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CODES AND RATES FOR COVID-19 CRISIS EVENT FY 19-21 24-Hour Access to Care- 877-685-2415 Business Administrative Matters - 866.998.2597 Service Code Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective date End Date 99441 CR Physician Telephone Patient Service, 5-10 min, COVID- 19 Medicaid B 001 Physician per event $ 16.82 3/10/2020 TBD 99441 CR Physician Telephone Patient Service, 5-10 min, COVID- 19 Medicaid B 112 CNP per event $ 14.30 3/10/2020 TBD 99441 CR Physician Telephone Patient Service, 5-10 min, COVID- 19 Medicaid B 999 Physician Assistant per event $ 14.30 3/10/2020 TBD 99442 CR Phone E/M Phys/QHP 11-20 min, COVID-19 Medicaid B 001 Physician per event $ 33.50 3/10/2020 TBD 99442 CR Phone E/M Phys/QHP 11-20 min, COVID-19 Medicaid B 112 CNP per event $ 28.48 3/10/2020 TBD 99442 CR Phone E/M Phys/QHP 11-20 min, COVID-19 Medicaid B 999 Physician Assistant per event $ 28.48 3/10/2020 TBD 99443 CR Phone E/M 21-30 min, COVID-19 Medicaid B 001 Physician per event $ 75.00 3/10/2020 TBD 99443 CR Phone E/M 21-30 min COVID-19 COVID-19 Medicaid B 112 CNP per event $ 63.75 3/10/2020 TBD 99443 CR Phone E/M 21-30 min COVID-19 COVID-19 Medicaid B 999 Physician Assistant per event $ 63.75 3/10/2020 TBD 98966 CR Telephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19 Medicaid B 109 Licensed Doctoral Psychologist per event $ 17.41 3/10/2020 TBD 98966 CR Telephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19 Medicaid B 110 LCSW, LPC & LMFT per event $ 13.06 3/10/2020 TBD 98966 CR Telephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19 Medicaid B 111 Certified Clinical Nurse Specialist per event $ 17.41 3/10/2020 TBD 98966 CR Telephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19 Medicaid B 112 CNP per event $ 17.41 3/10/2020 TBD 98966 CR Telephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19 Medicaid B 999 Physician Assistant per event $ 17.41 3/10/2020 TBD 98966 CR Telephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19 Medicaid B 998 Provisionally and Associate Level Licensed per event $ 13.06 3/10/2020 TBD 98966 CR Telephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19 Medicaid B 001 Physician per event $ 17.41 3/10/2020 TBD
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  • CODES AND RATES FOR COVID-19 CRISIS EVENT FY 19-21

    24-Hour Access to Care- 877-685-2415 Business Administrative Matters - 866.998.2597

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    99441 CRPhysician Telephone Patient Service, 5-10 min, COVID-19

    Medicaid B 001 Physician per event $ 16.82 3/10/2020 TBD

    99441 CRPhysician Telephone Patient Service, 5-10 min, COVID-19

    Medicaid B 112 CNP per event $ 14.30 3/10/2020 TBD

    99441 CRPhysician Telephone Patient Service, 5-10 min, COVID-19

    Medicaid B 999 Physician Assistant per event $ 14.30 3/10/2020 TBD

    99442 CR Phone E/M Phys/QHP 11-20 min, COVID-19 Medicaid B 001 Physician per event $ 33.50 3/10/2020 TBD

    99442 CR Phone E/M Phys/QHP 11-20 min, COVID-19 Medicaid B 112 CNP per event $ 28.48 3/10/2020 TBD

    99442 CR Phone E/M Phys/QHP 11-20 min, COVID-19 Medicaid B 999 Physician Assistant per event $ 28.48 3/10/2020 TBD

    99443 CR Phone E/M 21-30 min, COVID-19 Medicaid B 001 Physician per event $ 75.00 3/10/2020 TBD

    99443 CR Phone E/M 21-30 min COVID-19 COVID-19 Medicaid B 112 CNP per event $ 63.75 3/10/2020 TBD

    99443 CR Phone E/M 21-30 min COVID-19 COVID-19 Medicaid B 999 Physician Assistant per event $ 63.75 3/10/2020 TBD

    98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19

    Medicaid B 109Licensed Doctoral Psychologist

    per event $ 17.41 3/10/2020 TBD

    98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19

    Medicaid B 110 LCSW, LPC & LMFT per event $ 13.06 3/10/2020 TBD

    98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19

    Medicaid B 111Certified Clinical Nurse Specialist

    per event $ 17.41 3/10/2020 TBD

    98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19

    Medicaid B 112 CNP per event $ 17.41 3/10/2020 TBD

    98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19

    Medicaid B 999 Physician Assistant per event $ 17.41 3/10/2020 TBD

    98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19

    Medicaid B 998Provisionally and Associate Level Licensed

    per event $ 13.06 3/10/2020 TBD

    98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19

    Medicaid B 001 Physician per event $ 17.41 3/10/2020 TBD

  • Page 2 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19

    Medicaid B 128 LPA per event $ 13.06 3/10/2020 TBD

    98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19

    Medicaid B 129 LCAS per event $ 13.06 3/10/2020 TBD

    98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19

    Medicaid B 109Licensed Doctoral Psychologist

    per event $ 34.82 3/10/2020 TBD

    98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19

    Medicaid B 110 LCSW, LPC & LMFT per event $ 26.12 3/10/2020 TBD

    98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19

    Medicaid B 111Certified Clinical Nurse Specialist

    per event $ 34.82 3/10/2020 TBD

    98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19

    Medicaid B 112 CNP per event $ 34.82 3/10/2020 TBD

    98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19

    Medicaid B 999 Physician Assistant per event $ 34.82 3/10/2020 TBD

    98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19

    Medicaid B 998Provisionally and Associate Level Licensed

    per event $ 26.12 3/10/2020 TBD

    98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19

    Medicaid B 001 Physician per event $ 34.82 3/10/2020 TBD

    98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19

    Medicaid B 128 LPA per event $ 26.12 3/10/2020 TBD

    98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19

    Medicaid B 129 LCAS per event $ 26.12 3/10/2020 TBD

    98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19

    Medicaid B 109Licensed Doctoral Psychologist

    per event $ 52.24 3/10/2020 TBD

    98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19

    Medicaid B 110 LCSW, LPC & LMFT per event $ 39.18 3/10/2020 TBD

    98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19

    Medicaid B 111Certified Clinical Nurse Specialist

    per event $ 52.24 3/10/2020 TBD

    98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19

    Medicaid B 112 CNP per event $ 52.24 3/10/2020 TBD

    98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19

    Medicaid B 999 Physician Assistant per event $ 52.24 3/10/2020 TBD

  • Page 3 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19

    Medicaid B 998Provisionally and Associate Level Licensed

    per event $ 39.18 3/10/2020 TBD

    98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19

    Medicaid B 001 Physician per event $ 52.24 3/10/2020 TBD

    98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19

    Medicaid B 128 LPA per event $ 39.18 3/10/2020 TBD

    98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19

    Medicaid B 129 LCAS per event $ 39.18 3/10/2020 TBD

    99421 CR OL DIG E/M SVC 5-10 MIN, COVID-19 Medicaid B 112 CNP per event $ 18.88 3/10/2020 TBD

    99421 CR OL DIG E/M SVC 5-10 MIN, COVID-19 Medicaid B 001 Physician per event $ 18.88 3/10/2020 TBD

    99421 CR OL DIG E/M SVC 5-10 MIN, COVID-19 Medicaid B 999 Physician Assistant per event $ 18.88 3/10/2020 TBD

    99422 CR OL DIG E/M SVC 11-20 MIN, COVID-19 Medicaid B 112 CNP per event $ 37.70 3/10/2020 TBD

    99422 CR OL DIG E/M SVC 11-20 MIN, COVID-19 Medicaid B 001 Physician per event $ 37.70 3/10/2020 TBD

    99422 CR OL DIG E/M SVC 11-20 MIN, COVID-19 Medicaid B 999 Physician Assistant per event $ 37.70 3/10/2020 TBD

    99423 CR OL DIG E/M SVC 21+ MIN, COVID-19 Medicaid B 112 CNP per event $ 60.92 3/10/2020 TBD

    99423 CR OL DIG E/M SVC 21+ MIN, COVID-19 Medicaid B 001 Physician per event $ 60.92 3/10/2020 TBD

    99423 CR OL DIG E/M SVC 21+ MIN, COVID-19 Medicaid B 999 Physician Assistant per event $ 60.92 3/10/2020 TBD

    99446 CR NTRPROF PH1/NTRNET/EHR 5-10, COVID-19 Medicaid B 001 Physician per event $ 22.50 3/10/2020 TBD

    99447 CR NTRPROF PH1/NTRNET/EHR 11-20, COVID-19 Medicaid B 001 Physician per event $ 45.42 3/10/2020 TBD

    99448 CR NTRPROF PH1/NTRNET/EHR 21-30, COVID-19 Medicaid B 001 Physician per event $ 67.92 3/10/2020 TBD

    99449 CR NTRPROF PH1/NTRNET/EHR 31/>, COVID-19 Medicaid B 001 Physician per event $ 90.50 3/10/2020 TBD

  • Page 4 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    H2017 CRIndividual Rehabilitation, Coordination and Support, COVID-19, DIRCS

