Behavioral Health Policies, Standards, and Billing References

• Third Party Liability (TPL) [07/01/2022]
• Telehealth Policy [01/01/2021]
• Service Documentation Standards [01/01/2022]
• Treatment Plan Standards [07/01/2018]
• Neuro/Psychological Testing Policy [01/01/2022]
• Medicaid Service Providers [01/07/2018]

Third Party Liability (TPL) [07/01/2022]
Providers are responsible for billing the payor who has primary responsibility for a service. There is a hierarchy to payers when a member has multiple insurances or is eligible for multiple benefit coverages. In general, private insurance should be billed first and then federal or state payers would be secondary. Medicaid is called the payer of last resort because Federal regulations require that all available health insurance benefits be used before Medicaid considers payment. With few exceptions, claims for members with health insurance resources are denied when the claim does not show insurance payment or denial information. 

When a Medicaid practitioner serves a member who is covered by both Medicare and Medicaid [i.e. considered dually eligible], they must submit claims for processing by Medicare before billing the MCE. Medicaid practitioners who serve dually eligible members must be enrolled with Medicare to bill the responsible primary payor. Effective April 1, LPCs, LMFTs and LACs who serve Medicare members are required to enroll as Medicare providers. Claims for services provided by an unlicensed behavioral health practitioner under the supervision of a Medicare-enrolled provider submitting claims as the rendering provider can be submitted directly to the MCE. These claims must include the HO modifier in the first available position after any required modifiers, to indicate the practitioner performing the service is not eligible to be covered by Medicare. Claims for services not covered by Medicare can be submitted directly to the MCE.

Medicaid does not automatically pay commercial health insurance co-pays, coinsurance, or deductibles. If the commercial health insurance benefit is the same or more than the Health First Colorado benefit allowance, no additional payment will be made. Providers cannot bill members for the difference between commercial health insurance payments and their billed charges when Medicaid does not make additional payment. The provider also cannot bill members for co- pay/deductibles assessed by the TPL. A provider must be contracted with all coverages a member has in order to comply with TPL policies. A provider cannot use a primary coverage denial resulting from being an out-of-network provider as appropriate TPL documentation when billing Medicaid. For additional information on TPL, please refer to this published FAQ.

Telehealth Policy [01/01/2021]
Telehealth is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distance. At one time, telehealth in Medicaid had been referred to as telemedicine. Under the Medicaid Capitated Behavioral Health Benefit MCEs have the flexibility to authorize the use of outpatient treatment services to be delivered via audiovisual and telephone modalities when it is clinically viable and appropriate. The BHA does not limit the use of telehealth at licensed and designated facilities. Services provided via telehealth should be indicated by Place of Service 02 – “Telehealth Provided Other than in Member’s Home” or 10 – “Telehealth Provided in Member’s Home”. These place of service codes are not included on any coding page but should be used per each MCEs policy guidance.
Other standard requirements for telehealth services provided to a member include: 

1. All services must be synchronous. 
2. Any health benefits provided through telehealth shall meet the same standard of care as in- person care. 
3. The availability of services through telehealth in no way alters the scope of practice of any health care provider; nor does it authorize the delivery of health care services in a setting or manner not otherwise authorized by law. 
4. Services may be delivered by telephone only when it is clinically appropriate, no other form of service delivery is possible, and this is documented in the clinical record. When a service is provided by telephone (Audio Only) modifier FQ should be used in the first available position on a claim.
5. Members that are new to a provider must contact the provider to initiate services.
6. Services for established members must be consistent with the members’ treatment plan. 
7. Providers must document the member’s consent, either verbal or written, to receive telehealth services. 
8. Record-keeping and member privacy standards should comply with normal BHA and Medicaid requirements, HIPAA and 42 CFR Part 2 requirements. 
9. Services not otherwise covered by the BHA, or Health First Colorado are not covered when delivered via telehealth. 
10. Providers may only bill procedure codes which they are contracted with a MCE to bill.

Service Documentation Standards [01/01/2022]

Providers have the discretion to design the format of a service note that captures documentation in line with these guidelines and general professional standards for clinical care. Documenting clinical encounters is essential to quality clinical care and lays the foundation for coding and billing, as well as telling the story of the person’s treatment over time. Documentation is also evidence of several important factors: 

1. That a service was provided. 
2. That there is clinical rationale and medical necessity for the service. 
3. That the service code utilized is appropriate to the encounter. 

Whether the individual served is engaged and/or benefiting from the service.

The following information must be documented for all clinical encounters submitted for reimbursement: 

1. Date of Service (DOS) 
2. Start and end time/duration of session and total contact time with person-served or collateral(s) 
3. Session setting/place of service 
4. Reason for the encounter, description of services provided, and interventions utilized 
5. Provider’s dated signature and relevant qualifying credential. A title should be included where no credential is held.

Depending on the purpose and details of the encounter, including the type of service, duration and mode of delivery, details are included to indicate medical necessity of the services provided, including (as appropriate): 

1. Documentation of consent to participate in the service (e.g. consenting to Telehealth) 
2. The individual’s response to the service and/or demonstrated benefit from the service provided 
3. Assessments, which may include treatment history, results of screening and/or diagnostic tools, Mental Status Exam (MSE), and clinical impressions.
4. Relevance to the treatment/service plan. 
5. Plan(s) for follow-up, including coordination of care, referrals, and recommendations

Shift Notes Documentation should include a description of all individual and group services rendered during the course of the shift/day. These can all be included in the same documentation or in a separate note as applicable (e.g. skills training group, individual therapy, med administration services, although included in the per diem, should be identified separately.)

Treatment Plan Standards [07/01/2018]

Clinical standards and best practice recommend that quality care should begin with a diagnostic evaluation or assessment of a member which would then inform a treatment/service plan. Outside of correct coding and appropriate documentation standards, Medicaid does not have any rules or guidelines that govern when an evaluation/assessment is completed, how frequently it is repeated, or what details are included. Additionally, while MCEs will audit providers and determine that assessments and treatment plans are documented and billed appropriately, there are no billing rules that require certain services to be billed before other services. For example, practitioners do not have to bill 90791 or H0032 before they bill 90834.

Neuro/Psychological Testing Policy [01/01/2022]

When a provider receives a referral for neuro/psychological testing the provider will determine the scope of testing needed based on a review of available member history and existing clinical documentation. Based on the primary condition being assessed or ruled out, a provider will identify the primary payer (RAE or FFS). 

• RAE - If the referring diagnosis is part of the Capitated Behavioral Health Benefit (responsibility of the RAE), the provider should first seek Prior Authorization according to RAE policy. If the concluding diagnosis is a non-covered RAE diagnosis, the provider should still submit the claim to the RAE. 
• FFS - If the referring diagnosis is part of the FFS benefit, then the provider needs to submit their claim to Gainwell for reimbursement. If the testing yields a diagnosis which is part of the Capitated Behavioral Health Benefit (responsibility of the RAE), the provider should still submit the claim to Gainwell and additionally use modifier code ‘SC’ to indicate it is an exception. 

Medicaid Service Providers [01/07/2018]

This is a list of practitioners who can provide hands-on care of behavioral health services. The services performed must be within the scope of the practitioner’s practice and license. This list is not meant to indicate who can enroll with or submit claims to Medicaid.