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 and Children’s Medical Services Health Plan offer In Lieu of Services (ILOS) to provide 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 standard 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. Maximum of 15 days per month. |
| Service Type | Per day |
| Prior Authorization | Prior authorization is not required for the first 3 day of an emergency involuntary admission. After stabilization, the 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: In-Patient Psychiatric Hospital
| 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 3 day of an emergency involuntary admission. After stabilization, the 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 Free Standing Psychiatric Hospital. |
| Procedure Code | 124 |
Service Description
A Free Standing Psychiatric Hospital is a short-term alternative to inpatient psychiatric hospitalization and provides brief intensive services for patients presenting in acute crisis. The purpose of a Free Standing Psychiatric Hospital 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 or H0035 |
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: Emergency Behavioral Health Care
| Limits | Prescribing Rules |
|---|---|
| Service Limits | Medical necessity applies. |
| Service Type | Per hour |
| Prior Authorization | No |
| Eligible Members | All ages who are experiencing a behavioral health crisis and may benefit from the service as a diversion to an inpatient admission, emergency room, 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
Mobile Crisis Assessment and Intervention 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. All efforts are made by the Mobile Crisis team to stabilize the individual in crisis and support them in access to ongoing behavioral health, or other, services to promote their stability. Mobile Crisis Services may be appropriate in a number of different settings including home, school, placement settings, emergency rooms, office, and other community locations.
In lieu of: Inpatient Detoxification Hospital Care
| Limits | Prescribing Rules |
|---|---|
Service Limits | Medical necessity applies. |
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. |
Service Type | Per unit (1 unit = 15 minutes) |
Prior Authorization | Prior authorization is not 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. |
Service Type | Per day |
Prior Authorization | Prior authorization is not required. |
Eligible Members | Members 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. |
Service Type | Per unit (1 unit = 15 minutes) |
Prior Authorization | Prior authorization is not 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. |
Service Type | Per unit (1 unit = 15 minutes) |
Prior Authorization | Prior authorization is not 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 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. 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 | Any member with a substance abuse or mental health diagnosis that meets medical necessity criteria for Short Term Residential treatment. |
Provider Type | Licensed substance abuse or mental health residential treatment center. |
Procedure Codes | 1001: mental health 1002: substance abuse H0018: pregnant women with SUD |
Service Description
These services are intended for adults with a primary Axis I substance dependence or mental health diagnosis requiring a more restrictive treatment environment. This service is highly structured and located within a licensed residential treatment center or mental health facility. This treatment approaches substance abuse and mental health conditions using whole person approach and addresses problems with conduct, attitudes, moods, values and emotional management. Programs are designed to treat members with significant social and psychological problems.
In lieu of: Inpatient or Residential Treatment
| Limits | Prescribing Rules |
|---|---|
Service Limits | Medical necessity applies. |
Service Type | Per unit (1 unit = 15 minutes) |
Prior Authorization | Prior authorization is not required. |
Eligible Members | Members ages 12 -17 who are experiencing mental health issues, are at risk for or actively engaging in delinquent activity or substance misuse and are at risk for or in out of home placement. |
Provider Type | Bachelor’s or Master’s Level behavioral health practitioner under supervision of a licensed behavioral health clinician. Practitioner rendering services must be employed by, and under supervision of, a licensed/certified Multi-Systemic Therapy (MST) team and organization. Rendering practitioner must complete an initial five (5) day training by an MST certified Master’s Level trainer and then be certified, or actively participating in the certification process, including on-going training, supervision, and coaching by certified MST experts to ensure fidelity. |
Procedure Codes | H2033 |
Service Description
Multi-Systemic Therapy (MST) is an evidenced based practice of intensive treatment for troubled youth delivered in multiple settings. This program aims to promote pro-social behavior and reduce criminal activity, mental health symptomology, out-of-home placements, and illicit substance use in 12- to 17-yearold youth. The MST program addresses the core causes of delinquent and antisocial conduct by identifying key drivers of the behaviors through an ecological assessment of the youth, his or her family, and school and community. The intervention strategies are personalized to address the identified drivers. The program is delivered for an average of three to five months, and services are available 24/7, which enables timely crisis management and allows families to choose which times will work best for them. Therapists from licensed MST providers take on only a small caseload at any given time so that they can be available to meet their clients’ needs. MST teams use a structured fidelity assessment approach to ensure clinical service delivery is consistent with the MST model.
In lieu of: Inpatient Detoxification or Psychiatric Hospital Care
| Limits | Prescribing Rules |
|---|---|
Service Limits | No limits with prior authorization and medical necessity. |
Service Type | Per day |
Prior Authorization | Yes |
Eligible Members | Members with a substance abuse or mental health diagnosis who can benefit from a community based treatment program to prevent, or reduce the need for, inpatient psychiatric and detoxification hospitalization and to reduce or stabilize symptoms and functional impairment of a substance use or co-occurring disorder. |
Provider Type | Licensed Intensive Outpatient Program |
Procedure Codes | 906, H0015: substance abuse S9480, 905: mental health |
Service Description
An Intensive Outpatient Program (IOP) is time limited and includes a scheduled series of behavioral health sessions appropriate to the individual treatment plan of a patient. IOP primarily consists of counseling and education about mental health and addiction-related problems. IOP operates on a small scale and does not require the intensive residential or partial day services typically offered by the larger, more comprehensive treatment facilities. 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 are to prevent or reduce the need for inpatient psychiatric and detoxification hospitalization and to reduce or stabilize symptoms and functional impairment of a mental health, substance use or co-occurring disorder. Most IOP programs generally provide 9 to19 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: 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.
Effective: Oct. 1, 2021