1115 Institution for Mental Disease substance use disorder demonstration waiver

On July 24, 2023, the Nevada Department of Health and Human Services Division of Health Care Financing and Policy released an announcement related to the residential substance use disorder benefit. This announcement included the following:

The Centers for Medicare & Medicaid Services (CMS) has granted Nevada Medicaid the approval to implement the 1115 Institution for Mental Disease (IMD) Substance Use Disorder (SUD) Demonstration Waiver. The purpose of the waiver implementation is to waive the current IMD rule, which bars the use of federal Medicaid funds to finance services for individuals ages 22 to 64 residing in institutions for mental diseases or IMDs. IMDs are hospitals, nursing homes, or other institutions with more than 16 beds that are primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases other than dementia or intellectual disabilities.

Effective October 1, 2024

We will cover the following medically necessary services for qualified provider types:

• ASAM Level 3.1
• ASAM Level 3.5
• ASAM Level 3.7 Withdrawal Management

This applies to Provider Type 93 in IMD setting. More information regarding Provider Type 93: Provider News, June 21, 2024

Reminder: Providers must have a National Provider Identifier (NPI) to enroll in the new PT 93 specialties. Once a provider has received approval from the state, they must submit their contract request/credentialing application to us for processing.

To enroll with us, providers will use the enrollment function in Availity Essentials. Find more information here: Joining our network is easy.

This applies to the following procedure codes:

• H0011
• H0018
• H0019
• H0047

Provider guidance for submitting authorization requests

Refer to the following online resources:

• Sign up for provider orientation in this Provider News article. Orientation covers our authorization processes and much more.
• Precertification requirements are explained here.
• Behavior health forms and other forms can be found on the Forms page of our Nevada provider site.

Prior authorization (PA) requirements will remain the same; the policy for PAs is not changing.

Once enrolled as a PT 93 provider:

• A new form FA-11D Substance Use Treatment/Outpatient Behavioral Health Authorization Request (nv.gov) must be submitted.
• The provider must request to transfer any remaining units from the PT 17 specialty 215 authorization to the new PT 93 authorization.

Availity Essentials

We are transitioning to the authorization application in Availity. You may already be familiar with the Availity multipayer authorization application because thousands of providers are already using it for submitting PAs for other payers. We are eager to make it available to our providers, too.

Interactive Care Reviewer (ICR) is still available. If you need to refer to an authorization that was submitted through ICR, you will still have access to that information. We have developed a pathway to access your ICR dashboard. You will simply follow the prompts provided through Availity’s authorization app. To make it even more convenient, you can pin your authorizations from the ICR application to your authorization application dashboard in Availity.

Innovation in process

While the Availity authorization application grows to provide you with information specific to our health plans, you may still need to access ICR for:

• Appeals.
• Behavioral health authorizations and inquiries.
• Federal Employee Program authorizations and inquiries.

Notices in Availity’s authorization application will guide you through the process for accessing ICR for alternate authorization and appeals functions.

Training is available

If you aren’t already familiar with the Availity authorization application, training is available. Once you are logged in to Availity, visit the training section to enroll for an upcoming live webcast or to access an on-demand recording at the authorization training site.

Now, give it a try

Accessing Availity’s authorization application is easy. Ask your organization’s Availity administrator to ensure that you have the authorization role assignment. Without the role assignment, you will not be able to access the authorization application. Then, just log on to Availity.com to access the application through the Patient Registration tab by selecting Authorizations and Referrals.

We’re here to help

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management representative or call Provider Services at 844-396-2330.

To join the Carelon Behavioral Health, Inc. network, visit Join our network (carelongbheavioralhealth.com). If you have questions for Carelon Behavioral Health, write them directly at provider.inquiry@carelon.com or refer to their Provider contact information (carelonbehavioralhealth.com).

Note: PA requests for certain services may require additional documentation to determine medical necessity.