Revised: August 31, 2021

  • Overview
  • Eligible Providers
  • Eligible Members
  • Covered Services
  • Noncovered Services
  • Billing
  • Legal References
  • Overview

    Substance use disorder (SUD) services include assessment of needs, treatment planning and interventions to address client needs as a result of substance use.

    Effective Oct. 1, 2020, until July 1, 2022, SUD treatment services may be accessed directly by going to a provider (Direct Access) or obtaining a service agreement from a county or tribal placing authority. Beginning July 1, 2022, there will no longer be a service agreement process, Direct Access will be the only way to access SUD services.

    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:

  • • Licensed Residential SUD treatment programs
  • • Licensed Non-Residential (Outpatient) SUD treatment programs
  • • Counties
  • • Tribes
  • • Recovery Community Organizations (RCO)
  • • Hospitals
  • Licensed Professionals in Private Practice
  • • Licensed Withdrawal Management programs
  • • Detox programs
  • 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.

  • • Licensed Residential SUD treatment programs
  • • Licensed Non-Residential (Outpatient) SUD treatment programs
  • • Tribes
  • • Licensed Withdrawal Management programs
  • • Approved out-of-state SUD providers
  • 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 has not yet been determine financially eligible but has SUD treatment needs, they may access services through Behavioral Health Fund (BHF) if they meet clinical and financial eligibility requirements:

  • • BHF financial eligibility determinations are made by the member’s Tribe or county of residence. For a person to be eligible for BHF, they must meet the financial eligibility guidelines in Behavioral Health Funds (BHF) Eligibility Detremination (DHS-6770) (PDF).
  • • Clinical eligibility is determined via the Rule 25 assessment or a comprehensive assessment. See exceptions in the SUD Withdrawal Management Services section of the MHCP Provider Manual.
  • 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, NM or EH 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:

  • • Nonresidential individual and group treatment services
  • • Residential high, medium, and low-intensity treatment services
  • • Hospital-based inpatient treatment
  • • Room and board (when associated with SUD residential treatment)
  • • Freestanding room and board (when associated with SUD non-residential treatment)
  • • Comprehensive assessment
  • • Treatment coordination
  • • Recovery peer support
  • • Residential withdrawal management (245F license)
  • • Medication assisted therapies (MAT). MAT services are reimbursed on a per diem basis and may also be included as an add-on to the residential treatment service per diem. MAT may include:
  • • MAT-Methadone
  • • MAT-all other
  • • MAT-Methadone-PLUS
  • • MAT-all other-PLUS
  • *The IHS encounter rate is not available for self-administered medication therapy.
  • 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% over the basic per diem rates identified in the BHF Service Rate Grid with Dollar Amounts (DHS-7612) (PDF).

    The 15% Residential Treatment rate enhancement is effective July 22, 2020.

    To receive the 15% 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% 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 non-residential treatment services effective Jan. 1, 2021.

    Medication Assisted Treatment
    Programs providing medication assisted treatment (MAT) 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. MAT services will be enhanced by 10% over the basic per diem rates identified in the BHF Service Rate Grid with Dollar Amounts effective 1-1-21 when delivered for the applicable level of care as outlined in the 1115 Level of Care Requirements (DHS-7326) (PDF).

    MAT 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 medication-assisted treatment services on site or facilitate access to medication-assisted treatment services off site. MAT may include:

  • • MAT-Methadone-PLUS
  • • MAT-all other-PLUS
  • • MAT services may be provided through consultation off-site by a qualified practitioner and reimbursed through the member’s medical benefits.
  • When providers are paid an encounter rate, encounter payments are not available for self-administered medication.

    Noncovered Services

    The following are not covered:

  • • Rule 25 chemical use assessments
  • • Services delivered before the completion of a Rule 25 or comprehensive assessment
  • • Room-and-board services not clinically or medically necessary
  • • Treatment services delivered to people enrolled in a managed care plan, with the exception of room-and-board services
  • • Detoxification services
  • • Comprehensive assessement, treatment coordination, peer support and non residential treatment services when provided by the residential provider receiving a per diem payment for the same date of service and for the same client.
  • • Medication assisted therapies (MAT) guest dosing
  • Billing

    SUD services can be billed with a service agreement or through the Direct Access Process. Providers are encouraged to verify member eligibility in MN–ITS on a monthly basis.

    Service Agreement Billing

    The service agreement process expires on June 30, 2022.

