Purpose 

This medical policy outlines Highmark Health Options services for substance use disorder outpatient treatment services over 18.

Definitions

Highmark Health Options (HHO) – Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services Delaware Medicaid: Diamond State Health Plan (DSHP), Delaware Healthy Children Program (DHCP), and Diamond State Health Plan Plus (DSHP) LTSS members.

Outpatient Services- Mental health and substance use disorder services provided in person in an ambulatory care setting such as a mental health center or substance use disorder clinic, hospital outpatient department, community health center, or practitioner’s office.

PROMISE-The PROMISE program (Promoting Optimal Mental Health for Individuals through Supports and Empowerment) targets individuals with behavioral health needs and functional limitations to offer an array of home and community-based services (HCBS) that are person-centered, recovery-oriented, and aimed at supporting beneficiaries in the community. PROMISE aims to improve clinical and recovery outcomes and reduce unnecessary institutional care through better care coordination, and thereby also reduce the growth in overall program costs.

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool https://www.highmarkhealthoptions.com/providers/prior-auth-lookup

Procedures

Conditions of Coverage

Provider Qualifications for all SUD and Addiction Services

This policy applies to psychiatrists (MD, DO), PhD. Level psychologists, Licensed Clinical Social Workers (LCSW), Advanced Practice Nurse Practitioners (ARNP), Licensed Marriage and Family Therapists (LMFT), Licensed Chemical Dependency Practitioner (LCDP), and Licensed Professional Counselor of Metal Health (LPCMH).

Claims for unlicensed staff (e.g., CADC’s, MSW’s) will bill using their licensed supervisor as the rendering provider number.

Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes.

• The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. 
• HHO OP SUD 03.25.2025.pdf

Limitations

Substance use disorder outpatient services for PROMISE enrolled members are not covered by HHO. For reimbursement of outpatient substance use disorder services for PROMISE members, contact the Delaware Division of Substance Abuse and Mental Health (DSAMH). 

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