PEER SUPPORT SERVICES

PEER SUPPORT SERVICES

1.0 Description of the Service Peer Support Services (PSS) are an evidenced-based mental health model of care that provides 

community-based recovery services directly to an adult diagnosed with a mental health or substance use disorder. PSS 

provides structured, scheduled services that promote recovery, self-determination, self-advocacy, engagement in self-care 

and wellness and enhancement of community living skills of individuals. PSS services are directly provided by Certified 

Peer Support Specialists (CPSS) who have self-identified as a person(s) in recovery from a mental health or substance use 

disorder. PSS can be provided in combination with other approved mental health or substance use services or as an 

independent service. Due to the high prevalence of individuals with co-occurring disorders (mental health, substance use or 

physical health disorders), it is a priority that integrated treatment be available to individuals to be served. PSS are based on 

the belief that individuals diagnosed with serious mental health or substance use disorders can and do recover. The focus of 

the services is on the person, rather than the identified mental health or substance use disorder and emphasizes the acquisition, 

development, and expansion of rehabilitative skills needed to move forward in recovery. The services promote skills for 

coping with and managing symptoms while utilizing natural resources and the preservation and enhancement of community 

living skills. Peer Support Services (PSS) are provided one-on-one to the individual or in a group setting. Providing one-onone support builds on the relationship of mutuality between the individual and CPSS; supports the individual in 

accomplishing self-identified goals; and may further support the individual’s engagement in treatment. Peer Support Services 

provided in a group setting allow the individual the opportunity to engage in structured services with others who share similar 

recovery challenges or interest; improve or develop recovery skills; and explore community resources to assist the individual 

in his or her recovery. PSS are based on the individual’s needs and coordinated within the context of the individual’s PersonCentered Plan. Structured services provided by PSS include: a. Peer mentoring or coaching (one-on-one) - to encourage, 

motivate, and support the individual moving forward in recovery. Assist individual with setting self-identified recovery 

goals, developing recovery action plans, and solving problems directly related to recovery, such as finding housing, 

developing natural support system, finding new uses of spare time, and improving job skills. Assist with issues that arise in

connection with collateral problems such as legal issues or co-existing physical or mental challenges. b. Recovery resource 

connecting – connecting an individual to professional and nonprofessional services and resources available in the community 

that can assist an individual in meeting recovery goals. c. Skill Building Recovery groups – structured skill development 

groups that focus on job skills, budgeting and managing credit, relapse prevention, and conflict resolution skills and support 

recovery. d. Building community – assist an individual enhancing his or her social networks that promote and help sustain 

mental health and substance use disorder recovery. Organization of recovery-oriented services that provide a sense of 

acceptance and belonging to the community, promote learning of social skills and the opportunity to practice newly learned 

skills. 

1.1 Definitions a. Recovery – a process of change through which an individual improves their health and wellness, lives a 

self-directed life and strives to reach their full potential; to live, work, learn, and participate fully in their communities. b.

Self-Determination - the right of an individual to direct his or her own services, to make decisions concerning their health 

and well-being, and to have help to make decisions from whomever they choose. c. Self-Advocacy – identifying and 

purposefully asking for what one needs. d. Health – learning to overcome, manage or more successfully live with the 

symptoms and making healthy choices that support one’s physical and emotional wellbeing. e. Community – Developing 

and building upon relationships and social networks that provide support, friendship, love and hope. 2.0 Eligibility 

Requirements 2.1 Provisions 

2.1.1 General An eligible individual shall be enrolled with the LME-MCO on or prior to the date of service, meet the criteria 

for a state-funded Benefit Plan and shall meet the criteria in Section 3.0 of this policy. 

2.1.2 Specific State funds shall cover Peer Support Services for an eligible individual who is 18 years of age and older and 

meets the criteria in Section 

3.0 of this policy. 3.0 When the Service Is Covered 

3.1 General Criteria Covered State funds shall cover the service related to this policy when medically necessary, and: a. the 

service is individualized, specific, and consistent with symptoms or confirmed diagnosis under treatment, and not in excess 

of the individual’s needs; b. the service can be safely furnished, and no equally effective and more conservative or less costly 

treatment is available statewide; and c. the service is furnished in a manner not primarily intended for the convenience of the 

individual, the individual’s caretaker, or the provider.

