RFP 250000002670 - Appendix 4 - Major Service Category Mapping.docx.pdf

APPENDIX 4 – MAJOR SERVICE CATEGORY

MAPPING

Request for Proposal No. 250000002670 Prepaid Inpatient Health Plan (PIHP)

See below for details.

Draft and Confidential 7/25/2025

State of Michigan, Department of Health and Human Services

Medicaid BH Program Procurement

Appendix 1 - Major Service Category Mapping

Service Code

MH, SUD, and/or

CCBHC Service Category Major Service Category Reporting Units

680100 MH Inpatient Inpatient Day

680114 MH Inpatient Inpatient Day

680124 MH Inpatient Inpatient Day

680134 MH Inpatient Inpatient Day

680154 MH Inpatient Inpatient Day

730100 MH Inpatient Inpatient Day

730114 MH Inpatient Inpatient Day

730124 MH Inpatient Inpatient Day

730134 MH Inpatient Inpatient Day

730154 MH Inpatient Inpatient Day

0370 MH Other Therapy Other Encounter

0710 MH Other Therapy Other Encounter

0901 MH Other Therapy Other Encounter

0906 SUD Outpatient Services SUD Outpatient Day

0912 MH Outpatient Services Other Day

0913 MH Outpatient Services Other Day

1002 SUD Residential Services Residential Services Day

00104 MH Other Therapy Other Minutes

001040901 MH Other Therapy Other Minutes

0362T MH Assessments and Testing Prevention, E&M, Assessments and Testing First 30 Minutes

0373T MH Autism Services Autism Services 15 Minutes

80305 SUD Outpatient Services SUD Outpatient Encounter

80306 SUD Outpatient Services SUD Outpatient Encounter

80307 SUD Outpatient Services SUD Outpatient Encounter

90785 MH, SUD, CCBHC Psychiatric diagnostic evaluation Prevention, E&M, Assessments and Testing Encounter

90785Y1 MH, SUD, CCBHC Psychiatric diagnostic evaluation Prevention, E&M, Assessments and Testing Encounter

90785Y2 MH, SUD, CCBHC Psychiatric diagnostic evaluation Prevention, E&M, Assessments and Testing Encounter

90785Y4 MH, SUD, CCBHC Psychiatric diagnostic evaluation Prevention, E&M, Assessments and Testing Encounter

90791 MH, SUD, CCBHC Psychiatric diagnostic evaluation Prevention, E&M, Assessments and Testing Encounter

90791QJ MH, SUD, CCBHC Psychiatric diagnostic evaluation Prevention, E&M, Assessments and Testing Encounter

90791WX MH, SUD, CCBHC Psychiatric diagnostic evaluation Prevention, E&M, Assessments and Testing Encounter

90791Y4 MH, SUD, CCBHC Psychiatric diagnostic evaluation Prevention, E&M, Assessments and Testing Encounter

90792 MH, SUD, CCBHC Psychiatric diagnostic evaluation Prevention, E&M, Assessments and Testing Encounter

90792QJ MH, SUD, CCBHC Psychiatric diagnostic evaluation Prevention, E&M, Assessments and Testing Encounter

90792WX MH, SUD, CCBHC Psychiatric diagnostic evaluation Prevention, E&M, Assessments and Testing Encounter

90792Y4 MH, SUD, CCBHC Psychiatric diagnostic evaluation Prevention, E&M, Assessments and Testing Encounter

