№ files_lp_3_process_7_037589
File format: docx Character count: 13069 File size: 56 KB
Administrative clinical review checklist outlining criteria and documentation requirements for authorization, continuation, and compliance monitoring of ACTT services under Medicaid and State-funded benefit plans.
Service Name: Assertive Community Treatment Team (ACTT)
Clinical Coverage Policy: 8A-1
Service Code: H0040
Service Code Modifier: H0040 (DJ)
Funding Sources: Medicaid; State-Funded
Document Type: Clinical review and authorization checklist
Applicable Population: Members receiving MH/SA/DD services
Age Criteria References: Under 21 (EPSDT); Adults 21 and over
Required Documentation: PCP/Treatment Plan; Service Order; Comprehensive Crisis Plan; Comprehensive Clinical Assessment (CCA); LOCUS/CALOCUS/ASAM; CANS (if age 5 or younger); ATR worksheet
Diagnostic Standards Referenced: ICD-10; DSM-5
Authorization Types: Initial; Concurrent; Annual
Review Categories: Pre-Review; Unable to Process Criteria; Administrative Denial; Service Exclusions; High Priority Diagnosis
Oversight Considerations: Medical necessity; Quality of Care; Peer Review; HIPAA compliance
System References: Alpha; AlphaMCS
Price: 8 / 10 USD
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