3.2 Specific Criteria Covered

3.2.1 Specific criteria covered by State Funds State funds shall cover Peer Support Services when ALL of the following 

criteria are met: a. The individual has a mental health or substance use diagnosis as defined by the Diagnostic and Statistical 

Manual of Mental Disorders Fifth Edition (DSM-5) or any subsequent editions of this reference material, other than a sole 

diagnosis of intellectual and developmental disability; b. The individual meets the Level of Care criteria for Locus Level 1 

or the American Society of Addiction Medicine (ASAM) Level 1 criteria; c. There is no evidence to support that alternative 

interventions would be equally or more effective based on North Carolina community practice standards; and d. The 

individual has documented identified needs, in at least ONE or more of the following areas (related to diagnosis): 1. 

Acquisition of skills needed to manage symptoms and utilize community resources; 2. Assistance needed to develop selfadvocacy skills to achieve decreased dependency on the mental health system; 3. Assistance and support needed to prepare 

for a successful work experience; 4. Peer modeling needed to take increased responsibilities for his or her own recovery; or 

5. Peer supports needed to develop or maintain daily living skills. 

3.2.2 Admission Criteria A comprehensive clinical assessment (CCA), that demonstrates medical necessity must be 

completed by a licensed professional prior to the provision of this service. If a substantially equivalent assessment is 

available, reflects the current level of functioning, and contains all the required elements as outlined in community practice 

standards, as well as, in all applicable federal and state requirements, it may be used as part of the current CCA. Relevant 

clinical information must be obtained and documented in the individual’s PersonCentered Plan (PCP). 

3.2.3 Continued Stay Criteria The individual meets criteria for continued stay if any ONE of the following applies: a. The 

desired outcome or level of functioning has not been restored, improved, or sustained over the time frame documented in the 

individual’s PCP; b. The individual continues to be at risk for relapse based on current clinical assessment, and history, or

the tenuous nature of the functional gains; or c. Continuation of service is supported by documentation of the individual’s 

progress toward goals within the individual’s PCP.

3.2.4 Transition and Discharge Criteria The individual meets the criteria for discharge if any ONE of the following applies: 

a. The individual’s level of functioning has improved with respect to the goals outlined in the PCP, inclusive of a transition 

plan to step down to a lower level of care; b. The individual has achieved positive life outcomes that support stable and 

ongoing recovery and is no longer in need of Peer Support Services; c. The individual is not making progress or is regressing, 

and all reasonable strategies and interventions have been exhausted, indicating a need for more intensive services; or d. The

individual chooses to withdraw from Peer Support Services or the legally responsible person(s) chooses to withdraw the 

individual from services. For individuals receiving state funded services who are new to the enhanced MH/DD/SAS service 

delivery system, a completed LME-MCO Consumer Admission and Discharge Form must be submitted to the LME-MCO. 

4.0 When the Service Is Not Covered 

4.1 General Criteria Not Covered State funds shall not cover the service related to this policy when: a. the individual does 

not meet the eligibility requirements listed in Section 2.0; b. the individual does not meet the criteria listed in Section 3.0; c.

the service duplicates another provider’s service; or d. the service is experimental, investigational, or part of a clinical trial. 

4.2 Specific Criteria Not Covered 

4.2.1 Specific Criteria Not Covered by State Funds State funds shall not cover the following activities of Peer Support 

Services: a. Transportation for the individual or family members; b. Habilitation activities; c. Time spent performing, 

attending or participating in recreational activities unless tied to specific planned social skill assistance; d. Clinical and 

administrative supervision of the Peer Support Specialist which is covered as an indirect cost and part of the rate; e. Covered 

services that have not been rendered; f. Childcare services or services provided as a substitute for the parent or other 

individuals responsible for providing care and supervision; g. Services provided to teach academic subjects or as a substitute 

for education personnel; h. Interventions not identified in the individual’s Person-Centered Plan; i. Services provided without 

prior authorization; j. Services provided to children, spouse, parents or siblings of the individual under treatment or others 

in the individual’s life to address problems not directly related to the individual’s needs and not listed on the Person-Centered 

Plan; and k. Payment for room and board. 

