Service Service Code(s) Duration: Frequency: Amount

1 Effective Date 1 Service Service Code(s) Description of Service Utilization Management Treatment Services Substance abuse Assessment H0001 The assessment process provides an accurate diagnosis along with recommendations for follow-up or care. Recommendations may include addiction treatment or referrals to physical and mental health practitioners, family counselors, or other helping professionals. Completed Addiction Severity Index. *If a CADC-I completes the assessment it will not be counted completed until it has been reviewed and approved by the clinical supervisor. Duration: NA Frequency: NA Amount : One (1) assessment at admission and one (1) assessment at discharge. Four (4) assessment cap per client per year. Level Early Intervention/ Prevention Not a SAPTA covered Service /Certified Only Level services can occur in any appropriate setting as defined by ASAM Third Edition.

2 Interventions may involve individual, group, or family counseling as well as other interventions delivered by the appropriate clinician. Level constitutes a Service for specific individuals who, for a specific reason, are at risk of developing substance-related or addictive behavior problems or those for whom the is not sufficient information to document a substance is or addictive disorder. This care approximates ASAM Criteria, Third Edition. Not Covered By SAPTA/Certified Only Level I Outpatient Services Individuals: H0047 Group: H0005 Non-residential specialized services on a scheduled basis for individuals with substance abuse problems or use disorders. Level I outpatient substance abuse services are provided in a SAPTA certified Outpatient facility which provides regularly scheduled individual, group and/or licensed family counseling. The program must provide, but is not limited to, professionally directed assessment/evaluation, group counseling, education, skill building, case management and individual counseling.

3 Services may be provided to patients discharged from a more intensive level of care or for clients who are resistant to treatment or higher levels of care, but are not necessarily limited to this. This care approximates ASAM Criteria, Third Edition. Services: Substance abuse assessment Comprehensive Evaluations (by the appropriately licensed staff) Individualized Treatment Planning Individual, group, and/or family therapy Family: To be included during course of treatment as clinically indicated Family education and information sessions as clinically indicated Intensity of Service is dependent upon individual and presenting symptoms and whether the Service is medically necessary. Duration: Not to exceed 90 days in one year Frequency: Up to three (3) sessions per week. Amount : Not to exceed a total of 60 sessions in one year Effective Date 2 *Twelve (12) Step Meetings or other Self-Help Meetings cannot be counted as billable Counseling Services.

4 Intensive Outpatient Treatment H0015 Non-residential specialized services on a scheduled basis for individuals with substance abuse problems or use disorders Intensive Outpatient (IOP) Substance abuse treatment is provided in a certified Level II facility which provides a broad range of highly clinically intensive clinical interventions. The program must provide but is not limited to professionally directed evaluation, group counseling, education, skill building, case management, and individual counseling. Services are provided in a structured environment for no less than nine (9) hours per week. Request for more than twelve (12) hours per week of services must be pre-approved. This care approximates ASAM Criteria, Third Edition A minimum of three (3) hours of treatment services must be provided on each billable day and include one individual session per week. IOP treatment will generally include intensive, moderate and step down components.

5 Services: Substance abuse assessments Comprehensive Evaluations (by the appropriately licensed staff) Individualized treatment planning Individual, group, and/or family therapy Family: To be included during course of treatment as clinically indicated Medical and psychiatric consultation Psychoparmacological consultation Medication management 24 hour crisis management Psychoeducation: Didactic sessions Family education and information sessions as clinically indicated *Twelve (12) Step Meetings or other Self-Help Meetings cannot be counted as billable Counseling Services. Intensity of Service is dependent upon individual and presenting symptoms and whether the Service is medically necessary. Duration: Not to exceed six (6) weeks. Frequency: Up to four (4) sessions per week. A minimum of three (3) hours of treatment services must be provided on each billable day and include one individual session per week.

6 A maximum of 12 hours of services will be allowed per week. Amount : Not to exceed a total of 40 sessions Effective Date 3 Intensity/Short Term Residential SAPTA Low Intensity/Short term residential facilities provide living accommodations in a structured environment that encourages each client to assume responsibility for their own rehabilitation. Low-intensity residential treatment is provided in a licensed residential facility which provides room, board, and didactic evidence based services designed to apply recovery skills, preventing relapse, improving emotional functioning, promoting personal responsibility and reintegrating the individual into work, education and family life. A minimum of 5 hours per week of structured activities must be provided on each billable week. This care approximates ASAM Criteria, Third Edition *Must be licensed by BHCQC Medical Services: Must be provided as per licensing requirements.

7 Services: Basic Skills Training Transportation Peer to Peer Medication Management (if necessary) Medical Services (these services must be available per licensing requirements Treatment and adjunct services shall not be provided but can be arranged for by the program if medically necessary. *Treatment services can be provided by treatment providers outside of the program. Half-way House Facilities shall encourage use of community resources by persons recovering from alcohol/drug use. There shall be written provisions for medical screening, care of clients requiring minor treatment or first aid and handling of medical emergencies. Structured Activities: Employment Vocational training Recovery Support Services Recreation Regular monitoring of medication adherence Opportunities for the client to be introduced to the potential benefits of addiction pharmacotherapy as a tool to manage his or her addictive disorder.)

8 *Self-help meetings may be included as part of structured activities Intensity of Service is dependent upon individual and presenting symptoms and whether the Service is medically necessary. Duration: Not to exceed 30 days. Frequency: A minimum of 5 hours per week of structured activities must be provided on each billable week. Amount : Not to exceed two (3) episodes per year per client. Effective Date 4 Staffing: A staff person shall be available to residents twenty-four (24) hours per day. The client/ staff ratio shall not exceed twelve (12) clients to one (1) staff person. The staff shall be composed of: A house manager; and Other staff sufficient to meet the client/staff standard. Clinically Managed Medium-High Intensity SAPTA Per ASAM Criteria, Level Adult, is a clinically managed high-intensity residential program that are designed to serve individuals who, because of specific functional limitations, need safe and stable living environments in order to develop and/or demonstrate sufficient recovery skills so that they do not immediately relapse or continue to use in an imminently dangerous manner upon transfer to a less intensive level of care.

9 Effective treatment approaches are rehabilitative in focus, addressing the patient s educational and vocational limitations, as well as his or her socially dysfunctional behavior, until the patient can be stabilized and is appropriately transferred to a less intensive level of care. A unit consists of one day (24 hour period. Clinically managed high intensity residential includes no less than 25 hours per week of counseling interventions. A minimum of 7 hours per day of structured activities must be provided on each billable day. Intervention focuses on reintegration into the greater community with particular emphasis on education and vocational development. This care approximates ASAM Criteria Third Edition *Must be licensed by BHCQC Services: Substance abuse assessment 24 hour crisis management Medical, psychiatric, psychological, services, which are available onsite or through consultation or referral.)

10 Medical and psychiatric consultation are available within 24 hours by telephone or in person, within a time frame appropriate to the severity and urgency of the consultation Individual, group, and/or family therapy Family therapy: To be included during course of treatment as clinically indicated Basic Skills Training Transportation Peer to Peer Medication Management (if necessary) Medical Services (these services must be available as per licensing Intensity of Service is dependent upon individual and presenting symptoms and whether the Service is medically necessary. Duration: 30 day maximum length of stay. Amount : Not to exceed two (3) episodes per year per client. Effective Date 5 requirements) Crisis Intervention (doesn t count against the required minimum Service hours) Psychosocial rehabilitation Structured Activities: 7 hours a day required. Example of activities: Motivational therapies and other evidence based practices are used.