In-Lieu-Of Services

Date: April 21, 2025

Attention: All Providers

Effective date: May 1, 2025

Call to action: Texas Children Health Plan (TCHP) would like to remind providers of the in-lieu-of services available to our members.

Please be aware that members are not required to utilize in-lieu-of services or settings instead of a covered service or setting, but may consider in-lieu-of services as an option when medically appropriate and cost effective. Texas Children’s Health Plan will provide the following HHSC-approved in-lieu-of services as medically appropriate settings as an option for our members who choose to consider an alternative level of care to acute care inpatient hospital setting:

• Partial Hospitalization Services (PHP)
• Intensive Outpatient Program (IOP) services

How this impacts providers: Service Coordination and Utilization Management collaborate to ensure in-lieu-of-services are considered during discharge planning from inpatient hospitalization and as part of the assessment for the next level of care. Coordination with TCHP's Case Management team is required when applicable regarding Utilization Management.

Prior Authorization Information

Prior authorization is required for in-lieu-of-services. Prior authorization requests for in-lieu-of-services can be securely submitted online via Texas Children’s Link, Provider portal is available at https://www.texaschildrenshealthplan.org/providers/link-provider-portal. Or send via fax to 832-825-8767 or toll-free 1-844-291-7505. Providers should include essential information as required in the UMCM 3.22 and include supporting clinical documentation.

Information for Specific Services

• Partial Hospitalization (PHP) Services- Providers of partial hospitalization services for mental health may include hospital outpatient departments and clinic/group practices enrolled in Medicaid and able to meet the below requirements with a multidisciplinary team approach to patient care under the direction of a physician. Members admitted to a PHP must be under the care of a physician who certifies the need for partial hospitalization services at a minimum of 20 hours per week of therapeutic services, as evidenced by their plan of care. When partial hospitalization is used to shorten an inpatient stay and transition the patient to a less intense LOC, there must be evidence of the need for the acute, intense, structured combination of services provided by a PHP.
• Intensive Outpatient (IOP) Program Services- Intensive outpatient services are organized non-residential services providing structured group and individual therapy, educational services, and life skills training which consists of at least 10 hours per week for four to 12 weeks, but less than 24 hours per Day. As required in Section 9 (SUD Services) of the Behavioral Health and Case Management Services Handbook (Vol. 2, Provider Handbooks) of the TMPPM, LOC and specific services provided must adhere to current evidence-based industry standards and guidelines for SUD treatment, such as those outlined in the current edition of the American Society of Addiction Medicine’s (ASAM’s) Treatment Criteria for Addictive Substance-Related and Co-Occurring Conditions.

Texas Children’s Health Plan Members must consent to receive in-lieu-of-services. Providers rendering the service obtain Member consent and provide to Texas Children’s Health Plan or HHSC upon request. TCHP will give providers 24 business hours to submit requested consent information.

Documentation Process for Member’s Consent

Texas Children’s Health Plan has an established standardized documentation system for recording members' choices regarding in-lieu-of services.

• Staff members are responsible for Member interactions to accurately document and update the chosen services in the member's plan of care.
• Staff regularly review and audit the documentation process to ensure accuracy and completeness.
• Member choices are integrated into the overall care management system for seamless coordination across different healthcare professionals involved in the member's care.

Reimbursement information 

• At the time of enrollment, all providers will sign a contract (attestation) agreeing to participate ILOS program.
• Participating members will sign agreement to receive in lieu of service
• All programs listed below requires 90 days Prior Authorization to be reimbursed for payments and to avoid duplication of payments.

Partial Hospitalization Program (PHP) is a program provided for Mental Health or Substance Use Disorder members.

• Services are rendered in a dedicated treatment center, either within a hospital setting or at a freestanding community mental health center.

Bill type

• Services billed on CMS 1500 claim form should be billed using H0035 (mental health partial hospitalization, treatment, less than 24 hrs) or S0201 (substance use disorder partial hospitalization services, less than 24 hrs, per diem). H0035 and S0201 are not reimbursable if billed on the same day.
• Services billed on CMS 1450 claim form should be billed using 912 or 913 in addition to H0035 (mental health partial hospitalization, treatment less than 24 hrs) or S0201 (substance use disorder partial hospitalization services less than 24 hrs per diem). H0035 and S0201 are not reimbursable if billed on the same day.
• Providers must obtain a prior authorization to be reimbursed for PHP programs.

Intensive Outpatient Program (IOP) is a step down program from PHP providing services to Mental Health and Substance Use Disorder members.

• Services are rendered in hospital outpatient departments, community mental health centers, Federally Qualified Health Centers (FQHC), Rural health clinics (RHC), addiction treatment centers and/or private clinics.

Bill Type

Services provided to members under IOP should be billed using the following procedure codes:

• When billed on a CMS 1500 claim form, procedure code H0015 (Alcohol and/or drug services; intensive outpatient) or S9480 (intensive outpatient psychiatric services) must be reported for reimbursement. H0015 and S9480 will not be reimbursed separately if billed on the same day.
• When using CMS 1450 claim form, procedure code H0015 (Alcohol and/or drug services, intensive outpatient) and SUD services revenue code 906 are required to be reported for reimbursement. When billing S9480 (intensive outpatient psychiatric services), revenue code 905 mental health service is required to be reported for reimbursement. H0015 and S9480 will not be reimbursed separately if billed on the same day.
• Providers must obtain a prior authorization for IOP service to be reimbursed.

Intensive Outpatient Program Partial Hospitalization Program Billing Grid

Next step for Providers: Providers must follow the guidance within this communication and are encouraged to share this information with their staff. 

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org. 

For access to all provider alerts: https://www.texaschildrenshealthplan.org/providers/provider-news/provider-alerts