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Behavioral Health Providers: Service and Claim Billing Guidelines for Withdrawal Management and Treatment Services

Date: 02/11/21

Please Note: This article was updated on July 22, 2022.

Superior appreciates the provisioning of Withdrawal Management and Treatment Services through our network providers, and encourages the delivery of all associated medically necessary and clinically appropriate facility and professional services for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) members.

As a reminder, Withdrawal Management and Treatment Services require prior authorization through Superior before provisioning these services. In addition, guidelines for billing and related reimbursement for these services are detailed below. Claims must be billed in compliance with these guidelines to be eligible for reimbursement.

  • Residential Withdrawal Management Services:
    • HCPC H0012 – Residential sub-acute detoxification for alcohol and/or drug services
      • Eligible for billing and reimbursement as a stand-alone code
      • Limited to once/day/patient, any provider
    • The following services must be billed with H0012 to be considered for reimbursement and are limited to once/day/patient, any provider:
      • HCPC H0031 – Mental health assessment by non-physician
      • HCPC S9445 – Patient education, not otherwise classified, non-physician provider, individual, per session
      • HCPC T1007 – Alcohol and/or substance abuse services, treatment plan development and/or modification
      • HCPC H0047 – Room and board for residential treatment services
        • Must be billed with H2035 or H0012 to be considered for reimbursement
        • Limited to once/day/patient, any provider
  • Outpatient Withdrawal Management Services:
    • HCPC H0016 – Alcohol and/or drug services; medical/somatic - medical intervention in ambulatory setting
      • Eligible for billing and reimbursement as a stand-alone code
      • Limited to once/day/patient, any provider
    • HCPC H0050 – Alcohol and/or drug services, brief intervention, per 15 minutes
    • HCPC S9445 – Patient education, not otherwise classified, non-physician provider, individual, per session
      • Must be billed with H0016 to be considered for reimbursement
      • Limited to once/day/patient, any provider
      • Eligible for reimbursement on the same date of service as outpatient SUD treatment by the same or different provider when medically necessary and identified in the person’s treatment plan
  • Residential Treatment Services:
    • HCPC H2035 – Residential Treatment Services
      • Limited to once/day/patient, any provider
  • Outpatient Treatment Services
    • HCPC H0004 – Behavioral health counseling and therapy, per 15 minutes
    • HCPC H0005 – Alcohol and/or drug services; group counseling by a clinician
      • Limited to 135 units of group counseling and 26 hours of individual counseling per calendar year when provided by a CDTF
      • Denied if billed on the same date of service as residential withdrawal management (procedure codes H0012, H0031, H0047, S9445, and T1007)
      • Denied if billed on the same date of service as residential treatment (procedure code H2035)

For questions, please call Provider Services at 1-877-391-5921 or contact your local Account Manager.