    Medicaid Bper 15 min unit

    $ 5.50 3/31/2020 1/31/2021

    H2017 CRIndividual Rehabilitation, Coordination and Support, COVID-19, DIRCS

    Medicaid Bper 15 min unit

    $ 5.50 2/1/2021 TBD

    T2013 TF CRCommunity Living & Supports Crisis/Disaster Related, COVID-19

    Medicaid Bper 15 min unit

    $ 5.84 4/1/2020 6/30/2022

    T2013 TF HQ CRCommunity Living & Supports Group Crisis/Disaster Related, COVID-19

    Medicaid Bper 15 min unit

    $ 3.26 4/1/2020 6/30/2022

    H0020 CR Opiod Treatment Crisis/Disaster Related, COVID-19 Medicaid B per day $ 2,200.00 3/13/2020 6/30/2020

    YP760 CR Group Living Low, COVID-19 State per day $ 71.88 3/23/2020 6/30/2021

    YP770 CR Group Living Mod, COVID-19 State per day $ 75.67 3/23/2020 6/30/2021

    YP770 HG CR Group Living Mod CURES, COVID-19 State per day $ 75.67 3/23/2020 6/30/2021

    YP710 CR Supervised Living Low, COVID-19 State per day $ 37.60 3/23/2020 6/30/2021

    YP720 CR Supervised Living Mod, COVID-19 State per day $ 70.10 3/23/2020 6/30/2021

    YP720 HG CR Supervised Living Mod CURES, COVID-19 State per day $ 70.10 3/23/2020 6/30/2021

    YP780 CR Group Living High, COVID-19 State per day $ 183.96 3/23/2020 6/30/2021

    S9484 CR Facility Based Crisis, COVID-19 Stateper 15 min unit

    $ 20.71 3/23/2020 1/31/2021

    S9484 CR Facility Based Crisis, COVID-19 Stateper 15 min unit

    $ 16.73 2/1/2021 6/30/2021

    S9484 HA CR Facility Based Crisis-Child, COVID-19 Stateper 15 min unit

    $ 20.71 3/23/2020 1/31/2021

    S9484 HA CR Facility Based Crisis-Child, COVID-19 Stateper 15 min unit

    $ 16.73 2/1/2021 6/30/2021

    S9484 CR Facility Based Crisis, COVID-19 Stateper 15 min unit

    $ 30.00 7/1/2021 6/30/2022

    S9484 HA CR Facility Based Crisis-Child, COVID-19 Stateper 15 min unit

    $ 30.00 7/1/2021 6/30/2022

    T2016 U1 U5 CR CLFS Level 1, COVID-19 Medicaid B per day $ 109.20 3/23/2020 12/31/2020

    T2016 U1 U5 CR CLFS Level 1, COVID-19 Medicaid B per day $ 96.60 1/1/2021 6/30/2022

  • Page 5 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    T2016 U2 U5 CR CLFS Level 2, COVID-19 Medicaid B per day $ 140.40 3/23/2020 12/31/2020

    T2016 U2 U5 CR CLFS Level 2, COVID-19 Medicaid B per day $ 124.20 1/1/2021 6/30/2022

    T2016 U3 U5 CR CLFS Level 3, COVID-19 Medicaid B per day $ 153.40 3/23/2020 12/31/2020

    T2016 U3 U5 CR CLFS Level 3, COVID-19 Medicaid B per day $ 135.70 1/1/2021 6/30/2022

    T2016 U4 U5 CR CLFS Level 4, COVID-19 Medicaid B per day $ 166.40 3/23/2020 12/31/2020

    T2016 U4 U5 CR CLFS Level 4, COVID-19 Medicaid B per day $ 147.20 1/1/2021 6/30/2022

    T2016 U5 CR CLFS Level 5, COVID-19 Medicaid B per day $ 179.67 3/23/2020 12/31/2020

    T2016 U5 CR CLFS Level 5, COVID-19 Medicaid B per day $ 158.94 1/1/2021 6/30/2022

    S9484 CR Facility Based Crisis, COVID-19 Medicaid Bper 15 min unit

    $ 20.71 3/23/2020 1/31/2021

    S9484 CR Facility Based Crisis, COVID-19 Medicaid Bper 15 min unit

    $ 16.73 2/1/2021 6/30/2021

    S9484 HA CR Facility Based Crisis-Child, COVID-19 Medicaid Bper 15 min unit

    $ 20.71 3/23/2020 1/31/2021

    S9484 HA CR Facility Based Crisis-Child, COVID-19 Medicaid Bper 15 min unit

    $ 16.73 2/1/2021 6/30/2021

    S9484 CR Facility Based Crisis, COVID-19 Medicaid Bper 15 min unit

    $ 30.00 7/1/2021 6/30/2022

    S9484 HA CR Facility Based Crisis-Child, COVID-19 Medicaid Bper 15 min unit

    $ 30.00 7/1/2021 6/30/2022

    S5145 CR Residential Treatment Level 2, COVID-19 Medicaid B per day $ 101.87 3/23/2020 4/30/2021

    S5145 HK CR IAFT, COVID-19 Medicaid B per day $ 265.79 3/23/2020 4/30/2021

    H0019 HQ CR Residential Level 3 (1-4 bed), COVID-19 Medicaid B per day $ 302.74 3/23/2020 12/31/2020

    H0019 HQ CR Residential Level 3 (1-4 bed), COVID-19 Medicaid B per day $ 267.81 1/1/2021 4/30/2021

    H0019 UR CR Residential Level 4 (5+ bed), COVID-19 Medicaid B per day $ 410.42 3/23/2020 12/31/2020

    H0019 UR CR Residential Level 4 (5+ bed), COVID-19 Medicaid B per day $ 363.06 1/1/2021 4/30/2021

    H0019 HK CR Residential Level 4 (1-4 bed), COVID-19 Medicaid B per day $ 410.42 3/23/2020 12/31/2020

  • Page 6 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    H0019 HK CR Residential Level 4 (1-4 bed), COVID-19 Medicaid B per day $ 363.06 1/1/2021 4/30/2021

    H0019 TJ CR Residential Level 3 (5+ bed), COVID-19 Medicaid B per day $ 246.68 3/23/2020 12/31/2020

    H0019 TJ CR Residential Level 3 (5+ bed), COVID-19 Medicaid B per day $ 218.22 1/1/2021 4/30/2021

    H0019 YA CR Residential Level 3 (1-4 bed) SA Youth, COVID-19 Medicaid B per day $ 435.50 3/23/2020 12/31/2020

    H0019 YA CR Residential Level 3 (1-4 bed) SA Youth, COVID-19 Medicaid B per day $ 385.25 1/1/2021 4/30/2021