90832 MH, CCBHC Psychotherapy Psychotherapy 30 Minutes

90832 SUD Outpatient Services SUD Outpatient 30 Minutes

90832QJ MH, CCBHC Psychotherapy Psychotherapy 30 Minutes

90832QJ SUD Outpatient Services SUD Outpatient 30 Minutes

90832ST MH, CCBHC Psychotherapy Psychotherapy 30 Minutes

90832ST SUD Outpatient Services SUD Outpatient 30 Minutes

90832STQJ MH, CCBHC Psychotherapy Psychotherapy 30 Minutes

90832STQJ SUD Outpatient Services SUD Outpatient 30 Minutes

90832Y1 MH, CCBHC Psychotherapy Psychotherapy 30 Minutes

90832Y1 SUD Outpatient Services SUD Outpatient 30 Minutes

90832Y2 MH, CCBHC Psychotherapy Psychotherapy 30 Minutes

90832Y2 SUD Outpatient Services SUD Outpatient 30 Minutes

90832Y4 MH, CCBHC Psychotherapy Psychotherapy 30 Minutes

90832Y4 SUD Outpatient Services SUD Outpatient 30 Minutes

90833 MH, CCBHC Psychotherapy Psychotherapy 30 Minutes

90833QJ MH, CCBHC Psychotherapy Psychotherapy 30 Minutes

90834 MH, CCBHC Psychotherapy Psychotherapy 45 Minutes

90834 SUD Outpatient Services SUD Outpatient 45 Minutes

90834QJ MH, CCBHC Psychotherapy Psychotherapy 45 Minutes

90834QJ SUD Outpatient Services SUD Outpatient 45 Minutes

90834ST MH, CCBHC Psychotherapy Psychotherapy 45 Minutes

90834ST SUD Outpatient Services SUD Outpatient 45 Minutes

90834STQJ MH, CCBHC Psychotherapy Psychotherapy 45 Minutes

90834STQJ SUD Outpatient Services SUD Outpatient 45 Minutes

90834Y1 MH, CCBHC Psychotherapy Psychotherapy 45 Minutes

90834Y1 SUD Outpatient Services SUD Outpatient 45 Minutes

90834Y2 MH, CCBHC Psychotherapy Psychotherapy 45 Minutes

90834Y2 SUD Outpatient Services SUD Outpatient 45 Minutes

90834Y4 MH, CCBHC Psychotherapy Psychotherapy 45 Minutes

90834Y4 SUD Outpatient Services SUD Outpatient 45 Minutes

90836 MH, CCBHC Psychotherapy Psychotherapy 45 Minutes

90836QJ MH, CCBHC Psychotherapy Psychotherapy 45 Minutes

90837 MH, CCBHC Psychotherapy Psychotherapy 60 Minutes

Appendix 1 Milliman Page 1

Medicaid BH Program Procurement

Appendix 1 - Major Service Category Mapping

Service Code

MH, SUD, and/or

CCBHC Service Category Major Service Category Reporting Units

90837 SUD Outpatient Services SUD Outpatient 60 Minutes

90837QJ MH, CCBHC Psychotherapy Psychotherapy 60 Minutes

90837QJ SUD Outpatient Services SUD Outpatient 60 Minutes

90837ST MH, CCBHC Psychotherapy Psychotherapy 60 Minutes

90837ST SUD Outpatient Services SUD Outpatient 60 Minutes

90837STQJ MH, CCBHC Psychotherapy Psychotherapy 60 Minutes

90837STQJ SUD Outpatient Services SUD Outpatient 60 Minutes

90837Y1 MH, CCBHC Psychotherapy Psychotherapy 60 Minutes

90837Y1 SUD Outpatient Services SUD Outpatient 60 Minutes

90837Y2 MH, CCBHC Psychotherapy Psychotherapy 60 Minutes

90837Y2 SUD Outpatient Services SUD Outpatient 60 Minutes

90837Y4 MH, CCBHC Psychotherapy Psychotherapy 60 Minutes

90837Y4 SUD Outpatient Services SUD Outpatient 60 Minutes

90838 MH, CCBHC Psychotherapy Psychotherapy 60 Minutes

90838QJ MH, CCBHC Psychotherapy Psychotherapy 60 Minutes

90839 MH, CCBHC Crisis Crisis First 30-74 Min.

90839QJ MH, CCBHC Crisis Crisis First 30-74 Min.

90839ST MH, CCBHC Crisis Crisis First 30-74 Min.

90839STQJ MH, CCBHC Crisis Crisis First 30-74 Min.

90839Y1 MH, CCBHC Crisis Crisis First 30-74 Min.

90839Y2 MH, CCBHC Crisis Crisis First 30-74 Min.

90839Y3 MH, CCBHC Crisis Crisis First 30-74 Min.

90839Y4 MH, CCBHC Crisis Crisis First 30-74 Min.

90840 MH, CCBHC Crisis Crisis Each Additional 30 Minutes

90840QJ MH, CCBHC Crisis Crisis Each Additional 30 Minutes

90840Y1 MH, CCBHC Crisis Crisis Each Additional 30 Minutes

90840Y2 MH, CCBHC Crisis Crisis Each Additional 30 Minutes

90840Y3 MH, CCBHC Crisis Crisis Each Additional 30 Minutes

90840Y4 MH, CCBHC Crisis Crisis Each Additional 30 Minutes

90846 MH, CCBHC Psychotherapy Psychotherapy 50 Minutes

90846 SUD Outpatient Services SUD Outpatient 50 Minutes

90846ST MH, CCBHC Psychotherapy Psychotherapy 50 Minutes

90846ST SUD Outpatient Services SUD Outpatient 50 Minutes

90846Y2 MH, CCBHC Psychotherapy Psychotherapy 50 Minutes

90846Y2 SUD Outpatient Services SUD Outpatient 50 Minutes

90846Y3 MH, CCBHC Psychotherapy Psychotherapy 50 Minutes

90846Y3 SUD Outpatient Services SUD Outpatient 50 Minutes

90846Y4 MH, CCBHC Psychotherapy Psychotherapy 50 Minutes

90846Y4 SUD Outpatient Services SUD Outpatient 50 Minutes

90847 MH, CCBHC Psychotherapy Psychotherapy 50 Minutes

90847 SUD Outpatient Services SUD Outpatient 50 Minutes

90847ST MH, CCBHC Psychotherapy Psychotherapy 50 Minutes

90847ST SUD Outpatient Services SUD Outpatient 50 Minutes

90847Y2 MH, CCBHC Psychotherapy Psychotherapy 50 Minutes

90847Y2 SUD Outpatient Services SUD Outpatient 50 Minutes

90847Y3 MH, CCBHC Psychotherapy Psychotherapy 50 Minutes

90847Y3 SUD Outpatient Services SUD Outpatient 50 Minutes

90847Y4 MH, CCBHC Psychotherapy Psychotherapy 50 Minutes

90847Y4 SUD Outpatient Services SUD Outpatient 50 Minutes

90849 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849 SUD Outpatient Services SUD Outpatient Encounter