    Bill MHCP for BHF-authorized services that are on the service agreement (SA) by doing the following:

  • • Review the information in the SA letter for accuracy (procedure codes and modifiers, dates, rates, number of units and so on).
  • • Contact the authorizing county or tribe if you believe that you received an incorrect SA letter and obtain a corrected SA letter before billing.
  • • Report the approved SA rate for the service provided on the claim service line (reporting other rates may result in an inaccurate unit decreased from the SA).
  • Direct Access Billing

    Effective Oct. 1, 2020, bill MHCP directly without a service agreement for:

  • • Residential treatment services from the Residential 5-digit Value Codes for Billing Direct Access list corresponding to the listed service combinations.
  • • Room and board services from the Room and Board 5-digit Value 24 Codes (DHS-7308) list corresponding to the listed service combinations.
  • • Outpatient services with the corresponding procedure code and rate enhancement modifiers from BHF Service Rate Grid with Dollar Amounts (DHS-7612)
  • 1115 Substance Use Disorder (SUD) System Reform Demonstraton 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
    0128
    0138
    0148
    0158

    None

    837I

    11X

    Per diem

    Inpatient hospital – treatment component only

    Day

    0944
    0945

    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
    0945
    0953

    None

    837I

    86X

    Per diem

    Freestanding room and board

    Day

    1003

    None

    837I

    86X

    Per diem

    Outpatient individual (nonresidential) treatment

    Hour

    0944
    0945
    0953

    H2035

    837I or 837P

    89X or 13X

    3 units per day

    Outpatient group (nonresidential) treatment

    Hour

    0944
    0945
    0953

    H2035 with modifier HQ

    837I or 837P

    89X or 13X

    10 units per day

    Nonresidential treatment – medication-assisted therapy (all other)

    Day

    H0047

    837P

    Per diem

    Nonresidential treatment – medication-assisted therapy plus (all other)

    Day

    H0047 with modifier UB

    837P

    Per diem

    Nonresidential treatment – medication-assisted therapy (methadone)

    Day

    H0020

    837P

    Per diem

    Nonresidential treatment – medication-assisted therapy plus (methadone)

    Day

    H0020 with modifier UA

    837P

    Per diem

    Treatment Coordination

    15 minute

    0944
    0945
    0953

    T1016 with modifier U8 HN

    837P

    89X or 13X

    8 units per day

    Peer Recovery Support

    15 minute

    H0038 with modifier U8

    837P

    8 units per day

    Comprehensive Assessment

    0944
    0945
    0953

    H0001

    837P

    89X or 13X

    2 allowable every rolling 6 months

    Billable Units and Time Requirements

    Nonresidential programs
    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
    H2036 is a per diem code used for treatment program services in a residential setting. Accordingly, the 30, 15 and five hours of clinical services required for the respective intensity level must be provided based on an 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:

  • • Value Code 80 and the number of inpatient covered days
  • • Enter Value Code 24 with the correct five-digit rate code from the Value Code 24 MCO Room and Board Billing (PDF) list that corresponds to the listed service combinations
  • 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:

  • • Use revenue code 1002 for residential treatment room and board
  • • Use revenue code 1003 for outpatient treatment room and board
  • 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 clinic billing

    Bill nonresidential medication-assisted therapy (MAT) and MAT Plus using the professional (837P) claim format. Report the appropriate place of service to distinguish on-site dosage(s) from take-home dosage(s). 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)

  • • Follow the TPL policy in the MHCP Provider Manual; see “Third Party Liability (TPL)” in Medicare and Other Insurance under Billing Policy.
  • • When a member has TPL for an authorized treatment placement, you must bill the TPL before billing MHCP. Check MN–ITS before submitting claims to MHCP. If MN–ITS indicates that TPL exists for the dates that you want to bill, you must first bill the third party displayed in MN–ITS for the dates. If you bill MHCP for dates of service when TPL exists, MHCP will deny the claim.
  • 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:

  • • Provider Questionnaire (embedded in Atrezzo)
  • • Comprehensive Assessment
  • • Initial Services or Initial Treatment Plan with measurable goals
  • • Documentation of treatment services; Treatment Plan Review
  • • Discharge/Transition Plan
  • 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
    (Chemical Dependency Treatment)
    Minnesota Statutes, 256B.031
    (Prepaid Health Plans)
    Minnesota Statutes, 256B.0759
    (Substance Use Disorder Demonstration)
    Minnesota Statutes, 256L
    (MinnesotaCare)
    Minnesota Rules, parts 9530.6405 to 9530.6505
    (Rule 31)
    Minnesota Rules, 9530.6600 to 9530.6655
    (Rule 25)
    Minnesota Rules, 9530.6800 to 9530.7030
    (Rule 24)
    Minnesota Rules, 9530.6510 to 9530.6590
    (Rule 32)
    Minnesota Rules, 9530.6615
    , subpart 2 (Rule 25, Staff Performing Assessment)
    Minnesota Rules, 9530.6605
    , subpart 21a (Rule 25, Definitions, Placing Authority)
    Code of Federal Regulations title 42
    , section 440.130(d)

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