    T2014 CR Res Support Level 2, COVID-19Medicaid Innovations

    per day $ 176.06 3/23/2020 12/31/2020

    T2014 CR Res Support Level 2, COVID-19Medicaid Innovations

    per day $ 155.74 1/1/2021 6/30/2022

    T2014 CG CR Res S Lev 2 AF, COVID-19Medicaid Innovations

    per day $ 176.06 3/23/2020 12/31/2020

    T2014 CG CR Res S Lev 2 AF, COVID-19Medicaid Innovations

    per day $ 155.74 1/1/2021 6/30/2022

    T2020 CR Res Support Level 3, COVID-19Medicaid Innovations

    per day $ 202.09 3/23/2020 12/31/2020

    T2020 CR Res Support Level 3, COVID-19Medicaid Innovations

    per day $ 178.77 1/1/2021 6/30/2022

    T2020 CG CR Res Support Level 3 AFL, COVID-19Medicaid Innovations

    per day $ 202.09 3/23/2020 12/30/2020

    T2020 CG CR Res Support Level 3 AFL, COVID-19Medicaid Innovations

    per day $ 178.77 1/1/2021 6/30/2022

    T2016 HI CR Residential Supports, COVID-19Medicaid Innovations

    per day $ 278.30 3/23/2020 12/31/2020

    T2016 HI CR Residential Supports, COVID-19Medicaid Innovations

    per day $ 246.19 1/1/2021 6/30/2022

    T2016 HI CG CR Res Supports Level 5 AFL, COVID-19Medicaid Innovations

    per day $ 285.16 3/23/2020 12/31/2020

    T2016 HI CG CR Res Supports Level 5 AFL, COVID-19Medicaid Innovations

    per day $ 252.25 1/1/2021 6/30/2022

    T2033 CR Supported Living, COVID-19Medicaid Innovations

    per day $ 198.21 3/23/2020 12/31/2020

    T2033 CR Supported Living, COVID-19Medicaid Innovations

    per day $ 175.34 1/1/2021 6/30/2022

    T2033 U1 CR Supported Living, COVID-19Medicaid Innovations

    per 15 min unit

    $ 6.12 3/23/2020 12/31/2020

    T2033 U1 CR Supported Living, COVID-19Medicaid Innovations

    per 15 min unit

    $ 5.41 1/1/2021 6/30/2022

  • Page 7 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    T2033 TF CR Supported Living, COVID-19Medicaid Innovations

    per day $ 279.72 3/23/2020 12/31/2020

    T2033 TF CR Supported Living, COVID-19Medicaid Innovations

    per day $ 247.44 1/1/2021 6/30/2022

    T2033 U2 CR Supported Living, COVID-19Medicaid Innovations

    per 15 min unit

    $ 6.12 3/10/2020 12/31/2020

    T2033 U2 CR Supported Living, COVID-19Medicaid Innovations

    per 15 min unit

    $ 5.41 1/1/2021 6/30/2022

    T2033 HI CR Supported Living, COVID-19Medicaid Innovations

    per day $ 239.32 3/23/2020 12/31/2020

    T2033 HI CR Supported Living, COVID-19Medicaid Innovations

    per day $ 211.70 1/1/2021 6/30/2022

    H2016 CR Res Supports Level 1, COVID-19Medicaid Innovations

    per day $ 135.17 3/23/2020 12/31/2020

    H2016 CR Res Supports Level 1, COVID-19Medicaid Innovations

    per day $ 119.57 1/1/2021 6/30/2022

    H2016 CG CR Res Supports Level 1 AFL, COVID-19Medicaid Innovations

    per day $ 135.17 3/23/2020 12/31/2020

    H2016 CG CR Res Supports Level 1 AFL, COVID-19Medicaid Innovations

    per day $ 119.57 1/1/2021 6/30/2022

    H2016 HI CR Res Supports Level 4, COVID-19Medicaid Innovations

    per day $ 228.10 3/23/2020 12/31/2020

    H2016 HI CR Res Supports Level 4, COVID-19Medicaid Innovations

    per day $ 201.78 1/1/2021 6/30/2022

    H2016 HI CG CR Res Supports Level 4 AFL, COVID-19Medicaid Innovations

    per day $ 228.10 3/23/2020 12/31/2020

    H2016 HI CG CR Res Supports Level 4 AFL, COVID-19Medicaid Innovations

    per day $ 201.78 1/1/2021 6/30/2022

    T2013 TF CR Community Living Supports (CLS), COVID-19Medicaid Innovations

    per 15 min unit

    $ 5.84 4/1/2020 6/30/2022

    T2013 TF HQ CR Community Living Supports GROUP (CLS), COVID-19Medicaid Innovations

    per 15 min unit

    $ 3.26 4/1/2020 6/30/2022

    T2013 TF U4 CR B3- Community Living Supports (CLS), COVID-19 Medicaid B3per 15 min unit

    $ 5.84 4/1/2020 6/30/2022

    T2013 TF HQ U4 CRB3- Community Living Supports GROUP (CLS), COVID-19

    Medicaid B3per 15 min unit

    $ 3.26 4/1/2020 6/30/2022

    T2014 CG U4 CR B3- Res Support Level 2 AFL, COVID-19 Medicaid B3 per day $ 176.06 3/23/2020 12/31/2020

    T2014 CG U4 CR B3- Res Support Level 2 AFL, COVID-19 Medicaid B3 per day $ 155.74 1/1/2021 6/30/2022

    T2014 U4 CR B3- Res S L 2, COVID-19 Medicaid B3 per day $ 176.06 3/23/2020 12/31/2020

  • Page 8 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    T2014 U4 CR B3- Res S L 2, COVID-19 Medicaid B3 per day $ 155.74 1/1/2021 6/30/2022

    T2020 U4 CR B3- Res Support Level 3, COVID-19 Medicaid B3 per day $ 202.09 3/23/2020 12/31/2020

    T2020 U4 CR B3- Res Support Level 3, COVID-19 Medicaid B3 per day $ 178.77 1/1/2021 6/30/2022

    T2020 CG U4 CR B3- Res Support Level 3 AFL, COVID-19 Medicaid B3 per day $ 202.09 3/23/2020 12/31/2020

    T2020 CG U4 CR B3- Res Support Level 3 AFL, COVID-19 Medicaid B3 per day $ 178.77 1/1/2021 6/30/2022

    H2016 HI U4 CR B3- Res Supports Level 4, COVID-19 Medicaid B3 per day $ 228.10 3/23/2020 12/31/2020

    H2016 HI U4 CR B3- Res Supports Level 4, COVID-19 Medicaid B3 per day $ 201.78 1/1/2021 6/30/2022

    H2016 HI CG U4 CR B3- Res Supports Level 4 AFL, COVID-19 Medicaid B3 per day $ 228.10 3/23/2020 12/31/2020

    H2016 HI CG U4 CR B3- Res Supports Level 4 AFL, COVID-19 Medicaid B3 per day $ 201.78 1/1/2021 6/30/2022

    H2016 U4 CR B3- Res Supports Level 1, COVID-19 Medicaid B3 per day $ 135.17 3/23/2020 12/31/2020

    H2016 U4 CR B3- Res Supports Level 1, COVID-19 Medicaid B3 per day $ 119.58 1/1/2021 6/30/2022

    S5135 U5 GTHome Monitoring through Virtual Supervision Systems, COVID-19

    Medicaid Bper 15 min unit

    $ 6.00 4/3/2020 6/30/2022

    YA400 GT CRHome Monitoring through Virtual Supervision Systems, COVID-19

    Stateper 15 min unit

    $ 6.00 4/3/2020 6/30/2021

    YA341 CR Assertive Engagement, COVID-19 Stateper 15 min unit

    $ 15.00 3/10/2020 6/30/2021

    T2033 U1 XU CRSupported Living- Periodic, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per 15 min unit

    $ 4.71 3/13/2020 TBD

    T2033 HI XU CRSupported Living Level II, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per day $ 184.09 3/13/2020 TBD

    T2033 TF XU CRSupported Living Level III, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per day $ 215.17 3/13/2020 TBD

    T2033 XU CRSupported Living Level I, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per day $ 152.47 3/13/2020 TBD

    T2027 XU CRDays Supports – Developmental Day, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per 15 min unit

    $ 25.52 3/13/2020 TBD

  • Page 9 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    T2021 HQ XU CR Day Supports - Group, COVID-19 (Retainer Payments)Medicaid Innovations

    per hour $ 15.28 3/13/2020 TBD

    T2021 XU CRDay Supports - Individual, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per hour $ 25.72 3/13/2020 TBD

    T2020 XU CRResidential Supports Level 3, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per day $ 155.45 3/13/2020 TBD

    T2020 CG XU CRResidential Supports Level 3, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per day $ 155.45 3/13/2020 TBD