90849ST MH, CCBHC Psychotherapy Psychotherapy Encounter

90849ST SUD Outpatient Services SUD Outpatient Encounter

90849UN MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UN SUD Outpatient Services SUD Outpatient Encounter

90849UNST MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UNST SUD Outpatient Services SUD Outpatient Encounter

90849UNY2 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UNY2 SUD Outpatient Services SUD Outpatient Encounter

90849UNY3 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UNY3 SUD Outpatient Services SUD Outpatient Encounter

90849UNY4 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UNY4 SUD Outpatient Services SUD Outpatient Encounter

90849UP MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UP SUD Outpatient Services SUD Outpatient Encounter

90849UPST MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UPST SUD Outpatient Services SUD Outpatient Encounter

90849UPY2 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UPY2 SUD Outpatient Services SUD Outpatient Encounter

Appendix 1 Milliman Page 2

Medicaid BH Program Procurement

Appendix 1 - Major Service Category Mapping

Service Code

MH, SUD, and/or

CCBHC Service Category Major Service Category Reporting Units

90849UPY3 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UPY3 SUD Outpatient Services SUD Outpatient Encounter

90849UPY4 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UPY4 SUD Outpatient Services SUD Outpatient Encounter

90849UQ MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UQ SUD Outpatient Services SUD Outpatient Encounter

90849UQST MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UQST SUD Outpatient Services SUD Outpatient Encounter

90849UQY2 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UQY2 SUD Outpatient Services SUD Outpatient Encounter

90849UQY3 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UQY3 SUD Outpatient Services SUD Outpatient Encounter

90849UQY4 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UQY4 SUD Outpatient Services SUD Outpatient Encounter

90849UR MH, CCBHC Psychotherapy Psychotherapy Encounter

90849UR SUD Outpatient Services SUD Outpatient Encounter

90849URST MH, CCBHC Psychotherapy Psychotherapy Encounter

90849URST SUD Outpatient Services SUD Outpatient Encounter

90849URY2 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849URY2 SUD Outpatient Services SUD Outpatient Encounter

90849URY3 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849URY3 SUD Outpatient Services SUD Outpatient Encounter

90849URY4 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849URY4 SUD Outpatient Services SUD Outpatient Encounter

90849US MH, CCBHC Psychotherapy Psychotherapy Encounter

90849US SUD Outpatient Services SUD Outpatient Encounter

90849USST MH, CCBHC Psychotherapy Psychotherapy Encounter

90849USST SUD Outpatient Services SUD Outpatient Encounter

90849USY2 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849USY2 SUD Outpatient Services SUD Outpatient Encounter

90849USY3 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849USY3 SUD Outpatient Services SUD Outpatient Encounter

90849USY4 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849USY4 SUD Outpatient Services SUD Outpatient Encounter

90849Y2 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849Y2 SUD Outpatient Services SUD Outpatient Encounter

90849Y3 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849Y3 SUD Outpatient Services SUD Outpatient Encounter

