System Reform Demonstration providers must meet the standards for each level of care provided as published in the 1115 Level of Care Requirements (DHS-7326) (PDF) and be implemented by the dates identified in the “Date the requirement will be implemented” column in the enrolled provider’s 1115 Substance Use Disorder System Reform Enrollment Checklist (DHS-7325) (PDF).
Residential
Rates for residential treatment services delivered for the applicable level of care will be enhanced by 15 percent over the basic per diem rates identified in the BHF Service Rate Grid with Dollar Amounts (DHS-7612) (PDF).
The 15 percent Residential Treatment rate enhancement is effective July 22, 2020.
To receive the 15 percent rate enhancement when billing services, include the Value code 24 and the appropropriate five-digit rate code from the Residential 5-digit Value Codes for Billing Direct Access.
The following are not eligible for the 1115 Demonstration residential rate enhancement: hospitals and Withdrawal Management services:
Outpatient
Individual and group treatment services will be increased by 10 percent over the base rates identified in the BHF Service Rate Grid with Dollar Amounts (DHS-7612) (PDF) when delivered for the applicable level of care as outlined in the 1115 Level of Care Requirements (DHS-7326) (PDF).
Rate enhancements for nonresidential (outpatient) treatment services effective Jan. 1, 2021.
Substance Use Disorder treatment with Medications for Opioid Use Disorder (SUD-MOUD) services
Programs providing SUD-MOUD and licensed according to Minnesota Statute sections 245G.01 to 245G.17 and 245G.22, or applicable tribal license, must enroll in the demonstration as a Level 1.0 Outpatient or 2.1 Intensive Outpatient provider. SUD-MOUD services will be enhanced by 10 percent over the basic per diem rates identified in the BHF Service Rate Grid with Dollar Amounts (DHS-7612) when delivered for the applicable level of care as outlined in the 1115 Level of Care Requirements (DHS-7326) (PDF).
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. Participating demonstration 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
1115 Substance Use Disorder (SUD) System Reform Demonstration residential treatment services billing
You must submit all residential treatment claims with the 1115 value 24 code to receive the residential rate increase for residential treatment services. Refer to the Residential 5-digit Value Codes for Billing Direct Access and enter the appropriate five-digit value 24 code from the column “1115 value 24 code.”
See the MN–ITS User Guides for instructions on how to submit electronic claims.
Revenue and Procedure Codes
Refer to the BHF Service Rate Grid with Dollar Amounts (DHS-7612) 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 | 3 units per day |
Nonresidential (outpatient) individual treatment | Hour | H2035 | 837P | 3 units per day | ||
Nonresidential (outpatient) group treatment | Hour | 0944 | H2035 with modifier HQ | 837I | 89X or 13X | 10 units per day |
Nonresidential (outpatient) group treatment | Hour | H2035 HQ | 837P | 10 units per day | ||
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 | 8 units per day | ||
Comprehensive Assessment | 1 session | H0001 | 837P |
Billable Units and Time Requirements
Nonresidential (Outpatient) Services
H2035 is used for individual counseling and H2035 HQ is used for group treatment services provided in their respective settings. The code is defined as “alcohol and/or drug counseling per hour.” The code is defined by a unit of time. Unit of time is attained when the mid-point is passed, and more than half of the time must be spent performing the service for reporting a specific code, excluding any breaks.
Residential programs
0944, 0945, 0953 are per diem revenue codes used for treatment program services in a residential setting. The respective intensity level, high (30 hours), medium (15 hours) or low (5 hours) must be provided based on actual count of continuous minutes of treatment service provided. Breaks may not be included in these continuous minutes
Managed Care Organization (MCO) Enrollee
Coordinate services for MCO enrollees with their health plans. Room and Board are carved out from MCO plans. Bill treatment services to the plan and bill room and board to MHCP as follows:
Billing Freestanding and Residential Program Room-and-Board Charges
Bill freestanding or residential program room-and-board charges (revenue codes 1003 or 1002) that are authorized by the MCO directly to MHCP. Report the following information in the “Value Code” field:
Do not bill for services that require MCO authorization or services that are in an appeal process until the services are authorized.
At the Service Line:
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. If you are an IMD facility currently enrolled in the 1115 Demonstration, mark “1115 Provider” clearly at the top of the form.
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; see 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
To comply with the federal requirement for utilization reviews within the 1115 SUD System Reform Demonstration, providers must document level of care determination using the 1115 Demonstration Assessment and Placement Grid and submit this, along with the following supporting clinical documentation to the medical review agent, Kepro:
Legal References
Minnesota Statutes, 245F (Withdrawal Management Programs)
Minnesota Statutes, 245G (Chemical Dependency Licensed Treatment Facilities)
Minnesota Statutes, 254A.03 (Alcohol and Drug Abuse)
Minnesota Statutes, 254B (Substance Use Disorder Treatment)
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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