5.0 Requirements for and Limitations on Coverage 

5.1 Prior Approval State funds shall not require prior approval for Peer Support Services for the first twentyfour (24) 

unmanaged units in a state fiscal year. State funded PSS shall require prior approval for Peer Support Services beyond the 

unmanaged units limit. Refer to Subsection 

5.3 for additional limitations. A service order must be signed prior to or on the first day PSS are rendered. Refer to Subsection 

5.4 of this policy. LME-MCOs can offer less restrictive limitations on unmanaged units but cannot impose more restrictive 

limitations than the State-Funded Policy. All units beyond state-funded limitations or limitations imposed by the LME-MCO 

require prior approval. LME-MCOs that offer less restrictive limitations on unmanaged units than that of the state-funded 

policy shall provide assurance that there are mechanisms in place to prevent over-billing for services. Providers shall seek 

prior approval if they are uncertain that the individual has reached the unmanaged unit limit for the fiscal year. Providers 

shall seek prior approval if the individual is engaged in other behavioral health or substance use services. Providers shall 

collaborate with the individual’s existing provider to develop an integrated plan of care. Prior authorization is not a guarantee 

of claim payment. 5.2 Prior Approval Requirements 

5.2.1 General The provider(s) shall submit to the LME-MCO the following: a. the prior approval request (if unmanaged 

visits have been exhausted); and b. all health records and any other records that support the individual has met the specific

criteria in Subsection 3.2 of this policy. 

5.2.2 Specific Utilization management of covered services is a part of the assurance of medically necessary service provision. 

Authorization, which is an aspect of utilization management, validates approval to provide a medically necessary covered 

service to an eligible individual. 

Initial Authorization Services are based upon a finding of medical necessity, must be directly related to the individual’s 

diagnostic and clinical needs, and are expected to achieve the specific rehabilitative goals detailed in the individual’s PersonCentered Plan (PCP). Medical necessity is determined by North Carolina community practice standards, as verified by the 

LME-MCO who evaluates the request to determine if medical necessity supports intensive services. Medically necessary 

services are authorized in the most cost-effective modes, if the treatment that is made available is similarly efficacious as 

services requested by the individual’s physician, therapist, or another licensed practitioner. The medically necessary service 

must be recognized as an accepted method of treatment. To request an initial authorization, the CCA, service order for 

medical necessity, PCP, and the required LME-MCO authorization request form must be submitted to the LME-MCO. State 

funds may cover up to 270 units of service (individual and group) for 90 days for the initial authorization period, if medically 

necessary. Refer to Subsection

5.4 for Service Order requirements. Reauthorization Re-authorization requests must be submitted to the LME-MCO 10-

days prior to the end date of the individual’s active authorization. State funds may cover up to 270 units of service (individual 

and group) for 90 days for subsequent reauthorization periods, if medically necessary. Reauthorization is based on medical 

necessity documented in the PCP, the authorization request form, and supporting documentation. The duration and frequency 

at which PSS is provided must be based on medical necessity and progress made by the individual toward goals outlined in 

the PCP. Additional units may be authorized as clinically appropriate. If medical necessity dictates the need for increased 

service duration and frequency, clinical consideration must be given to interventions with a more intense clinical component.

Note: Any denial, reduction, suspension, or termination of service requires notification to the individual, legally responsible 

person or both about the individual’s appeal rights pursuant to G.S. 43B-147(a)(9) and Rules10A NCAC27I .0601-.0609. 

5.3 Additional Limitations or Requirements 

a) An individual can receive PSS from only one provider organization during an active authorization period.

b) Family members or legally responsible person(s) of the individual are not eligible to provide this service to the 

individual.

c) An individual with a sole diagnosis of Intellectual/Developmental Disabilities is not eligible for PSS funded by 

state funds. 

d) PSS must not be provided during the same authorization period when an individual is receiving Assertive 

Community Treatment Team (ACTT), Community Support Team (CST), Psychosocial Rehabilitation (PSR) or 

Respite services.

e) PSS must not be provided at the same time of day when an individual is receiving Substance Abuse Intensive 

Outpatient Program (SAIOP) or Substance Abuse Comprehensive Outpatient Treatment (SACOT), Partial 

Hospitalization, Day Activity or Individual Support services. 

f) PSS services must not be duplicative of other state funded services the individual is receiving. g. Only the time 

during which the individual receives PSS may service be billed to state funds. Service may not be billed at the same 

hours of the day when another statefunded service is being provided (e.g. SAIOP and PSS cannot be billed for the 

same block of time in a day.). 

g) Transportation of an individual is not covered as a service for this state-funded policy. Any provision of services 

provided to an individual during travel must be indicated in the PCP prior to the travel and must have corresponding 

documentation supporting intervention provided. 

Note: PSS is not a “first responder” service. As documented in the individual’s PCP Comprehensive Prevention and 

Intervention Crisis Plan, the PSS provider shall coordinate with other service providers to ensure “first responder” coverage 

and crisis response. 