    T2014 XU CR Residential Supports Level 2, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per day $ 135.43 3/13/2020 TBD

    T2014 CG XU CRResidential Supports Level 2, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per day $ 135.43 3/13/2020 TBD

    H2016 HI XU CRResidential Supports Level 4, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per day $ 175.46 3/13/2020 TBD

    H2016 XU CRResidential Supports Level 1, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per day $ 103.98 3/13/2020 TBD

    H2016 CG XU CRResidential Supports Level 1, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per day $ 103.98 3/13/2020 TBD

    H2016 HI CG XU CRResidential Supports Level 4, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per day $ 175.46 3/13/2020 TBD

    T2013 TF XU CR CLS Individual, COVID-19 (Retainer Payments)Medicaid Innovations

    per 15 min unit

    $ 5.56 3/13/2020 TBD

    T2013 TF HQ XU CR CLS Group, COVID-19 (Retainer Payments)Medicaid Innovations

    per 15 min unit

    $ 3.10 3/13/2020 TBD

    H2025 XU CRSupported Employment. COVID-19 (Retainer Payments)

    Medicaid Innovations

    per 15 min unit

    $ 7.75 3/13/2020 TBD

    H2025 TS XU CRSE Long Term Follow Along, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per 15 min unit

    $ 7.75 3/13/2020 TBD

    H2025 TS CR SE Long Term Follow Up, COVId-19Medicaid

    Innovationsper 15 min

    unit $ 8.91 3/13/2020 6/30/2020

    H2025 TS CR SE Long Term Follow Up, COVId-19Medicaid

    Innovationsper 15 min

    unit $ 9.30 7/1/2020 1/31/2021

    H2025 TS CR SE Long Term Follow Up, COVId-19Medicaid

    Innovationsper 15 min

    unit $ 8.14 2/1/2021 6/30/2022

  • Page 10 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    H2015 HQ XU CRCommunity Networking Group, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per 15 min unit

    $ 9.30 3/13/2020 TBD

    H2015 XU CRCommunity Networking – Individual, COVID-19 (Retainer Payments)

    Medicaid Innovations

    per 15 min unit

    $ 5.61 3/13/2020 TBD

    *911 Psychiatric Residential Treatment Facility (PRTF) Medicaid B per diem *Varies 4/20/2020 TBD

    YP831 CR Behavioral Health Counseling, COVID-19 State per event $ 23.60 6/1/2020 6/30/2021

    YP832 CRBEHAVIORAL HEALTH COUNSELING GROUP, COVID-19

    State per event $ 8.70 6/1/2020 6/30/2021

    YP834 CRBehavioral Health Counseling - Family Therapy without Client, COVID-19

    State per event $ 23.60 6/1/2020 6/30/2021

    YP835 CR Alcohol and/or Drug Group Counseling, COVID-19 State per event $ 6.10 6/1/2020 6/30/2021

    Q3014 CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 112 CNP per day $ 25.00 6/1/2020 1/31/2021

    Q3014 CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 112 CNP per day $ 21.87 2/1/2021 6/30/2021

    Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 109Licensed Doctoral Psychologist

    per day $ 25.50 6/1/2020 1/31/2021

    Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 110 LCSW, LPC & LMFT per day $ 19.06 6/1/2020 1/31/2021

    Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 999 Physician Assistant per day $ 25.50 6/1/2020 1/31/2021

    Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 1 Physician per day $ 28.06 6/1/2020 1/31/2021

    Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 109Licensed Doctoral Psychologist

    per day $ 22.31 2/1/2021 6/30/2021

    Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 110 LCSW, LPC & LMFT per day $ 16.67 2/1/2021 6/30/2021

    Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 999 Physician Assistant per day $ 22.31 2/1/2021 6/30/2021

    Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 1 Physician per day $ 24.55 2/1/2021 6/30/2021

    H0031 CR Mental Health Assessment, COVID-19 State per event $ 14.06 6/1/2020 1/31/2021

    H0031 CR Mental Health Assessment, COVID-19 Medicaid per event $ 14.06 6/1/2020 1/31/2021

  • Page 11 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    H0031 CR Mental Health Assessment, COVID-19 State per event $ 12.31 2/1/2021 6/30/2021

    H0031 CR Mental Health Assessment, COVID-19 Medicaid per event $ 12.31 2/1/2021 6/30/2021

    99409 CRoutpatient treatment screening and eval by provisionally licensed staff, COVID-19

    Medicaid 1 Physician per event $ 72.49 6/1/2020 7/31/2020

    99409 CRoutpatient treatment screening and eval by provisionally licensed staff, COVID-19

    Medicaid 110 LCSW, LPC & LMFT per event $ 72.49 6/1/2020 7/31/2020

    99409 CRoutpatient treatment screening and eval by provisionally licensed staff, COVID-19

    Medicaid 999 Physician Assistant per event $ 72.49 6/1/2020 7/31/2020

    99408 CRoutpatient treatment screening and eval by provisionally licensed staff Seperate Structure, COVID-19

    Medicaid 1 Physician per event $ 36.88 6/1/2020 7/31/2020

    99408 CRoutpatient treatment screening and eval by provisionally licensed staff Seperate Structure, COVID-19

    Medicaid 110 LCSW, LPC & LMFT per event $ 36.88 6/1/2020 7/31/2020

    99408 CRoutpatient treatment screening and eval by provisionally licensed staff Seperate Structure, COVID-19

    Medicaid 999 Physician Assistant per event $ 36.88 6/1/2020 7/31/2020

    99407 CREP Smoking and tobacco use cessation counsel service provided under Medicaid EPSDT, COVID-19

    Medicaid per event $ 26.83 6/1/2020 7/31/2020

    99406 CRsmoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes, COVID-19

    Medicaid 1 Physician per event $ 14.32 6/1/2020 7/31/2020

    99406 CRsmoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes, COVID-19

    Medicaid 112 CNP per event $ 14.32 6/1/2020 7/31/2020

    99406 CRsmoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes, COVID-19

    Medicaid 999 Physician Assistant per event $ 14.32 6/1/2020 7/31/2020

    99357 CRprolonged physician service in inpatient setting, requiring, COVID-19

    Medicaid 1 Physicianper time limit

    $ 102.65 6/1/2020 7/31/2020

    99357 CRprolonged physician service in inpatient setting, requiring, COVID-19

    Medicaid 112 CNPper time limit

    $ 79.32 6/1/2020 7/31/2020

    99357 CRprolonged physician service in inpatient setting, requiring, COVID-19

    Medicaid 999 Physician Assistantper time limit

    $ 93.31 6/1/2020 7/31/2020

    99356 CRprolonged physician service in inpatient setting, requiring, COVID-19

    Medicaid 1 Physicianper time limit

    $ 101.94 6/1/2020 7/31/2020

  • Page 12 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    99356 CRprolonged physician service in inpatient setting, requiring, COVID-19