90849Y4 MH, CCBHC Psychotherapy Psychotherapy Encounter

90849Y4 SUD Outpatient Services SUD Outpatient Encounter

90853UN MH, CCBHC Psychotherapy Psychotherapy Encounter

90853UN SUD Outpatient Services SUD Outpatient Encounter

90853UNQJ MH, CCBHC Psychotherapy Psychotherapy Encounter

90853UNQJ SUD Outpatient Services SUD Outpatient Encounter

90853UNY2 MH, CCBHC Psychotherapy Psychotherapy Encounter

90853UNY2 SUD Outpatient Services SUD Outpatient Encounter

90853UNY4 MH, CCBHC Psychotherapy Psychotherapy Encounter

90853UNY4 SUD Outpatient Services SUD Outpatient Encounter

90853UP MH, CCBHC Psychotherapy Psychotherapy Encounter

90853UP SUD Outpatient Services SUD Outpatient Encounter

90853UPQJ MH, CCBHC Psychotherapy Psychotherapy Encounter

90853UPQJ SUD Outpatient Services SUD Outpatient Encounter

90853UPY2 MH, CCBHC Psychotherapy Psychotherapy Encounter

90853UPY2 SUD Outpatient Services SUD Outpatient Encounter

90853UPY4 MH, CCBHC Psychotherapy Psychotherapy Encounter

90853UPY4 SUD Outpatient Services SUD Outpatient Encounter

90853UQ MH, CCBHC Psychotherapy Psychotherapy Encounter

90853UQ SUD Outpatient Services SUD Outpatient Encounter

90853UQQJ MH, CCBHC Psychotherapy Psychotherapy Encounter

90853UQQJ SUD Outpatient Services SUD Outpatient Encounter

90853UQY2 MH, CCBHC Psychotherapy Psychotherapy Encounter

90853UQY2 SUD Outpatient Services SUD Outpatient Encounter

90853UQY4 MH, CCBHC Psychotherapy Psychotherapy Encounter

90853UQY4 SUD Outpatient Services SUD Outpatient Encounter

90853UR MH, CCBHC Psychotherapy Psychotherapy Encounter

90853UR SUD Outpatient Services SUD Outpatient Encounter

90853URQJ MH, CCBHC Psychotherapy Psychotherapy Encounter

90853URQJ SUD Outpatient Services SUD Outpatient Encounter

90853URY2 MH, CCBHC Psychotherapy Psychotherapy Encounter

Appendix 1 Milliman Page 3

Medicaid BH Program Procurement

Appendix 1 - Major Service Category Mapping

Service Code

MH, SUD, and/or

CCBHC Service Category Major Service Category Reporting Units

90853URY2 SUD Outpatient Services SUD Outpatient Encounter

90853URY4 MH, CCBHC Psychotherapy Psychotherapy Encounter

90853URY4 SUD Outpatient Services SUD Outpatient Encounter

90853US MH, CCBHC Psychotherapy Psychotherapy Encounter

90853US SUD Outpatient Services SUD Outpatient Encounter

90853USQJ MH, CCBHC Psychotherapy Psychotherapy Encounter

90853USQJ SUD Outpatient Services SUD Outpatient Encounter

90853USY2 MH, CCBHC Psychotherapy Psychotherapy Encounter

90853USY2 SUD Outpatient Services SUD Outpatient Encounter

90853USY4 MH, CCBHC Psychotherapy Psychotherapy Encounter

90853USY4 SUD Outpatient Services SUD Outpatient Encounter

90863 MH Other Other Encounter

90870 MH Other Other Encounter

908700901 MH Other Other Encounter

90887 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

92507 MH Other Therapy Other Encounter

92508 MH Other Therapy Other Encounter

92521 MH Other Therapy Other Encounter

92522 MH Other Therapy Other Encounter

92523 MH Other Therapy Other Encounter

92524 MH Other Therapy Other Encounter

92526 MH Other Therapy Other Encounter

92607 MH Other Therapy Other First Hour

92608 MH Other Therapy Other Each Additional 30 Minutes

92609 MH Other Therapy Other Encounter

92610 MH Other Therapy Other Encounter

92626 MH Other Other First Hour

92627 MH Other Other Each Additional 15 Minutes

92630 MH Other Other Encounter

92633 MH Other Other Encounter

96105 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

96105WX MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

96110 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

96110QJ MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

96110WX MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

96112 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing First Hour

96112QJ MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing First Hour

96112WX MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing First Hour

96113 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Each Additional 30 Minutes

96113QJ MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Each Additional 30 Minutes

96113WX MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Each Additional 30 Minutes

96116 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Per Hour

96116WX MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Per Hour

96121 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Each Additional Hour

96127 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

96127WX MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

96130 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing First Hour

96130QJ MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing First Hour

96131 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Each Additional Hour

96131QJ MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Each Additional Hour

96132 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing First Hour

96133 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Each Additional Hour

96136 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing First 30 Minutes

96136QJ MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing First 30 Minutes

96137 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Each Additional 30 Minutes

96137QJ MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Each Additional 30 Minutes

96138 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing First 30 Minutes

96139 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Each Additional 30 Minutes

96146 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

96372 MH, SUD, CCBHC Medication Administration Medication Administration/Medication Assisted Treatment Encounter

96372QJ MH, SUD, CCBHC Medication Administration Medication Administration/Medication Assisted Treatment Encounter

96372Y4 MH, SUD, CCBHC Medication Administration Medication Administration/Medication Assisted Treatment Encounter

97110 MH Other Therapy Other 15 Minutes

97112 MH Other Therapy Other 15 Minutes

97113 MH Other Therapy Other 15 Minutes

97116 MH Other Therapy Other 15 Minutes

97124 MH Other Therapy Other 15 Minutes

97129 MH Other Therapy Other 15 Minutes

97130 MH Other Therapy Other 15 Minutes

Appendix 1 Milliman Page 4

Medicaid BH Program Procurement

Appendix 1 - Major Service Category Mapping

Service Code

MH, SUD, and/or

CCBHC Service Category Major Service Category Reporting Units

97140 MH Other Therapy Other 15 Minutes

97150 MH Other Therapy Other Encounter

97151 MH Assessments and Testing Prevention, E&M, Assessments and Testing 15 Minutes

97151U5 MH Assessments and Testing Prevention, E&M, Assessments and Testing 15 Minutes