5.4 Service Orders Service orders are a mechanism to demonstrate medical necessity for a service and are based upon an 

assessment of the individual’s needs. A signed service order must be completed by a physician, licensed psychologist, 

physician assistant, or nurse practitioner, per his or her scope of practice. ALL the following apply to a service order: a. 

Backdating of the service order is not allowed; b. Each service order must be signed and dated by the authorizing professional 

and must indicate the date on which the service was ordered; c. A service order must be in place prior to or on the first day

that the service is initially provided to bill state funds for the service; and d. Service orders are valid for one calendar year. 

Medical necessity must be reviewed, and service must be ordered at least annually, based on the date of the original PCP 

service order. 

5.5 Documentation Requirements The service record documents the nature and course of an individual’s progress in 

treatment. To bill state funds, providers must ensure that their documentation is consistent with the requirements contained 

in this policy. The staff member who provides the service is responsible for documenting the services billed to and 

reimbursed by state funds. The staff person who provides the service shall sign and date the written entry. The signature 

must include credentials for professionals or job title for associate professionals. A qualified professional (QP) shall 

countersign service notes written by staff who do not have QP status within 48 hours of service delivery. The PCP and a 

documented discharge plan must be discussed with the individual and documented in the service record. 

5.5.1 

Contents of a Service Note For this service, a full service note for each contact or intervention for each date of service, 

written and signed by the person who provided the service is required. More than one intervention, activity, or goal may be 

reported in one service note, if applicable. 

a) A service note must document ALL following elements: a. Individual’s name; 

b) b. Service record identification number; 

c) c. Date of the service provision; 

d) d. Name of service provided; 

e) e. Type of contact (face-to-face, phone);

f) f. Place of service;

g) g. Purpose of contact as it relates to the PCP goals;

h) h. Description of the intervention provided. Documentation of the intervention must accurately reflect treatment for 

the duration of time indicated;

i. Duration of service, start and end time of intervention; total amount of time spent performing the 

intervention; 

i) j. Assessment of the effectiveness of the intervention and the individual’s progress towards the individual’s goals; 

and 

j) k. Date and signature and credentials or job title of the staff member who provided the service.

6.0 Provider(s) Eligible to Bill for the Service To be eligible to bill for the service related to this policy, the provider(s) shall: 

a. meet LME-MCO qualifications for participation; 

b. have a current and signed Department of Health and Human Services (DHHS) Provider Administrative Participation 

Agreement; and 

c. bill only for services that are within the scope of their clinical practice, as defined by the appropriate licensing entity. 

6.1 Provider Qualifications and Occupational Licensing Entity Regulations Peer Support Services must be delivered by 

practitioners employed by organizations that: 

a) meet the provider qualification policies, procedures, and standards established by the NC Division of MH/DD/SAS; 

b) meet the requirements of 10A NCAC 27G; 

c) demonstrate that they meet these standards by being credentialed and contracted by an LME-MCO; 

d) within one calendar year of enrollment as a provider with the LME-MCO, achieve national accreditation with at 

least one of the designated accrediting agencies; and 

e) become established as a legally constituted entity capable of meeting all the requirements of the DMH/DD/SAS 

Bulletins and service implementation standards.

6.2 Provider Certifications PSS must be provided by a Peer Support Specialist certified by North Carolina’s Peer Support 

Specialist Program. 

6.2.1 Staff Requirements The Peer Support Services (PSS) program is provided by qualified providers with the capacity and 

adequate workforce to offer this service to individuals meeting a stat funded Benefit Plan. The PSS program must have the 

ability to offer this service at any time of the day, including evening times or weekends, as needed by the individual and 

specified in the individual’s PCP. The PSS program must be under the direction of a full-time Qualified Professional (QP) 

who meets the requirements according to 10A NCAC 27G .0104 (19). The PSS program must have designated qualified 

staff to provide supervision to CPSS at any time; 24 hours a day; 7 days a week. The maximum program staff ratios are as 

follows: QP-to-CPSS is 1:8; CPSS-to individual is 1:15; and group ratio for CPSS Group Facilitator-to-Individuals is 1:12. 

CPSS shall not work outside the scope of their certification or core competencies. CPSS shall only provide services to an 

individual with similar lived experiences. The following charts provide required services of the PSS Program Supervisor and 

core competencies of relationship building and peer support interaction for the CPSS (according to NC’s Certified Peer 

Support Specialist Program). 

Trained in quality supervisory skills. 

