Billing Guidance for Organizations with SUPR Grant Funded
Peer Recovery Support Services
Effective October 1, 2024, all licensed and grant funded substance use disorder (SUD) treatment providers who deliver Peer Recovery Support (PRS) services are required to bill Medicaid for all applicable customers. The Illinois Department of Human Services/Division of Substance Use Prevention and Recovery (IDHS/SUPR) SUPR is excited to share this important change with you as it will expand access to sustainable PRS services for many Illinois residents.
IDHS/SUPR released a Smart Alert on September 9 called Smart Alert-New Provider Notice Issued by HFS for Recovery Support, notifying organization of the approaching changes. The provision of PRS services for all Medicaid-eligible customers must follow the Service Definition, Medical Necessity, Staff Qualifications, and Billing and Reimbursements specified in the Provider Notice that was issued September 4, 2024, by the Illinois Health and Human Services (HFS).
Historically, these services have been funded through SUPR grants and were not billable to Medicaid. We have developed a policy and billing guideline to ensure that PRS services delivered on or after October 1, 2024, are correctly billed to Medicaid and for uninsured patients to the State grant.
Organizations should note that Medicaid reimbursement for PRS is only allowed for patients receiving substance use disorder (SUD) treatment services. Please ensure that this guidance is shared with the appropriate billing and clinical staff involved in the delivery or billing of PRS services.
Please direct any questions to the SUPR Help Desk, DoIT.SUPRHelp@illinois.gov.
Peer Recovery Support Services Revised Billing Procedure
October 2024
The Illinois Department of Human Services/Division of Substance Use Prevention and Recovery (IDHS/SUPR) billing procedure has been revised to reflect the inclusion of Peer Recovery Support Services (PRS), formerly called Recovery Support Services (RSS), as a Medicaid covered benefit effective October 1, 2024. The following policy and billing guidance is provided to ensure that Medicaid is correctly billed for a recovery support service delivered on or after October 1, 2024, to a Medicaid covered recipient who is receiving substance use disorder (SUD) treatment in a SUPR licensed organization.
Definition:
PRS are non-clinical recovery supports provided by individuals trained and certified to utilize their own personal lived experience/expertise in recovery from mental health and/or substance use challenges to support other individuals in their journey of recovery from substance use and/or mental health or other behavioral health challenges. These services are not just about offering and receiving help, but about doing so based on a shared understanding, respect, and mutual empowerment, making everyone feel valued and respected. (Link to /IDHS/SUPR website page: Peer Recovery Support Services)
Staff Qualifications:
PRS are provided as an individual service by a peer specialist, operating under the supervision of a qualified "professional staff" as defined in 77 Ill. Admin. Code 2060 (Part 2060 Alcoholism and Substance Abuse Treatment and Intervention Licenses) and who meet the following qualifications:
- At least 18 years of age
- Have a minimum of one year recovery from substance use, mental health, or co-occurring substance use and mental health challenges.
- Certified by the Illinois Certification Board (ICB, Inc.) as a Certified Recovery Support Specialist (CRSS) or as a Certified Peer Recovery Support Specialist (CPRS) or be certified within one year of employment date.
- Demonstrate the ability to work within agency structure, accept supervision, and participate as a member of a multi-disciplinary team, when applicable.
Differences Between Clinical Services and PRS:
Both clinical services and peer recovery support services are critical for people who are facing substance use challenges and are on their journey of recovery. Despite their differences, both services share a common ground of unconditional positive regard for the individual and a mutual desire to establish a connection. This shared understanding helps the individual feel understood, enhancing the effectiveness of the services.
Certified and licensed clinicians with expertise and formal training provide clinical services and provide diagnosis, treatment, and medication monitoring for SUD conditions as authorized by Administrative Rule, Part 206O and their professional license or certification.
Certified peer specialists are staff with lived experience/expertise who use what they have learned through their recovery process to walk alongside a person's journey in recovery. These staff do not provide clinical services. Through their relationship and shared experience, they provide practical and emotional support that helps a person sustain recovery through social connectedness and community. The emphasis is on empowerment, recovery, and peer-to-peer relationships.
Medical Necessity:
Billing and Reimbursement:
Revised Department Automated Reporting and Tracking System (DARTS) and the DARTS record layout manual are under revision and will be emailed to organizations by November 1, 2024. These revisions will be needed to bill as follows:
- The established rate for PRS is $101.44 per staff hour. Reimbursement for PRS is available for Medicaid fee for service and Medicaid Managed Care (MCO) claiming and for SUPR grant contract funds.
- PRS provided to patients in an MCO are reimbursed by submitting HCPCS code 2014 on the 837P claim format to the appropriate MCO.
- PRS provided to Medicaid patients not in an MCO (fee for service) must be submitted directly to SUPR through DARTS. All demographic fields must be completed, including a Recipient Identification Number (RIN) and the service should be billed using the Darts Medicaid (DM) funding code, the community intervention (CI) program number (42), the applicable site number and activity code 21.
- As the payer of last resort, PRS provided to non-Medicaid patients who qualify for grant funding (fee for service) must be submitted directly to SUPR through DARTS and can be delivered pre- and post- treatment as well during treatment. All demographic fields must be completed, including a Recipient Identification Number (RIN) and the service should be billed using the DARTS Contract (DC) funding code, the community intervention (CI) program number (42), the applicable site number and activity code 21.
Other Billing Requirements:
- For Medicaid covered patients, transportation to and from a medical service should not be billed as PRS because it is delivered and billed by a Medicaid enrolled transportation vendor (HFS Non-Emergency Medical Transportation). All other patient transportation can be billed as PRS if it is an assessed need against Medicaid or contract funds, as applicable.
- All PRS are delivered person-to-person as an individual service. Group services are not billable as PRS using Medicaid or contract funds.
Documentation:
PRS should be documented in a Recovery Plan that reflects assessed need determined by the ASAM Assessment. PRS must be signed by the staff delivering the service and indicate the activity, time date and duration. PRS must also be delivered in accordance with all other service specifications contained within the current Contractual Policy Manual (CPM) .
PRS will be monitored by SUPR monitoring staff to ensure that Medicaid requirements and any additional contract specifications are met, as they will be subject to post payment audit.