97153 MH Autism Services Autism Services 15 Minutes

97154UN MH Autism Services Autism Services 15 Minutes

97154UP MH Autism Services Autism Services 15 Minutes

97154UQ MH Autism Services Autism Services 15 Minutes

97154UR MH Autism Services Autism Services 15 Minutes

97154US MH Autism Services Autism Services 15 Minutes

97155 MH Autism Services Autism Services 15 Minutes

97156 MH Autism Services Autism Services 15 Minutes

97157UN MH Autism Services Autism Services 15 Minutes

97157UP MH Autism Services Autism Services 15 Minutes

97157UQ MH Autism Services Autism Services 15 Minutes

97157UR MH Autism Services Autism Services 15 Minutes

97157US MH Autism Services Autism Services 15 Minutes

97158 MH Autism Services Autism Services 15 Minutes

97158UN MH Autism Services Autism Services 15 Minutes

97158UP MH Autism Services Autism Services 15 Minutes

97158UQ MH Autism Services Autism Services 15 Minutes

97158UR MH Autism Services Autism Services 15 Minutes

97158US MH Autism Services Autism Services 15 Minutes

97161 MH Other Therapy Other Encounter

97161WX MH Other Therapy Other Encounter

97162 MH Other Therapy Other Encounter

97162WX MH Other Therapy Other Encounter

97163 MH Other Therapy Other Encounter

97163WX MH Other Therapy Other Encounter

97164 MH Other Therapy Other Encounter

97165 MH Other Therapy Other Encounter

97165WX MH Other Therapy Other Encounter

97166 MH Other Therapy Other Encounter

97166WX MH Other Therapy Other Encounter

97167 MH Other Therapy Other Encounter

97167WX MH Other Therapy Other Encounter

97168 MH Other Therapy Other Encounter

97168WX MH Other Therapy Other Encounter

97530 MH Other Therapy Other 15 Minutes

97530Y4 MH Other Therapy Other 15 Minutes

97533 MH Other Therapy Other 15 Minutes

97535 MH Other Therapy Other 15 Minutes

97537 MH Other Therapy Other 15 Minutes

97542 MH Other Therapy Other 15 Minutes

97750 MH Other Therapy Other 15 Minutes

97755 MH Other Therapy Other 15 Minutes

97760 MH Other Therapy Other 15 Minutes

97761 MH Other Other 15 Minutes

97763 MH Other Therapy Other 15 Minutes

97802 MH Assessments and Testing Prevention, E&M, Assessments and Testing 15 Minutes

97802WX MH Assessments and Testing Prevention, E&M, Assessments and Testing 15 Minutes

97803 MH Assessments and Testing Prevention, E&M, Assessments and Testing 15 Minutes

97803WX MH Assessments and Testing Prevention, E&M, Assessments and Testing 15 Minutes

97804 MH Other Therapy Other 30 Minutes

97804UN MH Other Therapy Other 30 Minutes

97804UP MH Other Therapy Other 30 Minutes

97804UQ MH Other Therapy Other 30 Minutes

97804UR MH Other Therapy Other 30 Minutes

97804US MH Other Therapy Other 30 Minutes

97810 SUD Other Other Encounter

97811 SUD Other Other Encounter

98966 MH Other Other Encounter

98967 MH Other Other Encounter

98968 MH Other Other Encounter

99202 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99202QJ MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99202Y4 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99203 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99203QJ MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

Appendix 1 Milliman Page 5

Medicaid BH Program Procurement

Appendix 1 - Major Service Category Mapping

Service Code

MH, SUD, and/or

CCBHC Service Category Major Service Category Reporting Units

99203Y4 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99204 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99204QJ MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99204Y4 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99205 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99205QJ MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99205Y4 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99211 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99211QJ MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99211Y4 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99212 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99212QJ MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99212Y4 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99213 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99213QJ MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99213Y4 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99214 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99214QJ MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99214Y4 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99215 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99215QJ MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99215Y4 MH, SUD, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99221 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99222 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99223 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99223Y4 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99224 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99225 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99226 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99231 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99231Y4 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99232 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99232Y4 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99233 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99233Y4 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99238 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99239 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99304 MH Evaluation and Management Prevention, E&M, Assessments and Testing 25 minutes

99305 MH Evaluation and Management Prevention, E&M, Assessments and Testing 35 Minutes

99306 MH Evaluation and Management Prevention, E&M, Assessments and Testing 45 Minutes

99307 MH Evaluation and Management Prevention, E&M, Assessments and Testing 10 Minutes

99308 MH Evaluation and Management Prevention, E&M, Assessments and Testing 15 Minutes

99309 MH Evaluation and Management Prevention, E&M, Assessments and Testing 25 minutes

99310 MH Evaluation and Management Prevention, E&M, Assessments and Testing 35 Minutes

99324 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99325 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99326 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99327 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99328 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99334 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99335 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99336 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99337 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99341 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99342 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99343 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99344 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99345 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99347 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99347Y4 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99348 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99349 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99350 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99354 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99355 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99381 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99382 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99383 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99384 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

Appendix 1 Milliman Page 6

Medicaid BH Program Procurement

Appendix 1 - Major Service Category Mapping

Service Code

MH, SUD, and/or

CCBHC Service Category Major Service Category Reporting Units

99385 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99386 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99387 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99391 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99392 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99393 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99394 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99395 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99396 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99397 MH, CCBHC Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99415 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99416 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99417 MH Evaluation and Management Prevention, E&M, Assessments and Testing Encounter

99441 MH Other Other Encounter

99442 MH Other Other Encounter

99443 MH Other Other Encounter

99506 MH, CCBHC Medication Administration Medication Administration/Medication Assisted Treatment Encounter

99506Y4 MH, CCBHC Medication Administration Medication Administration/Medication Assisted Treatment Encounter

A0080 MH Other Other Per mile

A0090 MH Other Other Per mile

A0100 MH, SUD Other Other Per one-way trip

A0110 MH, SUD Other Other Per one-way trip

A0120 MH Other Other Per one-way trip

A0120Y4 MH Other Other Per one-way trip

A0130 MH Other Other Per one-way trip

A0140 MH Other Other Per one-way trip

A0425 MH Other Other Per Mile

A0427 MH Other Other Refer to code descriptions.

