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In Lieu of Services Resource Guide

Your Guide to Behavioral Health Treatment Options

We are proud to work with you to improve the physical and behavioral health of our members, your patients. Sunshine Health’s new In Lieu of Services (ILOS) offer alternative services that are medically appropriate substitutes for Medicaid benefits. These services are intended to help avoid or eliminate the need for higher level of care or more costly services in the future — while providing patients with a wider selection of treatment options.

Your patients may choose the Medicaid covered benefit, rather than the ILOS benefit. If your patient agrees to the ILOS, please be sure to document this choice in the patient’s clinical record.

This Resource Guide describes the ILOS benefits, eligibility requirements, limits and prescribing rules. If you have any questions, please call Provider Services at 1-844-477-8313

In lieu of: Inpatient Psychiatric Hospital

Limits Prescribing Rules
Service Limits Medical necessity applies. No day limit per calendar year.
Service Type Per day
Prior Authorization Prior authorization is not required for the first 24 hours of an emergency admission. After stabilization, admission is subject to prior authorization for continued stay.
Eligible Members All ages who meet medical necessity criteria and can be diverted from Inpatient Psychiatric Hospitalization, Emergency Room or Out of Home Placement.
Provider Type Must be provided in a Licensed Crisis Stabilization Unit.
Procedure Code 129

Service Description

A Crisis Stabilization Unit is a short-term alternative to inpatient psychiatric hospitalization and provides brief intensive services for patients presenting in acute crisis.

The purpose of a Crisis Stabilization Unit is to examine, stabilize and redirect members to the most appropriate and least restrictive treatment settings consistent with their needs. Treatment is aimed at restoring members’ ability to maintain safety while enhancing their recovery, so they can successfully return to the community.

Services include: assessment and treatment services 24 hours a day, 7 days a week for children, adolescents and adults; psychiatric evaluation; medication management; and psychiatrist rounds daily. 

In lieu of: Inpatient Detoxification Hospital Care

Limits Prescribing Rules
Service Limits Medical necessity applies. Maximum of 15 days per month.
Service Type Per day
Prior Authorization Prior authorization is not required for the first 24 hours of an emergency admission. After stabilization, admission is subject to prior authorization for continued stay.
Eligible Members All ages for whom detoxification is indicated, meets ASAM Criteria Level 3.7 WM, and can be diverted from Inpatient Detoxification Hospitalization, Emergency Room or Out of Home Placement.
Provider Type Must be provided in a Detoxification or Addiction Receiving Facility licensed under s. 397, F.S.
Procedure Code 169

Service Description

A Detoxification or Addiction Receiving Facility provides emergency substance abuse services within a free-standing detoxification center. At this level of care, physicians are available 24 hours per day by telephone. A physician should be available to assess the patient within 24 hours of admission (or sooner, if medically necessary) and should be available to provide onsite monitoring of care and further evaluation on a daily basis. An RN or other qualified nursing specialist should be present to administer an initial assessment. A nurse must be responsible for overseeing the monitoring of the patient’s progress and medication administration on an hourly basis, if needed. Appropriately licensed and credentialed staff should be available to administer medications.

Services include: 24-hour supervision; observation; and support for patients who are intoxicated or experiencing withdrawal. 

In lieu of: Inpatient Psychiatric Hospital Care

Limits PRESCRIBING RULES
Service Limits Medical necessity applies. No day limit per calendar year.
Service Type Per day
Prior Authorization Prior authorization is required.
Eligible Members All ages with mental health or substance use disorder(s) where PHP services can shorten the length of stay in an inpatient facility or eliminate the need for an inpatient stay.
Provider Type Licensed hospital
Procedure Codes 912, 913

Service Description

Partial Hospitalization Services (PHS) typically include four to six hours of daily structured programming, offered five days per week, where member is required to attend the program daily. PHS offers a therapeutic milieu; nursing; psychiatric evaluation; medication management; and group, individual and family therapy. Partial Hospitalization Services can be used as a transitional (step down from inpatient) program to shorten the length of stay in an inpatient facility or to eliminate the need for an inpatient stay when clinically appropriate.