• Possess knowledge of the CPSS role and work, as well as, understand the principles and philosophy of recovery 

and the code of ethics of the NC Peer Support Specialist Certification Program. 

• Understand and support the role of the CPSS. • Understand and promote the individual’s recovery.

• Advocate for the CPSS and PSS across the organization and in the community. 

• Promote both the professional and personal growth of the CPSS within established human resource standards.

• Coordinate assessments needed for the individual. If appropriately licensed, the QP may conduct the assessments.

• Collaborate with individual(s) and CPSS to develop recovery-oriented person-centered treatment plan(s) for the 

individual that demonstrates consideration for integrated care. 

• Conduct at least one face-to-face contact with the individual within 90 days of PSS being initiated and no less that 

every 90 days thereafter to monitor the individual’s progress and 

• effectiveness of the program; and to review with the individual, the goals of their PCP and document progress. 

• Plan work assignment, monitor, review and evaluate work performance of program staff and facilitates staff 

meetings.

•

Certified Peer Support Specialist

• Provide administrative and supportive supervision to program staff individually at least once per month or more if 

needed. Provision of supervision must be based on the experience of the individual staff. 

• Collaborate with program staff to assess strengths and areas of growth and develop an individual supervision plan.

• Collaborate and foster collegial roles with program staff.

• Determine team caseload size based on the level of acuity and needs of the individual(s). 

• Facilitate or co-facilitate skill building recovery groups based on the needs or request of individuals.

• Ensure referrals for community resources requested by the individual(s) are completed. 

• Knowledge of peer support principles, values and ethics.

• Ability to share lived experience to support, encourage and enhance an individual’s treatment and recovery. 

• Possess recovery-oriented skills and knowledge to provide peer support services. 

• Ability to collaborate with the program QP to assess their own strengths and areas of growth and develop a 

supervision plan. 

• Ability to collaborate with an individual to explore and identify barriers to accessing community resources or 

treatment providers. 

• Ability to model and mentor recovery values, attitudes, beliefs, and personal actions to encourage wellness and 

resilience for individuals served and to promote a recovery environment in the community, residence, and 

workplace. 

• Ability to explore with an individual served, the importance and creation of a wellness identity through open sharing 

and challenging viewpoints. 

• Ability to promote an individual’s opportunity for personal growth by identifying teachable moments for building 

relationship skills to empower the individual and enhance personal responsibility. 

• Ability to model and share decisions-making tools to enhance an individual’s healthy decision-making process. 

• Ability to provide examples of healthy social interactions and facilitate familiarity with, and connection to, the local 

community. 

• Ability to recognize and appropriately respond to conditions that constitute an emergency to include both physical 

and behavioral health crisis utilizing the emergency response procedure of employer. 

• Ability to provide support to the individual in navigating systems (medical, social services, or legal). 

• Ability to promote self-advocacy by facilitating each individual’s learning about his or her human and legal rights 

and supporting the individual while exercising those rights to support the empowerment of the individual. 

• 6.2.2 Training Requirements To provide effective peer support services, all PSS program staff shall possess the 

knowledge and competencies of peer support principles, values and ethics and participate in additional trainings 

required to provide the service. Required trainings for PSS program staff are as follows:

6.2.2 Training Requirements To provide effective peer support services, all PSS program staff shall possess the knowledge 

and competencies of peer support principles, values and ethics and participate in additional trainings required to provide the 

service. Required trainings for PSS program staff are as follows:

Timeframe Training Required Who Total Minimum Hours Required Within 30 calendar days of hire to provide service • 3 

hours of Peer Support Services Policy components review • 1 hour of Documentation Training • All staff 4 hours Within 90 

calendar days of hire to provide service • 3 hours of Peer Support Supervisor Training • 12 hours of Person-Centered Thinking 

• 3 hours of PCP Instructional Elements with Comprehensive Prevention and Intervention Crisis Plan Training • Peer Support 

Services Program Supervisor 18 hours Annually • Continuing education • All staff 10 hours

Peer support program staff shall complete initial requirements of training identified above within identified timeframes. The 

initial training requirements may be waived by the hiring agency if the employee can produce documentation certifying that 

training was completed no more than 24-months prior to hire date. Peer support program staff shall participate in additional 

hours of peer support related training that is appropriate for the population being served. Additional training options for all 

PSS program staff include: a. Trauma Informed Care b. Wellness and Recovery Action Plan (WRAP) c. Whole Health 