E1399 MH Other Other Item

G0176 MH, CCBHC Other Therapy Other Encounter

G0177 MH, CCBHC Other Other Encounter Session at least 45 min

G0177UN MH, CCBHC Other Other Encounter Session at least 45 min

G0177UNY4 MH, CCBHC Other Other Encounter Session at least 45 min

G0177UP MH, CCBHC Other Other Encounter Session at least 45 min

G0177UPY4 MH, CCBHC Other Other Encounter Session at least 45 min

G0177UQ MH, CCBHC Other Other Encounter Session at least 45 min

G0177UQY4 MH, CCBHC Other Other Encounter Session at least 45 min

G0177UR MH, CCBHC Other Other Encounter Session at least 45 min

G0177URY4 MH, CCBHC Other Other Encounter Session at least 45 min

G0177US MH, CCBHC Other Other Encounter Session at least 45 min

G0177USY4 MH, CCBHC Other Other Encounter Session at least 45 min

G0177Y4 MH, CCBHC Other Other Encounter Session at least 45 min

G0409 SUD Outpatient Services SUD Outpatient 15 Minutes

G0466 MH Other Other Encounter

G0467 MH Other Other Encounter

G0469 MH Other Other Encounter

G0470 MH Other Other Encounter

G2067 SUD Medication Assisted Treatment Medication Administration/Medication Assisted Treatment 1 per week

G2068 SUD Medication Assisted Treatment Medication Administration/Medication Assisted Treatment 1 per week

G2073 SUD Medication Assisted Treatment Medication Administration/Medication Assisted Treatment 1 per month

G2074 SUD Medication Assisted Treatment Medication Administration/Medication Assisted Treatment 1 per week

G2076 SUD Medication Assisted Treatment Medication Administration/Medication Assisted Treatment 1 per week

G2077 SUD Medication Assisted Treatment Medication Administration/Medication Assisted Treatment 1 per year

G2077Y4 SUD Medication Assisted Treatment Medication Administration/Medication Assisted Treatment 1 per year

G2078 SUD Medication Assisted Treatment Medication Administration/Medication Assisted Treatment 1 per week

G2079 SUD Medication Assisted Treatment Medication Administration/Medication Assisted Treatment 1 per week

G2080 SUD Medication Assisted Treatment Medication Administration/Medication Assisted Treatment 1 per week

G2251 MH Other Other Encounter

H0001 SUD, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

H0001QJ SUD, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

H0001Y4 SUD, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

H0002 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

H0002QJ MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

H0002WX MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

H0003 SUD Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

H0004 SUD, CCBHC Outpatient Services SUD Outpatient 15 Minutes

H0004QJ SUD, CCBHC Outpatient Services SUD Outpatient 15 Minutes

H0004Y4 SUD, CCBHC Outpatient Services SUD Outpatient 15 Minutes

H0005UN SUD, CCBHC Outpatient Services SUD Outpatient Encounter

Appendix 1 Milliman Page 7

Medicaid BH Program Procurement

Appendix 1 - Major Service Category Mapping

Service Code

MH, SUD, and/or

CCBHC Service Category Major Service Category Reporting Units

H0005UNQJ SUD, CCBHC Outpatient Services SUD Outpatient Encounter

H0005UNY4 SUD, CCBHC Outpatient Services SUD Outpatient Encounter

H0005UP SUD, CCBHC Outpatient Services SUD Outpatient Encounter

H0005UPQJ SUD, CCBHC Outpatient Services SUD Outpatient Encounter

H0005UPY4 SUD, CCBHC Outpatient Services SUD Outpatient Encounter

H0005UQ SUD, CCBHC Outpatient Services SUD Outpatient Encounter

H0005UQQJ SUD, CCBHC Outpatient Services SUD Outpatient Encounter

H0005UQY4 SUD, CCBHC Outpatient Services SUD Outpatient Encounter

H0005UR SUD, CCBHC Outpatient Services SUD Outpatient Encounter

H0005URQJ SUD, CCBHC Outpatient Services SUD Outpatient Encounter

H0005URY4 SUD, CCBHC Outpatient Services SUD Outpatient Encounter

H0005US SUD, CCBHC Outpatient Services SUD Outpatient Encounter

H0005USQJ SUD, CCBHC Outpatient Services SUD Outpatient Encounter

H0005USY4 SUD, CCBHC Outpatient Services SUD Outpatient Encounter

H0006 SUD Case Management / Treatment Planning Case Management / Treatment Planning Encounter

H0006QJ SUD Case Management / Treatment Planning Case Management / Treatment Planning Encounter

H0006Y4 SUD Case Management / Treatment Planning Case Management / Treatment Planning Encounter