Within 24 hours of admission, the following must be completed:

  • An initial diagnostic interview by psychiatrist/physician.
  • A multidisciplinary bio-psychosocial assessment that includes an alcohol/ drug screening and assessment, as needed, and an initial treatment/ recovery plan.

The initial treatment/recovery plan must:

  • Integrate individual strengths, needs, abilities and preferences.
  • State measurable goals.
  • Include a documented discharge and relapse prevention plan completed within 24 hours of admission.

Additional services can include: consultation for general medical needs; psychological, pharmacy, laboratory and emergency medical services; dietary services if meals are served within the program; other diagnostic services; recreation and social services; access to community based rehabilitation/social services to help patients transition to the community; face-to-face psychiatrist (ARNP under psychiatrist supervision) visits 4 of 5 days; and treatment/recovery plan reviewed weekly or more often as necessary. 

In Lieu of: Inpatient Detoxification Hospital Care

Limits Prescribing Rules
Service Limits Medical Necessity applies.  Unlimited with prior authorization.
Service Type Per day
Prior Authorization Prior Authorization is required.
Eligible Members Members 21 or older with a substance use disorder where IOP can shorten the length of stay in an inpatient detoxification hospital or eliminate the need for an inpatient detoxification stay.
Provider Type Licensed Intensive Outpatient Substance Abuse Program
Procedure Codes 906, H0015

Service Description

An Intensive Outpatient Program (IOP) is time-limited and includes a scheduled series of sessions appropriate to the individual treatment plan of a patient. IOP for substance abuse primarily consists of counseling and education about addiction-related problems. The program is offered in the day or evening hours and can be a step-down from a more restrictive level of care or a step-up to prevent need for a more restrictive level of treatment. The goals of IOP for substance abuse are to prevent or reduce the need for inpatient detoxification hospitalization and to reduce or stabilize symptoms and functional impairment of a substance use or co-occurring disorder. Most IOP programs generally provide 9 to 19 hours of structured programming per week for adults and must operate at least 3 hours a day and 3 days per week. Evaluation, assessment, and treatment include: care coordination, individual/group/family therapy, crisis intervention, medication reconciliation, structured programming, psychiatric or medication evaluation as needed, psychosocial assessment, substance evaluation, toxicology screen, self-help, 12-step and education groups.

In lieu of: Emergency Behavioral Healthcare

Limits Prescribing Rules
Service Limits No more than 24 hours per calendar year. Maximum of 2 hours per day.
Service Type Per hour
Prior Authorization Prior authorization is not required.
Eligible Members All ages who are experiencing a behavioral health crisis and may benefit from the service as a diversion to the Emergency Room, Inpatient Admission, or Out of Home Placement.
Provider Type

Master’s level behavioral health clinician under supervision by a licensed behavioral health clinician. Mobile Crisis Team must include at least one licensed behavioral health clinician.

 

Procedure Code S9484

Service Description

A Mobile Crisis Team works to stabilize patients in crisis and connect them to ongoing behavioral health, or other services to promote their stability. Mobile Crisis Services may be appropriate in a number of different settings, including homes, schools, placement settings, emergency rooms, offices and other community locations.

Services include: onsite mobile crisis assessment; service referral; crisis intervention and behavioral health triage services for members identified as being in an acute crisis state. 

In lieu of: Inpatient Detoxification Hospital Care

Limits Prescribing Rules

Service Limits

Medical necessity applies. Members 0- 21 years old; up to 3 hours a day and no limits per calendar year. Members over 21; up to 3 hours per day and a 30-day limit per calendar year.

Service Type

Per day

Prior Authorization

Prior authorization is required.

Eligible Members

All ages with a substance use disorder and for whom ambulatory detoxification services can shorten the length of stay in an inpatient detoxification hospital or eliminate the need for an inpatient stay.