    Medicaid 112 CNPper time limit

    $ 78.78 6/1/2020 7/31/2020

    99356 CRprolonged physician service in inpatient setting, requiring, COVID-19

    Medicaid 999 Physician Assistantper time limit

    $ 92.68 6/1/2020 7/31/2020

    99355 CRprolonged physician service in office or outpatient setting, COVID-19

    Medicaid 112 CNPper time limit

    $ 85.39 6/1/2020 7/31/2020

    99355 CRprolonged physician service in office or outpatient setting, COVID-19

    Medicaid 1 Physicianper time limit

    $ 110.51 6/1/2020 7/31/2020

    99354 CRprolonged physician service in office or outpatient setting, COVID-19

    Medicaid 112 CNPper time limit

    $ 86.26 6/1/2020 7/31/2020

    99354 CRprolonged physician service in office or outpatient setting, COVID-19

    Medicaid 1 Physicianper time limit

    $ 111.64 6/1/2020 7/31/2020

    99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19

    Medicaid 112 CNPper time limit

    $ 191.80 6/1/2020 1/31/2021

    99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19

    Medicaid 999 Physician Assistantper time limit

    $ 225.64 6/1/2020 1/31/2021

    99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19

    Medicaid 1 Physicianper time limit

    $ 248.20 6/1/2020 1/31/2021

    99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19

    State 112 CNPper time limit

    $ 191.80 6/1/2020 1/31/2021

    99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19

    State 999 Physician Assistantper time limit

    $ 225.64 6/1/2020 1/31/2021

    99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19

    State 1 Physicianper time limit

    $ 248.20 6/1/2020 1/31/2021

    99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19

    Medicaid 112 CNPper time limit

    $ 167.82 2/1/2021 6/30/2022

    99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19

    Medicaid 999 Physician Assistantper time limit

    $ 197.43 2/1/2021 6/30/2022

    99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19

    Medicaid 1 Physicianper time limit

    $ 217.17 2/1/2021 6/30/2022

    99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19

    State 112 CNPper time limit

    $ 167.82 2/1/2021 6/30/2022

    99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19

    State 999 Physician Assistantper time limit

    $ 197.43 2/1/2021 6/30/2022

  • Page 13 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19

    State 1 Physicianper time limit

    $ 217.17 2/1/2021 6/30/2022

    99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19

    Medicaid 112 CNPper time limit

    $ 156.05 6/1/2020 1/31/2021

    99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19

    Medicaid 999 Physician Assistantper time limit

    $ 183.59 6/1/2020 1/31/2021

    99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19

    Medicaid 1 Physicianper time limit

    $ 201.95 6/1/2020 1/31/2021

    99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19

    State 112 CNPper time limit

    $ 156.05 6/1/2020 1/31/2021

    99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19

    State 999 Physician Assistantper time limit

    $ 183.59 6/1/2020 1/31/2021

    99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19

    State 1 Physicianper time limit

    $ 201.95 6/1/2020 1/31/2021

    99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19

    Medicaid 112 CNPper time limit

    $ 136.54 2/1/2021 6/30/2022

    99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19

    Medicaid 999 Physician Assistantper time limit

    $ 160.64 2/1/2021 6/30/2022

    99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19

    Medicaid 1 Physicianper time limit

    $ 176.70 2/1/2021 6/30/2022

    99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19

    State 112 CNPper time limit

    $ 136.54 2/1/2021 6/30/2022

    99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19

    State 999 Physician Assistantper time limit

    $ 160.64 2/1/2021 6/30/2022

    99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19

    State 1 Physicianper time limit

    $ 176.70 2/1/2021 6/30/2022

    99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19

    Medicaid 1 Physicianper time limit

    $ 135.96 6/1/2020 1/31/2021

    99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19

    Medicaid 112 CNPper time limit

    $ 105.06 6/1/2020 1/31/2021

    99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19

    Medicaid 999 Physician Assistantper time limit

    $ 123.60 6/1/2020 1/31/2021

    99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19

    State 1 Physicianper time limit

    $ 135.96 6/1/2020 1/31/2021

  • Page 14 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19

    State 112 CNPper time limit

    $ 105.06 6/1/2020 1/31/2021

    99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19

    State 999 Physician Assistantper time limit

    $ 123.60 6/1/2020 1/31/2021

    99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19

    Medicaid 1 Physicianper time limit

    $ 118.97 2/1/2021 6/30/2021

    99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19

    Medicaid 112 CNPper time limit

    $ 91.93 2/1/2021 6/30/2021

    99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19

    Medicaid 999 Physician Assistantper time limit

    $ 108.15 2/1/2021 6/30/2022

    99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19

    State 1 Physicianper time limit

    $ 118.97 2/1/2021 6/30/2021

    99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19

    State 112 CNPper time limit

    $ 91.93 2/1/2021 6/30/2021

    99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19

    State 999 Physician Assistantper time limit

    $ 108.15 2/1/2021 6/30/2021

    99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19

    Medicaid 1 Physicianper time limit

    $ 98.87 6/1/2020 1/31/2021

    99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19

    Medicaid 112 CNPper time limit

    $ 76.40 6/1/2020 1/31/2021

    99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19

    Medicaid 999 Physician Assistantper time limit

    $ 89.88 6/1/2020 1/31/2021

    99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19

    State 1 Physicianper time limit

    $ 98.87 6/1/2020 1/31/2021

    99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19

    State 112 CNPper time limit

    $ 76.40 6/1/2020 1/31/2021

    99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19

    State 999 Physician Assistantper time limit

    $ 89.88 6/1/2020 1/31/2021

    99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19

    Medicaid 1 Physicianper time limit

    $ 86.51 2/1/2021 6/30/2022

    99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19

    Medicaid 112 CNPper time limit

    $ 66.85 2/1/2021 6/30/2022

    99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19

    Medicaid 999 Physician Assistantper time limit

    $ 78.65 2/1/2021 6/30/2022

  • Page 15 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19

    State 1 Physicianper time limit

    $ 86.51 2/1/2021 6/30/2021

    99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19

    State 112 CNPper time limit

    $ 66.85 2/1/2021 6/30/2021

    99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19

    State 999 Physician Assistantper time limit

    $ 78.65 2/1/2021 6/30/2021

    99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19

    Medicaid 1 Physicianper time limit

    $ 52.78 6/1/2020 1/31/2021

    99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19

    Medicaid 112 CNPper time limit

    $ 40.78 6/1/2020 1/31/2021

    99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19

    Medicaid 999 Physician Assistantper time limit

    $ 47.98 6/1/2020 1/31/2021

    99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19

    State 1 Physicianper time limit

    $ 52.78 6/1/2020 1/31/2021

    99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19

    State 112 CNPper time limit

    $ 40.78 6/1/2020 1/31/2021

    99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19

    State 999 Physician Assistantper time limit

    $ 47.98 6/1/2020 1/31/2021

    99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19

    Medicaid 1 Physicianper time limit

    $ 46.18 2/1/2021 6/30/2022

    99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19

    Medicaid 112 CNPper time limit

    $ 35.68 2/1/2021 6/30/2022

    99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19

    Medicaid 999 Physician Assistantper time limit

    $ 41.98 2/1/2021 6/30/2022

    99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19

    State 1 Physicianper time limit

    $ 46.18 2/1/2021 6/30/2021

    99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19

    State 112 CNPper time limit

    $ 35.68 2/1/2021 6/30/2021

    99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19

    State 999 Physician Assistantper time limit

    $ 41.98 2/1/2021 6/30/2021

    99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19

    Medicaid 1 Physician per day $ 81.66 6/1/2020 1/31/2021

  • Page 16 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19

    Medicaid 112 CNP per day $ 63.10 6/1/2020 1/31/2021

    99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19

    Medicaid 999 Physician Assistant per day $ 74.23 6/1/2020 1/31/2021

    99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19

    State 1 Physician per day $ 81.66 6/1/2020 1/31/2021

    99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19

    State 112 CNP per day $ 63.10 6/1/2020 1/31/2021

    99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19

    State 999 Physician Assistant per day $ 74.23 6/1/2020 1/31/2021

    99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19

    Medicaid 1 Physician per day $ 71.45 2/1/2021 6/30/2022

    99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19

    Medicaid 112 CNP per day $ 55.21 2/1/2021 6/30/2022

    99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19

    Medicaid 999 Physician Assistant per day $ 64.95 2/1/2021 6/30/2022

    99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19

    State 1 Physician per day $ 71.45 2/1/2021 6/30/2021

    99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19

    State 112 CNP per day $ 55.21 2/1/2021 6/30/2021

    99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19

    State 999 Physician Assistant per day $ 64.95 2/1/2021 6/30/2021