H0010 SUD Withdrawal Management Withdrawal Management Day

H0012 SUD Withdrawal Management Withdrawal Management Day

H0014 SUD, CCBHC Withdrawal Management Withdrawal Management Day

H0015 SUD, CCBHC Outpatient Services SUD Outpatient Day

H0015QJ SUD, CCBHC Outpatient Services SUD Outpatient Day

H0015Y4 SUD, CCBHC Outpatient Services SUD Outpatient Day

H0018 MH Residential Services Residential Services Day

H0018W1 SUD Residential Services Residential Services Day

H0018W1Y4 SUD Residential Services Residential Services Day

H0018W3 SUD Residential Services Residential Services Day

H0018W3Y4 SUD Residential Services Residential Services Day

H0018W5 SUD Residential Services Residential Services Day

H0018W5Y4 SUD Residential Services Residential Services Day

H0018W7 SUD Residential Services Residential Services Day

H0018W7Y4 SUD Residential Services Residential Services Day

H0018Y4 MH Residential Services Residential Services Day

H0019W1 SUD Residential Services Residential Services Day

H0019W1Y4 SUD Residential Services Residential Services Day

H0019W3 SUD Residential Services Residential Services Day

H0019W3Y4 SUD Residential Services Residential Services Day

H0019W5 SUD Residential Services Residential Services Day

H0019W5Y4 SUD Residential Services Residential Services Day

H0019W7 SUD Residential Services Residential Services Day

H0019W7Y4 SUD Residential Services Residential Services Day

H0020 SUD Medication Assisted Treatment Medication Administration/Medication Assisted Treatment Encounter

H0022 SUD, CCBHC Prevention and Early Intervention Prevention, E&M, Assessments and Testing Encounter

H0022Y4 SUD, CCBHC Prevention and Early Intervention Prevention, E&M, Assessments and Testing Encounter

H0023 MH Additional Support Services Additional Support Services Encounter

H0025 MH, CCBHC Prevention and Early Intervention Prevention, E&M, Assessments and Testing Face to Face Contact

H0025Y4 MH, CCBHC Prevention and Early Intervention Prevention, E&M, Assessments and Testing Face to Face Contact

H0031 MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

H0031QJ MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

H0031WX MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

H0031WY MH, CCBHC Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

H0032 MH, CCBHC Case Management / Treatment Planning Case Management / Treatment Planning Encounter

H0032QJ MH, CCBHC Case Management / Treatment Planning Case Management / Treatment Planning Encounter

H0032TS MH, CCBHC Case Management / Treatment Planning Case Management / Treatment Planning Encounter

H0032TSQJ MH, CCBHC Case Management / Treatment Planning Case Management / Treatment Planning Encounter

H0032TSY4 MH, CCBHC Case Management / Treatment Planning Case Management / Treatment Planning Encounter

H0032Y4 MH, CCBHC Case Management / Treatment Planning Case Management / Treatment Planning Encounter

H0033 SUD, CCBHC Medication Assisted Treatment Medication Administration/Medication Assisted Treatment Encounter

H0034 MH, CCBHC Other Other 15 Minutes

H0034Y4 MH, CCBHC Other Other 15 Minutes

H0036 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036QJ MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036ST MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036STQJ MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UN MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UNQJ MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UNST MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UNSTQJ MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UNY2 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

Appendix 1 Milliman Page 8

Medicaid BH Program Procurement

Appendix 1 - Major Service Category Mapping

Service Code

MH, SUD, and/or

CCBHC Service Category Major Service Category Reporting Units

H0036UNY3 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UNY4 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UP MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UPQJ MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UPST MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UPSTQJ MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UPY2 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UPY3 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UPY4 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UQ MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UQQJ MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UQST MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UQSTQJ MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UQY2 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UQY3 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UQY4 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036UR MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036URQJ MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036URST MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036URSTQJ MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036URY2 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036URY3 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036URY4 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036US MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036USQJ MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036USST MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036USSTQJ MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036USY2 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036USY3 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036USY4 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036Y2 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036Y3 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0036Y4 MH, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038 MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038QJ MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038UN MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038UNQJ MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038UNY4 MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038UP MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038UPQJ MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038UPY4 MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038UQ MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038UQQJ MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038UQY4 MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038UR MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038URQJ MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038URY4 MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038US MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038USQJ MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038USY4 MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0038Y4 MH, SUD, CCBHC Additional Support Services Additional Support Services 15 Minutes

H0039 MH, CCBHC Assertive Community Treatment (ACT) Assertive Community Treatment (ACT) 15 Minutes

H0039QJ MH, CCBHC Assertive Community Treatment (ACT) Assertive Community Treatment (ACT) 15 Minutes

H0039UNQJ MH, CCBHC Assertive Community Treatment (ACT) Assertive Community Treatment (ACT) 15 Minutes

H0039UPQJ MH, CCBHC Assertive Community Treatment (ACT) Assertive Community Treatment (ACT) 15 Minutes

H0039UQQJ MH, CCBHC Assertive Community Treatment (ACT) Assertive Community Treatment (ACT) 15 Minutes

H0039URQJ MH, CCBHC Assertive Community Treatment (ACT) Assertive Community Treatment (ACT) 15 Minutes

H0039USQJ MH, CCBHC Assertive Community Treatment (ACT) Assertive Community Treatment (ACT) 15 Minutes