Provider Type

Licensed Ambulatory Detoxification Facility.

Procedure Code

S9475

Service Description

Ambulatory Detoxification Services without extended onsite monitoring provides clinical and medical management of physical and psychological withdrawal symptoms (from alcohol and other drugs) on an outpatient basis in a community setting.

These services are intended to stabilize the patient physically and psychologically using accepted detoxification protocols. Rendering provider agencies must be licensed as an Ambulatory Detoxification Facility.

Services include assessment and patient observation; medical history; monitoring of vital signs; treatment of withdrawal symptoms; substance abuse counselor consultation and referrals for ongoing addiction and substance abuse treatment. 

In lieu of: Psychosocial Rehabilitation Services

Limits Prescribing Rules

Service Limits

Medical necessity applies. Maximum 16 units, or 4 hours per day.

Service Type

Per unit (1 unit = 15 minutes)

Prior Authorization

Prior authorization is required.

Eligible Members

All ages with mental health or substance use disorder(s).

Provider Type

Certified recovery peer specialist under supervision of a licensed behavioral health clinician.

Procedure Code

H0038*

* No modifier; HQ for Group. 

Service Description

Peer support services are provided to members with behavioral health or substance use conditions provided by certified peer support specialists with similar behavioral health or substance use experiences. These peer support specialists are in recovery and are trained in delivering effective peer support.

These specialists serve as role models and advocates and are intended to provide ongoing support for enhancing wellness management, coping skills, independent living skills and assistance with recovery.

Services include offering support and teaching skills that promote recovery and positive social networking. These services supplement existing treatment with education, empowerment and system navigation.  

In lieu of: Clubhouse Services

Limits Prescribing Rules

Service Limits

Medical necessity applies. Maximum of 20 days per calendar year.

Service Type

Per day

Prior Authorization

Prior authorization is required.

Eligible Members

Members 18 years or older with a behavioral health diagnosis who could benefit from social skills support.

Provider Type

Certified recovery peer specialist, certified recovery support specialist, bachelor’s or master’s level behavioral health practitioner. All require supervision by a licensed behavioral health clinician. Psychiatric ARNP.

Procedure Code

S5102 HE

Service Description

A day club offering peer support and a flexible schedule of activities where clients can learn, practice and apply life skills that promote greater independence and enhance quality of life. Activities include social and recreational programs and outings that help develop specific skills intended to promote integration within the local community. 

In lieu of: Psychological Testing

Limits Prescribing Rules

Service Limits

Medical necessity applies. Maximum of 40 units or 10 hours per calendar year.

Service Type

Per unit (1 unit = 15 minutes)

Prior Authorization

Prior authorization is required.

Eligible Members

Children ages 0-5 years old experiencing developmental delays, or having difficulty bonding with caregivers, who may benefit from specialized programs.

Provider Type

Master’s level practitioner or above under supervision of a licensed practitioner of the healing arts with two years of experience working with children under age 6; training and experience in infant, toddler and child assessments; and 20 hours of documented training in: early childhood development; behavior observation; developmental screening; parent and child intervention and interaction; functional assessment; developmentally appropriate practice for serving infants; young children and their families; psychosocial assessment and diagnosis of young children; crisis intervention training.

Procedure Code

T1023HA

Service Description

Tests, inventories, questionnaires, structured interviews, structured observations, and systematic assessments that are administered to help assess the caregiver-child relationship and to help aid in the development of the treatment plan. These services are appropriate when a clinician or medical doctor identifies risk factors associated with child’s attachment or bonding with parent(s) or caregiver(s); a child’s parents or caregivers have demonstrated risk factors associated with child-rearing; or a child has been identified as in need of assessment to determine whether the child/family may benefit from participation. 

In lieu of: Therapeutic Behavioral Onsite Services

Limits Prescribing Rules

Service Limits

Medical necessity applies. Maximum of 36 units or 9 hours per month.

Service Type

Per unit (1 unit = 15 minutes)

Prior Authorization

Prior authorization is required.

