mh crisis interv mh ihbs non clinical mh act non clinical mh assertive comm trmt act

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					                                       MENTAL HEALTH SERVICES RATE SHEET
                                       MONTGOMERY COUNTY ADAMHS BOARD

              Prov Name (insert billing provider name)              Medicaid Only?            (Yes or No)
              Billing NPI (insert NPI)                              Non-Medicaid Only?        (Yes or No)
             Submitter ID (insert UPI)                              Date of Form:             Date
Provider Contact Name        (insert Name)
for Pricing


Procedure Code               Description                            Non Medicaid Rate         Withhold

Medicaid Billable Services
                  90801      MH ASSMT-PHYSICIAN
                  90862      MH PHARM MGMT
                  H0004      MH INDIV COUNS/THER
                  H0004      MH GROUP COUNS/THER
                  H0031      MH ASSMT-NON PHYSICIAN
                  H0036      MH INDIV COMM PSY SUPP
                  H0036      MH GROUP COMM PSY SUPP
                  H0040      MH ASSERTIVE COMM TRMT (ACT)
                  H2016      MH INTENSIVE HOME BASED (IHBS)
                  S0201      MH PARTIAL HOSP
                  S9484      MH CRISIS INTERV
Non-Medicaid Services
                  H0030 MH HOTLINE
                  H0038 MH SELF HELP/PEER SVC
                  H0046 MH OTHER HEALTHCARE
For procedures listed below, expanded procedure codes might be needed for pricing alternatives, e.g. M3141.
Please add rows at bottom of grid to enter the procedure code, description and rate for alternative prices
                  M1430      MH OCCUP THERAPY
                  M1440      MH ADJUNCT THERAPY
                  M1530      MH SCHOOL PSYCH
                  M1540      MH ADULT EDUC
                  M1550      MH SOCIAL REC
                  M1620      MH EMPLOY/VOC
                  M1810      MH IHBS NON-CLINICAL
                  M1910      MH ACT NON-CLINICAL
                  M2200      MH RESIDENTIAL CARE
                  M2240      MH COMM RESIDENCE
                  M2250      MH FOSTER CARE
                  M2260      MH SUBSIDIZED HOUSING
                  M2270      MH RESPITE CARE
                  M2280      MH CRISIS CARE
                  M2290      MH TEMP HOUSING
                  M3120      MH CONSUMER OP
                  M3140      MH OTHER NON-HEALTHCARE
                  M4110      MH PREVENTION
                  M4120      MH CONSULTATION
                  M4130      MH INFO AND REFERRAL
                  M4140      MH COMMUNITY EDUC



* These services are reported in 15 minute increments and must be priced accordingly.
                                    ALCOHOL AND OTHER DRUG TREATMENT SERVICES RATE SHEET
                                             MONTGOMERY COUNTY ADAMHS BOARD

                   Prov Name (insert billing provider name)            Medicaid Only?
                   Billing NPI (insert NPI)                            Non-Medicaid Only?
                  Submitter ID (insert UPI)                            Date of Form:
Provider Contact Name for      (insert Name)
Pricing

Procedure Code                 Description                             Non Medicaid Rate
Medicaid Billable Services
H0001                          ASSESSMENT
H0003                          LABORATORY URINALYSIS
H0004                          AOD INDIV COUNS/THERAPY ***
H0005                          GROUP COUNSELING ***
H0006                          CASE MANAGEMENT
H0007                          CRISIS INTERVENTION
H0014                          AMBULATORY DETOXIFICATION
H0015                          INTENSIVE OUTPATIENT
H0016                          MEDICAL/SOMATIC
H0020                          METHADONE ADMINISTRATION
NON-MEDICAID SERVICES
H0030                           AOD HOTLINE
                        99236 23 HOUR OBSERVATION BED
H0009                           ACUTE HOSPITAL DETOX
H0012                           SUB ACUTE DETOXIFICATION
H0017                           BHMCRT: HOSPITAL SETTING
H0018                           BHMCRT: NON-HOSPITAL
H0019                           BHNON-MEDICAL CRT
H0021                           TRAINING
H0022                           INTERVENTION
H0023                           OUTREACH
H0047                           AOD SERVICES NOS
T1006                           AoD FAMILY/COUPLE COUNS ***
T1009                           CHILDCARE
T1010                           MEALS
For the Procedures listed below, expanded procedure codes might be needed for pricing alternatives e.g., M3141, M3142.
Please use the blank lines at the bottom of the grid to enter the procedure code, description and rate for alternative prices.
A0230                           MCR: NON-HOSPITAL SETTING
A0510                           REFERRAL AND INFORMATION
A0560                           CONSULTATION
A0610                           INFORMATION DISSEMINATION
A0620                           EDUCATION (PREVENTION)
A0630                           COMM. BASED PROCESS
A0640                           ENVIRONMENTAL
A0650                           PROBLEM ID AND REF
A0660                           ALTERNATIVES
A0740                           ROOM AND BOARD
A0750                           TRANSPORTATION
A0780                           URINE DIP SCREENING
A1210                           MCR: HOSPITAL SETTING
A1220                           NMR: NON-ACUTE RES SETTING
 RATE SHEET
D

             (Yes or No)
             (Yes or No)
             Date



             Withhold




atives e.g., M3141, M3142.
d rate for alternative prices.

				
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