H0045 MH, CCBHC Additional Support Services Additional Support Services Day

H0045UN MH, CCBHC Additional Support Services Additional Support Services Day

H0045UP MH, CCBHC Additional Support Services Additional Support Services Day

H0045UQ MH, CCBHC Additional Support Services Additional Support Services Day

H0045UR MH, CCBHC Additional Support Services Additional Support Services Day

H0045US MH, CCBHC Additional Support Services Additional Support Services Day

H0046 MH Additional Support Services Additional Support Services Encounter

H0046UN MH Additional Support Services Additional Support Services Encounter

H0046UP MH Additional Support Services Additional Support Services Encounter

H0046UQ MH Additional Support Services Additional Support Services Encounter

H0046UR MH Additional Support Services Additional Support Services Encounter

Appendix 1 Milliman Page 9

Medicaid BH Program Procurement

Appendix 1 - Major Service Category Mapping

Service Code

MH, SUD, and/or

CCBHC Service Category Major Service Category Reporting Units

H0046US MH Additional Support Services Additional Support Services Encounter

H0048 SUD Assessments and Testing Prevention, E&M, Assessments and Testing Encounter

H0050 SUD, CCBHC Prevention and Early Intervention Prevention, E&M, Assessments and Testing 15 Minutes

H0050QJ SUD, CCBHC Prevention and Early Intervention Prevention, E&M, Assessments and Testing 15 Minutes

H0050Y4 SUD, CCBHC Prevention and Early Intervention Prevention, E&M, Assessments and Testing 15 Minutes

H2000 MH, CCBHC Case Management / Treatment Planning Case Management / Treatment Planning Encounter

H2000TS MH, CCBHC Case Management / Treatment Planning Case Management / Treatment Planning Encounter

H2010 MH, CCBHC Other Other 15 minutes

H2011 MH, SUD, CCBHC Crisis Crisis 15 Minutes

H2011HT MH, SUD, CCBHC Crisis Crisis 15 Minutes

H2011HTY4 MH, SUD, CCBHC Crisis Crisis 15 Minutes

H2011QJ MH, SUD, CCBHC Crisis Crisis 15 Minutes

H2011Y4 MH, SUD, CCBHC Crisis Crisis 15 Minutes

H2014 MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014QJ MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UN MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UNQJ MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UNWZ MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UNWZY4 MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UNY4 MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UP MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UPQJ MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UPWZ MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UPWZY4 MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UPY4 MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UQ MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UQQJ MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UQWZ MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UQWZY4 MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UQY4 MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014UR MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014URQJ MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014URWZ MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014URWZY4 MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014URY4 MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014US MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014USQJ MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014USWZ MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014USWZY4 MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014USY4 MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014WZ MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014WZY4 MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2014Y4 MH, CCBHC Skill Building Skill Building/Vocational Supports 15 minutes

H2015 MH Community Living Supports Community Living Supports 15 Minutes

H2015QJ MH Community Living Supports Community Living Supports 15 Minutes

H2015QJUJ MH Community Living Supports Community Living Supports 15 Minutes

H2015UJ MH Community Living Supports Community Living Supports 15 Minutes

H2015UJY4 MH Community Living Supports Community Living Supports 15 Minutes

H2015UN MH Community Living Supports Community Living Supports 15 Minutes

H2015UNQJ MH Community Living Supports Community Living Supports 15 Minutes

H2015UNQJUJ MH Community Living Supports Community Living Supports 15 Minutes

H2015UNUJ MH Community Living Supports Community Living Supports 15 Minutes

H2015UNUJY4 MH Community Living Supports Community Living Supports 15 Minutes

H2015UNY4 MH Community Living Supports Community Living Supports 15 Minutes

H2015UP MH Community Living Supports Community Living Supports 15 Minutes

H2015UPQJ MH Community Living Supports Community Living Supports 15 Minutes

H2015UPQJUJ MH Community Living Supports Community Living Supports 15 Minutes

H2015UPUJ MH Community Living Supports Community Living Supports 15 Minutes

H2015UPUJY4 MH Community Living Supports Community Living Supports 15 Minutes

H2015UPY4 MH Community Living Supports Community Living Supports 15 Minutes

H2015UQ MH Community Living Supports Community Living Supports 15 Minutes

H2015UQQJ MH Community Living Supports Community Living Supports 15 Minutes

H2015UQQJUJ MH Community Living Supports Community Living Supports 15 Minutes

H2015UQUJ MH Community Living Supports Community Living Supports 15 Minutes

H2015UQUJY4 MH Community Living Supports Community Living Supports 15 Minutes

H2015UQY4 MH Community Living Supports Community Living Supports 15 Minutes

H2015UR MH Community Living Supports Community Living Supports 15 Minutes

H2015URQJ MH Community Living Supports Community Living Supports 15 Minutes

H2015URQJUJ MH Community Living Supports Community Living Supports 15 Minutes

Appendix 1 Milliman Page 10

Medicaid BH Program Procurement

Appendix 1 - Major Service Category Mapping

Service Code

MH, SUD, and/or

CCBHC Service Category Major Service Category Reporting Units

H2015URUJ MH Community Living Supports Community Living…