    99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19

    Medicaid 1 Physician per day $ 54.61 6/1/2020 1/31/2021

    99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19

    Medicaid 112 CNP per day $ 42.19 6/1/2020 1/31/2021

    99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19

    Medicaid 999 Physician Assistant per day $ 49.64 6/1/2020 1/31/2021

  • Page 17 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19

    State 1 Physician per day $ 54.61 6/1/2020 1/31/2021

    99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19

    State 112 CNP per day $ 42.19 6/1/2020 1/31/2021

    99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19

    State 999 Physician Assistant per day $ 49.64 6/1/2020 1/31/2021

    99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19

    Medicaid 1 Physician per day $ 47.79 2/1/2021 6/30/2022

    99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19

    Medicaid 112 CNP per day $ 36.92 2/1/2021 6/30/2022

    99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19

    Medicaid 999 Physician Assistant per day $ 43.44 2/1/2021 6/30/2022

    99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19

    State 1 Physician per day $ 47.79 2/1/2021 6/30/2021

    99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19

    State 112 CNP per day $ 36.92 2/1/2021 6/30/2021

    99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19

    State 999 Physician Assistant per day $ 43.44 2/1/2021 6/30/2021

    99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19

    Medicaid 1 Physician per day $ 30.74 6/1/2020 1/31/2021

    99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19

    Medicaid 112 CNP per day $ 23.76 6/1/2020 1/31/2021

    99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19

    Medicaid 999 Physician Assistant per day $ 27.95 6/1/2020 1/31/2021

    99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19

    State 1 Physician per day $ 30.74 6/1/2020 1/31/2021

    99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19

    State 112 CNP per day $ 23.76 6/1/2020 1/31/2021

    99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19

    State 999 Physician Assistant per day $ 27.95 6/1/2020 1/31/2021

  • Page 18 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19

    Medicaid 1 Physician per day $ 26.90 2/1/2021 6/30/2022

    99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19

    Medicaid 112 CNP per day $ 20.79 2/1/2021 6/30/2022

    99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19

    Medicaid 999 Physician Assistant per day $ 24.45 2/1/2021 6/30/2022

    99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19

    State 1 Physician per day $ 26.90 2/1/2021 6/30/2021

    99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19

    State 112 CNP per day $ 20.79 2/1/2021 6/30/2021

    99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19

    State 999 Physician Assistant per day $ 24.45 2/1/2021 6/30/2021

    99220 CRinitial observation care, per day, high complexity, COVID-19

    Medicaid 1 Physician per day $ 177.31 6/1/2020 7/31/2020

    99220 CRinitial observation care, per day, high complexity, COVID-19

    Medicaid 112 CNP per day $ 137.02 6/1/2020 7/31/2020

    99219 CRinitial observation care, per day, moderate complexity, COVID-19

    Medicaid 1 Physician per day $ 126.43 6/1/2020 7/31/2020

    99219 CRinitial observation care, per day, moderate complexity, COVID-19

    Medicaid 112 CNP per day $ 97.69 6/1/2020 7/31/2020

    99219 CRinitial observation care, per day, moderate complexity, COVID-19

    Medicaid 999 Physician Assistant per day $ 114.94 6/1/2020 7/31/2020

    99218 CRinitial observation care, per day, low complexity, COVID-19

    Medicaid 1 Physician per day $ 76.34 6/1/2020 7/31/2020

    99218 CRinitial observation care, per day, low complexity, COVID-19

    Medicaid 112 CNP per day $ 58.99 6/1/2020 7/31/2020

    99217 CRobservation care discharge day management, COVID-19

    Medicaid 1 Physician per event $ 80.94 6/1/2020 7/31/2020

    99217 CRobservation care discharge day management, COVID-19

    Medicaid 112 CNP per event $ 62.54 6/1/2020 7/31/2020

    99217 CRobservation care discharge day management, COVID-19

    Medicaid 999 Physician Assistant per event $ 20.45 6/1/2020 7/31/2020

    99215 CRov estab pt, severe phys time approx 40 min, COVID-19

    Medicaid 1 Physicianper time limit

    $ 150.48 6/1/2020 1/31/2021

  • Page 19 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    99215 CRov estab pt, severe phys time approx 40 min, COVID-19

    Medicaid 112 CNPper time limit

    $ 116.28 6/1/2020 1/31/2021

    99215 CRov estab pt, severe phys time approx 40 min, COVID-19

    Medicaid 999 Physician Assistantper time limit

    $ 136.80 6/1/2020 1/31/2021

    99215 CRov estab pt, severe phys time approx 40 min, COVID-19

    State 1 Physicianper time limit

    $ 150.48 6/1/2020 1/31/2021

    99215 CRov estab pt, severe phys time approx 40 min, COVID-19

    State 112 CNPper time limit

    $ 116.28 6/1/2020 1/31/2021

    99215 CRov estab pt, severe phys time approx 40 min, COVID-19

    State 999 Physician Assistantper time limit

    $ 136.80 6/1/2020 1/31/2021

    99215 CRov estab pt, severe phys time approx 40 min, COVID-19

    Medicaid 1 Physicianper time limit

    $ 131.67 2/1/2021 6/30/2022

    99215 CRov estab pt, severe phys time approx 40 min, COVID-19

    Medicaid 112 CNPper time limit

    $ 101.75 2/1/2021 6/30/2022

    99215 CRov estab pt, severe phys time approx 40 min, COVID-19

    Medicaid 999 Physician Assistantper time limit

    $ 119.70 2/1/2021 6/30/2022

    99215 CRov estab pt, severe phys time approx 40 min, COVID-19

    State 1 Physicianper time limit

    $ 131.67 2/1/2021 6/30/2021

    99215 CRov estab pt, severe phys time approx 40 min, COVID-19

    State 112 CNPper time limit

    $ 101.75 2/1/2021 6/30/2021

    99215 CRov estab pt, severe phys time approx 40 min, COVID-19

    State 999 Physician Assistantper time limit

    $ 119.70 2/1/2021 6/30/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 1 Physicianper time limit

    $ 5.23 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 109Licensed Doctoral Psychologist

    per time limit

    $ 4.75 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 110 LCSW, LPC & LMFTper time limit

    $ 3.56 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 111Certified Clinical Nurse Specialist

    per time limit

    $ 4.04 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 112 CNPper time limit

    $ 4.04 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 128 LPAper time limit

    $ 3.56 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 129 LCASper time limit

    $ 3.56 6/1/2020 1/31/2021

  • Page 20 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    90785 CR Interactive Complexity Add-on, COVID-19 State 999 Physician Assistantper time limit

    $ 3.42 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 998Provisionally and Associate Level Licensed

    per time limit

    $ 3.56 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 1 Physicianper time limit

    $ 5.23 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 109Licensed Doctoral Psychologist

    per time limit

    $ 4.75 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit

    $ 3.56 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 111Certified Clinical Nurse Specialist

    per time limit

    $ 4.04 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 112 CNPper time limit

    $ 4.04 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 128 LPAper time limit

    $ 3.56 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 129 LCASper time limit

    $ 3.56 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 3.42 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 998Provisionally and Associate Level Licensed

    per time limit

    $ 3.56 6/1/2020 1/31/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 1 Physicianper time limit

    $ 4.58 2/1/2021 6/30/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 109Licensed Doctoral Psychologist

    per time limit

    $ 4.16 2/1/2021 6/30/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 110 LCSW, LPC & LMFTper time limit

    $ 3.12 2/1/2021 6/30/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 111Certified Clinical Nurse Specialist

    per time limit

    $ 3.54 2/1/2021 6/30/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 112 CNPper time limit

    $ 3.54 2/1/2021 6/30/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 128 LPAper time limit

    $ 3.12 2/1/2021 6/30/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 129 LCASper time limit

    $ 3.12 2/1/2021 6/30/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 999 Physician Assistantper time limit

    $ 2.99 2/1/2021 6/30/2021

    90785 CR Interactive Complexity Add-on, COVID-19 State 998Provisionally and Associate Level Licensed

    per time limit

    $ 3.12 2/1/2021 6/30/2021

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 1 Physicianper time limit

    $ 4.58 2/1/2021 6/30/2022

  • Page 21 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 109Licensed Doctoral Psychologist

    per time limit

    $ 4.16 2/1/2021 6/30/2022

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit

    $ 3.12 2/1/2021 6/30/2022

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 111Certified Clinical Nurse Specialist

    per time limit

    $ 3.54 2/1/2021 6/30/2022

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 112 CNPper time limit

    $ 3.54 2/1/2021 6/30/2022

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 128 LPAper time limit

    $ 3.12 2/1/2021 6/30/2022

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 129 LCASper time limit

    $ 3.12 2/1/2021 6/30/2022

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 2.99 2/1/2021 6/30/2022

    90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 998Provisionally and Associate Level Licensed

    per time limit

    $ 3.12 2/1/2021 6/30/2022

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 1 Physician per event $ 165.52 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 109Licensed Doctoral Psychologist

    per event $ 150.47 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 110 LCSW, LPC & LMFT per event $ 112.85 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 111Certified Clinical Nurse Specialist