Eligible Members

Members 0-21 years old with a Serious Emotional Disturbance (SED) diagnosis whose caregivers could benefit from assistance.

Provider Type

Bachelor’s level behavioral health practitioner under supervision of a licensed behavioral health clinician.

Procedure Code

T1027

Service Description

Services to help caregiver(s) understand and manage a member’s behavioral needs related to a Serious Emotional Disturbance (SED) diagnosis to promote the member’s development. Member is not required to be present, but may be if appropriate.

Services include: support groups or individual sessions for family members; psychosocial activities; and other education and support activities related to SED in children.

Family training and support does not include services that require a professional clinical license. However, services must be consistent with the provider’s qualifications. 

In lieu of: Therapeutic Group Care Services or Statewide Inpatient Psychiatric Program Services

Limits Prescribing Rules

Service Limits

Medical necessity applies. No day limits per calendar year.

Service Type

 Per day

Prior Authorization

Prior authorization is required.

Eligible Members

Members 0-21 years old with a Serious Emotional Disturbance (SED) diagnosis who could benefit from community based wraparound as a diversion to higher levels of residential care.

Provider Type

Certified Targeted Case Management (TCM) agency. Individual rendering services must be certified as a TCM through the Florida Certification Board. Must be under supervision and coaching by a certified TCM supervisor trained and certified as a Wraparound Coach. Practitioner must obtain complete Wraparound 101, or a similar health plan approved wraparound training prior to service provision. Must obtain certification as wraparound facilitator within one year of hire.

Procedure Code

H2022

Service Description

Community Based Wraparound is an individualized care planning and management service for children with complex needs. It includes structured, creative team meetings and care plans designed to meet the unique needs of children, caregivers and families. Wraparound team meetings include a child’s treatment team, social supports, non-traditional supports, and family members. Services are provided at flexible times and locations to accommodate the child’s and family’s needs. Treatment/Service Plans are frequently reviewed and updated. The emphasis is on integrating and maintaining the child in the community and building the child’s and family’s support network.

In lieu of: Inpatient Detoxification Hospital Care

Limits Prescribing Rules

Service Limits

Medical necessity applies. Maximum 60 days per calendar year. Members receiving these services for more than 15 days per month will be subject to IMD exclusion.

Service Type

Per day

Prior Authorization

Prior authorization is required.

Eligible Members

Pregnant members with a substance abuse diagnosis that are 21 years old or older.

Provider Type

Licensed substance abuse residential treatment center.

Procedure Code

H0018

Service Description

These services are intended for adults with a primary Axis I diagnosis of substance dependence requiring a more restrictive treatment environment to prevent the abuse of substances. This service is highly structured and located within a licensed substance abuse residential treatment center. This treatment approaches substance abuse as disorders of the whole person that are reflected in problems with conduct, attitudes, moods, values and emotional management. Level III.5 programs are designed to treat members with significant social and psychological problems. The goals of treatment are to promote abstinence from substance use and antisocial behavior and to effect a global change in member’s lifestyle, attitudes and values.  

In lieu of: Inpatient Hospital Services

Limits Prescribing Rules

Service Limits

60 days per calendar year.

Service Type

Per day

Prior Authorization

Prior authorization is required.

Eligible Members

Members for whom a skilled nursing facility can shorten the length of stay in an inpatient facility, or eliminate the need for an inpatient stay.

Provider Type

Licensed skilled nursing facility.

Procedure Codes

99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318

Service Description

Skilled nursing refers to a member’s need for care or treatment that can only be provided by licensed nurses. Nursing facility services provide 24-hour medical and nursing care in a residential setting, institution or a distinct part of an institution.

Examples of skilled nursing needs include bed and board, complex wound dressings, medications, supplies, equipment, social services, rehabilitation, tube feedings or rapidly changing health status. 

This Resource Guide describes the ILOS benefits, eligibility requirements, limits and prescribing rules. If you have any questions, please call Provider Services at 1-844-477-8313