Action Management (WHAM) d. Basic Mental Health and Substance Use 101 e. Mental Health First Aid f. Housing First, 

Permanent Supportive Housing, Tenancy Support Training

6.3 Expected Outcomes The expected outcomes for this service are specific to recommendations resulting from clinical 

assessments and meeting the identified goals in the individual’s PCP. Expected outcomes: 

a) increased engagement in self-directed recovery process; 

b) increased natural and social support networks; 

c) increased ability to engage in community activities; 

d) increased ability to live as independently as possible and use recovery skills to maintain a stable living arrangement; 

e) higher levels of empowerment and hopefulness in recovery; 

f) improved emotional, behavioral and physical health; g. improved quality of life; 

g) improved vocational skills;

h) decreased substance use; 

i) decreased frequency or intensity of crisis episodes; or k. decreased use of crisis services or hospitalizations.

7.0 Additional Requirements 

7.1 Compliance Provider(s) shall comply with the following in effect at the time the service is rendered: a. All applicable 

agreements, federal, state and local laws and regulations including the Health Insurance Portability and Accountability Act 

(HIPAA), 42 CFR Part 2 and record retention requirements; and b. All NC Division of MH/DD/SAS’s service definitions, 

guidelines, policies, provider manuals, implementation updates, and bulletins, DHHS, DHHS division(s) or fiscal 

contractor(s). 8.0 Policy Implementation and History Original Effective Date: August 1, 2019

8.0 Policy Implementation and History Original Effective Date: August 1, 2019 History: Date Section or Subsection 

Amended Change 8/1/19 All Sections and Attachment(s) New policy implementing Peer Support Services.

Attachment A: Claims-Related Information Provider(s) shall comply with the, NCTracks Provider Claims and Billing 

Assistance Guide, DMH/DD/SAS bulletins, fee schedules, NC Division of MH/DD/SAS’s service definitions and any other 

relevant documents for specific coverage and reimbursement for state funds: 

A. Claim Type Professional (837P transaction) Institutional (837I transaction) B. International Classification of Diseases 

and Related Health Problems, Tenth Revisions, Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS) 

Provider(s) shall report the ICD-10-CM and Procedural Coding System (PCS) to the highest level of specificity that supports 

medical necessity. Provider(s) shall use the current ICD-10 edition and any subsequent editions in effect at the time of 

service. Provider(s) shall refer to the applicable edition for code description, as it is no longer documented in the policy. C. 

Code(s) Provider(s) shall report the most specific billing code that accurately and completely describes the procedure, 

product or service provided. Provider(s) shall use the Current Procedural Terminology (CPT), Health Care Procedure Coding 

System (HCPCS), and UB-04 Data Specifications Manual (for a complete listing of valid revenue codes) and any subsequent 

editions in effect at the time of service. Provider(s) shall refer to the applicable edition for the code description, as it is no 

longer documented in the policy. If no such specific CPT or HCPCS code exists, then the provider(s) shall report the 

procedure, product or service using the appropriate unlisted procedure or service code.

HCPCS Code(s) Billing Unit H0038 1 unit = 15 minutes H0038 HQ 1 unit = 15 minutes Unlisted 

Procedure or Service CPT: The provider(s) shall refer to and comply with the Instructions for Use of the CPT Codebook, 

Unlisted Procedure or Service, and Special Report as documented in the current CPT in effect at the time of service. HCPCS: 

The provider(s) shall refer to and comply with the Instructions for Use of HCPCS National Level II codes, Unlisted Procedure 

or Service and Special Report as documented in the current HCPCS edition in effect at the time of service. 

D. Modifiers Provider(s) shall follow applicable modifier guidelines

E. Billing Units Provider(s) shall report the appropriate code(s) used which determines the billing unit(s). Units are billed in 

15-minute increments. LME-MCOs and provider agencies shall monitor utilization of service by conducting record reviews 

and internal audits of units of service billed. LME-MCOs shall assess their PSS network providers’ adherence to service 

guidelines to assure quality services for individuals served.

F. Place of Service PSS is a direct periodic service provided in a range of community settings. It may be provided in the 

individual’s place of residence, community or in an office setting. It may not be provided in the residence of PSS staff. The

intent of the service is to be community-based rather than office-based. Telephone time is supplemental rather than a 

replacement of face to face contact and is limited to (20) percent or less of total service time provided per individual per 

fiscal year. Documentation of service rendered via telephone with the individual or collateral contacts (assisting individual 

with rehabilitation goals) must be documented according to Subsection 5.