    per event $ 127.90 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 112 CNP per event $ 127.90 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 128 LPA per event $ 112.85 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 129 LCAS per event $ 112.85 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 999 Physician Assistant per event $ 108.47 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 998Provisionally and Associate Level Licensed

    per event $ 112.85 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 1 Physician per event $ 165.52 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 109Licensed Doctoral Psychologist

    per event $ 150.47 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 110 LCSW, LPC & LMFT per event $ 112.85 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 111Certified Clinical Nurse Specialist

    per event $ 127.90 6/1/2020 1/31/2021

  • Page 22 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 112 CNP per event $ 127.90 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 128 LPA per event $ 112.85 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 129 LCAS per event $ 112.85 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 999 Physician Assistant per event $ 108.47 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 998Provisionally and Associate Level Licensed

    per event $ 112.85 6/1/2020 1/31/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 1 Physician per event $ 144.83 2/1/2021 6/30/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 109Licensed Doctoral Psychologist

    per event $ 131.66 2/1/2021 6/30/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 110 LCSW, LPC & LMFT per event $ 98.74 2/1/2021 6/30/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 111Certified Clinical Nurse Specialist

    per event $ 111.91 2/1/2021 6/30/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 112 CNP per event $ 111.91 2/1/2021 6/30/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 128 LPA per event $ 98.74 2/1/2021 6/30/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 129 LCAS per event $ 98.74 2/1/2021 6/30/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 999 Physician Assistant per event $ 94.91 2/1/2021 6/30/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 998Provisionally and Associate Level Licensed

    per event $ 98.74 2/1/2021 6/30/2021

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 1 Physician per event $ 144.83 2/1/2021 6/30/2022

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 109Licensed Doctoral Psychologist

    per event $ 131.66 2/1/2021 6/30/2022

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 110 LCSW, LPC & LMFT per event $ 98.74 2/1/2021 6/30/2022

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 111Certified Clinical Nurse Specialist

    per event $ 111.91 2/1/2021 6/30/2022

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 112 CNP per event $ 111.91 2/1/2021 6/30/2022

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 128 LPA per event $ 98.74 2/1/2021 6/30/2022

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 129 LCAS per event $ 98.74 2/1/2021 6/30/2022

  • Page 23 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 999 Physician Assistant per event $ 94.91 2/1/2021 6/30/2022

    90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 998Provisionally and Associate Level Licensed

    per event $ 98.74 2/1/2021 6/30/2022

    90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19

    State 1 Physician per event $ 138.05 6/1/2020 1/31/2021

    90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19

    State 112 CNP per event $ 106.67 6/1/2020 1/31/2021

    90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19

    State 999 Physician Assistant per event $ 90.00 6/1/2020 1/31/2021

    90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19

    Medicaid 1 Physician per event $ 138.05 6/1/2020 1/31/2021

    90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19

    Medicaid 112 CNP per event $ 106.67 6/1/2020 1/31/2021

    90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19

    Medicaid 999 Physician Assistant per event $ 90.00 6/1/2020 1/31/2021

    90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19

    State 1 Physician per event $ 120.79 2/1/2021 6/30/2021

    90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19

    State 112 CNP per event $ 93.33 2/1/2021 6/30/2021

    90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19

    State 999 Physician Assistant per event $ 78.75 2/1/2021 6/30/2021

    90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19

    Medicaid 1 Physician per event $ 120.79 2/1/2021 6/30/2022

    90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19

    Medicaid 112 CNP per event $ 93.33 2/1/2021 6/30/2022

    90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19

    Medicaid 999 Physician Assistant per event $ 78.75 2/1/2021 6/30/2022

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 1 Physicianper time limit

    $ 68.96 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 109Licensed Doctoral Psychologist

    per time limit

    $ 62.69 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit

    $ 47.02 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 111Certified Clinical Nurse Specialist

    per time limit

    $ 53.28 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 112 CNPper time limit

    $ 53.28 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 128 LPAper time limit

    $ 47.02 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 129 LCASper time limit

    $ 47.02 6/1/2020 1/31/2021

  • Page 24 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 45.13 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 998Provisionally and Associate Level Licensed

    per time limit

    $ 47.02 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 1 Physicianper time limit

    $ 68.96 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 109Licensed Doctoral Psychologist

    per time limit

    $ 62.69 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 110 LCSW, LPC & LMFTper time limit

    $ 47.02 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 111Certified Clinical Nurse Specialist

    per time limit

    $ 53.28 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 112 CNPper time limit

    $ 53.28 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 128 LPAper time limit

    $ 47.02 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 129 LCASper time limit

    $ 47.02 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 999 Physician Assistantper time limit

    $ 45.13 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 998Provisionally and Associate Level Licensed

    per time limit

    $ 47.02 6/1/2020 1/31/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 1 Physicianper time limit

    $ 60.33 2/1/2021 6/30/2022

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 109Licensed Doctoral Psychologist

    per time limit

    $ 54.85 2/1/2021 6/30/2022

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit

    $ 41.14 2/1/2021 6/30/2022

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 111Certified Clinical Nurse Specialist

    per time limit

    $ 46.62 2/1/2021 6/30/2022

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 112 CNPper time limit

    $ 46.62 2/1/2021 6/30/2022

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 128 LPAper time limit

    $ 41.14 2/1/2021 6/30/2022

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 129 LCASper time limit

    $ 41.14 2/1/2021 6/30/2022

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 39.49 2/1/2021 6/30/2022

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 998Provisionally and Associate Level Licensed

    per time limit

    $ 41.14 2/1/2021 6/30/2022

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 1 Physicianper time limit

    $ 60.33 2/1/2021 6/30/2021

  • Page 25 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 109Licensed Doctoral Psychologist

    per time limit

    $ 54.85 2/1/2021 6/30/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 110 LCSW, LPC & LMFTper time limit

    $ 41.14 2/1/2021 6/30/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 111Certified Clinical Nurse Specialist

    per time limit

    $ 46.62 2/1/2021 6/30/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 112 CNPper time limit

    $ 46.62 2/1/2021 6/30/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 128 LPAper time limit

    $ 41.14 2/1/2021 6/30/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 129 LCASper time limit

    $ 41.14 2/1/2021 6/30/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 999 Physician Assistantper time limit

    $ 39.49 2/1/2021 6/30/2021

    90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 998Provisionally and Associate Level Licensed

    per time limit

    $ 41.14 2/1/2021 6/30/2021

    90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 State 1 Physicianper time limit

    $ 46.08 6/1/2020 1/31/2021

    90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 State 112 CNPper time limit

    $ 35.60 6/1/2020 1/31/2021

    90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 State 999 Physician Assistantper time limit

    $ 29.15 6/1/2020 1/31/2021

    90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 Medicaid 1 Physicianper time limit

    $ 46.08 6/1/2020 1/31/2021

    90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 Medicaid 112 CNPper time limit

    $ 35.60 6/1/2020 1/31/2021

    90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 29.15 6/1/2020 1/31/2021

    90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 State 1 Physicianper time limit

    $ 40.32 2/1/2021 6/30/2021

    90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 State 112 CNPper time limit

    $ 31.15 2/1/2021 6/30/2021

    90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 State 999 Physician Assistantper time limit

    $ 25.50 2/1/2021 6/30/2021

    90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 Medicaid 1 Physicianper time limit

    $ 40.32 2/1/2021 6/30/2022

    90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 Medicaid 112 CNPper time limit

    $ 31.15 2/1/2021 6/30/2022

    90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 25.50 2/1/2021 6/30/2022

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 1 Physicianper time limit

    $ 89.56 6/1/2020 1/31/2021

  • Page 26 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 109Licensed Doctoral Psychologist

    per time limit

    $ 81.42 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 110 LCSW, LPC & LMFTper time limit

    $ 61.07 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 111Certified Clinical Nurse Specialist

    per time limit

    $ 69.20 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 112 CNPper time limit

    $ 69.20 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 128 LPAper time limit

    $ 61.07 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 129 LCASper time limit

    $ 61.07 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 999 Physician Assistantper time limit

    $ 58.42 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 998Provisionally and Associate Level Licensed

    per time limit

    $ 61.07 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 1 Physicianper time limit

    $ 89.56 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 109Licensed Doctoral Psychologist

    per time limit

    $ 81.42 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit

    $ 61.07 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 111Certified Clinical Nurse Specialist

    per time limit

    $ 69.20 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 112 CNPper time limit

