Covered and Noncovered Services : Covered Services and Requirements

Group Treatment

Group behavioral treatment is defined as a single session having a minimum of two and maximum of eight members per group and is facilitated by:

• A single provider servicing multiple members during a single session.
• A secondary assisting provider, who may be reimbursed for a group of four or more members.

Provider and Member Eligibility

Medicaid-enrolled behavioral treatment licensed supervisors and behavioral treatment therapists may render group adaptive behavior treatment with protocol modification as the provider leading the group. A secondary assisting provider may render group adaptive behavior treatment by protocol for group sizes of four or more members. Secondary assisting providers may be a behavioral treatment licensed supervisor, behavioral treatment therapist, or behavioral treatment technician.

Treatment may be authorized for members with diagnoses or conditions associated with deficient adaptive or maladaptive behavior when the provider demonstrates the medical necessity of the proposed group behavioral treatment service for the member via the PA request process.

Coverage Limitations

Coverage is limited to no more than eight units (two hours) total per member per day. A member receiving comprehensive treatment must receive one-on-one treatment to be approved for group treatment. However, ForwardHealth may reimburse group treatment exclusively when members receive focused treatment.

Providers may determine the most clinically appropriate place of service for group behavioral treatment services.