    $ 69.20 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 128 LPAper time limit

    $ 61.07 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 129 LCASper time limit

    $ 61.07 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 58.42 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 998Provisionally and Associate Level Licensed

    per time limit

    $ 61.07 6/1/2020 1/31/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 1 Physicianper time limit

    $ 78.37 2/1/2021 6/30/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 109Licensed Doctoral Psychologist

    per time limit

    $ 71.24 2/1/2021 6/30/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 110 LCSW, LPC & LMFTper time limit

    $ 53.43 2/1/2021 6/30/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 111Certified Clinical Nurse Specialist

    per time limit

    $ 60.55 2/1/2021 6/30/2021

  • Page 27 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 112 CNPper time limit

    $ 60.55 2/1/2021 6/30/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 128 LPAper time limit

    $ 53.43 2/1/2021 6/30/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 129 LCASper time limit

    $ 53.43 2/1/2021 6/30/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 999 Physician Assistantper time limit

    $ 51.11 2/1/2021 6/30/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 998Provisionally and Associate Level Licensed

    per time limit

    $ 53.43 2/1/2021 6/30/2021

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 1 Physicianper time limit

    $ 78.37 2/1/2021 6/30/2022

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 109Licensed Doctoral Psychologist

    per time limit

    $ 71.24 2/1/2021 6/30/2022

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit

    $ 53.43 2/1/2021 6/30/2022

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 111Certified Clinical Nurse Specialist

    per time limit

    $ 60.55 2/1/2021 6/30/2022

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 112 CNPper time limit

    $ 60.55 2/1/2021 6/30/2022

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 128 LPAper time limit

    $ 53.43 2/1/2021 6/30/2022

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 129 LCASper time limit

    $ 53.43 2/1/2021 6/30/2022

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 51.11 2/1/2021 6/30/2022

    90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 998Provisionally and Associate Level Licensed

    per time limit

    $ 53.43 2/1/2021 6/30/2022

    90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 State 1 Physicianper time limit

    $ 74.87 6/1/2020 1/31/2021

    90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 State 999 Physician Assistantper time limit

    $ 47.35 6/1/2020 1/31/2021

    90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 State 112 CNPper time limit

    $ 57.85 6/1/2020 1/31/2021

    90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 Medicaid 1 Physicianper time limit

    $ 74.87 6/1/2020 1/31/2021

    90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 47.35 6/1/2020 1/31/2021

    90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 Medicaid 112 CNPper time limit

    $ 57.85 6/1/2020 1/31/2021

    90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 State 1 Physicianper time limit

    $ 65.51 2/1/2021 6/30/2021

  • Page 28 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 State 999 Physician Assistantper time limit

    $ 41.43 2/1/2021 6/30/2021

    90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 State 112 CNPper time limit

    $ 50.62 2/1/2021 6/30/2021

    90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 Medicaid 1 Physicianper time limit

    $ 65.51 2/1/2021 6/30/2022

    90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 41.43 2/1/2021 6/30/2022

    90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 Medicaid 112 CNPper time limit

    $ 50.62 2/1/2021 6/30/2022

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 1 Physicianper time limit

    $ 131.23 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 109Licensed Doctoral Psychologist

    per time limit

    $ 119.30 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 110 LCSW, LPC & LMFTper time limit

    $ 89.48 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 111Certified Clinical Nurse Specialist

    per time limit

    $ 101.41 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 112 CNPper time limit

    $ 101.41 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 128 LPAper time limit

    $ 89.48 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 129 LCASper time limit

    $ 89.48 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 999 Physician Assistantper time limit

    $ 85.55 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 998Provisionally and Associate Level Licensed

    per time limit

    $ 89.48 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 1 Physicianper time limit

    $ 131.23 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 109Licensed Doctoral Psychologist

    per time limit

    $ 119.30 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit

    $ 89.48 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 111Certified Clinical Nurse Specialist

    per time limit

    $ 101.41 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 112 CNPper time limit

    $ 101.41 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 128 LPAper time limit

    $ 89.48 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 129 LCASper time limit

    $ 89.48 6/1/2020 1/31/2021

  • Page 29 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 85.55 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 998Provisionally and Associate Level Licensed

    per time limit

    $ 89.48 6/1/2020 1/31/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 1 Physicianper time limit

    $ 114.83 2/1/2021 6/30/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 109Licensed Doctoral Psychologist

    per time limit

    $ 104.39 2/1/2021 6/30/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 110 LCSW, LPC & LMFTper time limit

    $ 78.30 2/1/2021 6/30/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 111Certified Clinical Nurse Specialist

    per time limit

    $ 88.74 2/1/2021 6/30/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 112 CNPper time limit

    $ 88.74 2/1/2021 6/30/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 128 LPAper time limit

    $ 78.30 2/1/2021 6/30/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 129 LCASper time limit

    $ 78.30 2/1/2021 6/30/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 999 Physician Assistantper time limit

    $ 74.85 2/1/2021 6/30/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 State 998Provisionally and Associate Level Licensed

    per time limit

    $ 78.30 2/1/2021 6/30/2021

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 1 Physicianper time limit

    $ 114.83 2/1/2021 6/30/2022

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 109Licensed Doctoral Psychologist

    per time limit

    $ 104.39 2/1/2021 6/30/2022

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit

    $ 78.30 2/1/2021 6/30/2022

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 111Certified Clinical Nurse Specialist

    per time limit

    $ 88.74 2/1/2021 6/30/2022

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 112 CNPper time limit

    $ 88.74 2/1/2021 6/30/2022

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 128 LPAper time limit

    $ 78.30 2/1/2021 6/30/2022

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 129 LCASper time limit

    $ 78.30 2/1/2021 6/30/2022

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 74.85 2/1/2021 6/30/2022

    90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 998Provisionally and Associate Level Licensed

    per time limit

    $ 78.30 2/1/2021 6/30/2022

    90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 State 1 Physicianper time limit

    $ 120.90 6/1/2020 1/31/2021

  • Page 30 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 State 112 CNPper time limit

    $ 93.42 6/1/2020 1/31/2021

    90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 State 999 Physician Assistantper time limit

    $ 78.61 6/1/2020 1/31/2021

    90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 Medicaid 1 Physicianper time limit

    $ 120.90 6/1/2020 1/31/2021

    90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 Medicaid 112 CNPper time limit

    $ 93.42 6/1/2020 1/31/2021

    90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 78.61 6/1/2020 1/31/2021

    90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 State 1 Physicianper time limit

    $ 105.79 2/1/2021 6/30/2021

    90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 State 112 CNPper time limit

    $ 81.74 2/1/2021 6/30/2021

    90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 State 999 Physician Assistantper time limit

    $ 68.79 2/1/2021 6/30/2021

    90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 Medicaid 1 Physicianper time limit

    $ 105.79 2/1/2021 6/30/2022

    90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 Medicaid 112 CNPper time limit

    $ 81.74 2/1/2021 6/30/2022

    90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 68.79 2/1/2021 6/30/2022

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 1 Physicianper time limit

    $ 165.37 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 109Licensed Doctoral Psychologist

    per time limit

    $ 150.34 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 110 LCSW, LPC & LMFTper time limit

    $ 112.75 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 111Certified Clinical Nurse Specialist

    per time limit

    $ 127.79 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 112 CNPper time limit

    $ 127.79 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 128 LPAper time limit

    $ 112.75 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 129 LCASper time limit

    $ 112.75 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 999 Physician Assistantper time limit

    $ 150.34 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 998Provisionally and Associate Level Licensed

    per time limit

    $ 112.75 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 1 Physicianper time limit

    $ 165.37 6/1/2020 1/31/2021

  • Page 31 of 58

    Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021

    Service Code

    Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective

    dateEnd Date

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 109Licensed Doctoral Psychologist

    per time limit

    $ 150.34 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit

    $ 112.75 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 111Certified Clinical Nurse Specialist

    per time limit

    $ 127.79 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 112 CNPper time limit

    $ 127.79 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 128 LPAper time limit

    $ 112.75 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 129 LCASper time limit

    $ 112.75 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 999 Physician Assistantper time limit

    $ 150.34 6/1/2020 1/31/2021

    90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 998Provisionally and Associate Level Licensed

    per time l


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