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Behavioral Health Services (Section 65) Frequently Asked Questions September 8, 2008 No. Question Answer Why were the previous four sections of policy The supplemental budget law (PL545) required ended to create the new Section 65? DHHS to consolidate mental health and substance abuse outpatient services into one section of the MaineCare Benefits Manual. What does the new policy do? It replaces Sections 111 (substance Abuse Treatment Services), 100 (Psychological Services), 58 (Licensed Clinical Social Worker, Licensed Clinical Professional Counselor and Licensed Marriage and Family Therapist Services) and 65 (Mental Health Services) with a new Section 65, titled Behavioral Health Services. Several initiatives are rolled into this consolidation including local code reduction, service re-design and rate standardization. Does it change reimbursement for any Yes, please see Chapter III. providers? Does it change how providers bill? Most services provided under the new Section 65 are subject to authorization and utilization management requirements, as explained in the rule. There is a significant reduction in the number of procedure codes that providers may use to bill MaineCare. These are the “local codes” that have been eliminated. What other changes are important? Some providers need a new provider agreement to bill for services under 65. These include Licensed Clinical Social Workers, Licensed Clinical Professional Counselors and Licensed Marriage and Family Therapists. Psychologists and other private practitioners need a provider agreement. Behavioral Health Services (65) FAQ Page 2 Was a new Medicare exempt code list No, at this time a new Medicare exempt code created for Section 65? list has not been created. For questions on individual services please call your Provider Relations specialist. Will secondary claims after Medicare require No, as long as Medicare has allowed the a PA? service. Can a client/member be seen for outpatient Yes. mental health and substance abuse on the same day? Are services provided by outside agencies as Yes, as long as the PA is done through APS. coverage during a provider’s vacation or other absence covered? Is it okay to bill a total of two hours per week, No. The base service is outpatient therapy from two different providers? Example is for unless the member sees one provider for an adult client with a diagnosis of gender substance abuse and one for mental health the identity, Aspergers and ADHD. One provider member should see one primary therapist to in private practice bills one hour per week avoid duplication of services. and one provider that is agency based bills one hour per week. Can a member receive Opioid replacement Yes. therapy (i.e. Methadone) at one agency and receive medication management (i.e. psychotropic medication) at a different agency? Medication Management after 30 minutes is After 30 minutes of medication management billed as outpatient therapy. How do the provider must bill as outpatient therapy providers bill for this after the first 30 using the same APS process. Services may minutes? And if this occurs, how do other not be duplicated. providers bill for outpatient therapy? How often can medication management be Medication management may be billed as billed? often as clinically indicated based on member’s needs and medication protocols – at least once every 90 days. Is it possible for a member to have separate No. The base service is outpatient therapy counselors for couples/family counseling and unless the member sees one provider for individual therapy? If so, how does this work substance abuse and one for mental health the with prior authorization? member should see one primary therapist to avoid duplication of services. What is the limit for a comprehensive exam? Comprehensive assessment is limited to 8 units annually. Exceptions are noted in Section 65.08-5.A. Behavioral Health Services (65) FAQ Page 3 An LCSW previously billing SA112 @ $72.00 Yes. for 4 units. Can the provider now bill H0004 and H2000? There does not seem to be a PHD in the If you are experiencing issues the Prior dropdown for outpatient procedures on the Authorization process please contact APS. APS web site. If two providers are billing outpatient services No, at this time APS does notify the second for the same member, will APS inform the provider. second provider of the first provider? How is the visit capture for members It is the provider’s responsibility to track the identified as non-categorical? number of services the non-categorical member is receiving. Is Suboxone included in outpatient therapy? No, Suboxone is not included in outpatient therapy. Suboxone is part MaineCare’s pharmacy benefit. Can an LCPC providing outpatient services Outpatient collaterals are included in the rate bill for collateral contacts? for all providers, for all ages. Can collateral services be provided for MaineCare covers collateral services for adults? children in Home and Community Based Treatment. Outpatient collaterals are included in the rate for all providers, for all ages. Can providers bill for interpreter no shows? No. Does MaineCare require an NPI number on Not at this time. claims? Where does the ITP get submitted? MaineCare does not require an ITP submission, except upon record audit. Please contact APS for their specific requirements. Is there a separate billing code for non face- No. to-face? Will August units be counted toward 32 units The policy was effective August 1 and all policy as a hard edit? Will APS subtract 4 units limits must be adhered to. from 32 as of September authorizations as a soft edit? Pricing for CADC services is specific in the Yes, please refer to Chapter III for substance agency setting. Are there distinct billing abuse billing amounts. amounts for LCPC/masters level versus non- masters level CADC? Behavioral Health Services (65) FAQ Page 4 Can mental health agencies previously Yes. treating substance abuse clients with mental health as a primary diagnosis continue to treat these patients? Is a referral from a physician required to A PA from APS is required. begin treatment or just a PA from APS? Is there a way to differentiate between a PA A PA issued from MaineCare is on MaineCare from MaineCare and a PA from APS? letterhead and a PA issued from APS is on APS letterhead. Crisis Resolution is now limited to 6 visits. A member may receive as many medically What if the member needs more than 6 necessary services as justified by clinical visits? documentation contained in the member’s record. If a provider needs to bill the same procedure Based on the Department issued rate letter the code for adults and children, for different provider is expected to bill the correct rate. rates, how will MaineCare determine what Members age 18 to 21 may choose to receive rate is to be paid? The age group 18 to 21 adult or children’s service. years of age can be billed as either a child or adult. Can physicians provide neurobehavioral Physicians can provide neurobehavioral status status exams and psychological testing? exams, but cannot do psychological testing. Can group and individual therapy be billed for Yes. the same day? How should pain management therapy be Yes. billed? As outpatient therapy? Does the 24 hour requirement for prior The APS web site is available 24 hours a day, authorization mean a 24 hour business day or 7 days a week. is it 24/7? Can providers meet with the parent/guardian Yes. without the member present and be reimbursed? Are second opinions covered? If so, how are If clinically necessary APS may authorize the they billed? service. Does psychological testing for children Yes this service is covered and no, it does not (diagnosis of autism, MR aspersers, bipolar, require prior authorization through APS. ADHD tec.) fall under the new 65 or another program? Does need to receive prior authorization through APS? Behavioral Health Services (65) FAQ Page 5 Is in-home geriatric care covered in the new Yes. section 65? Is Diagnosis 799.9 or other unknown and No. unspecified valid for coverage? Is an MHRT provider only eligible to bill for an No. alcohol-related diagnosis? Can a member have Methadone Treatment No. co-occurring with outpatient treatment for substance abuse? Do providers who bill both mental health and Yes, please contact provider enrollment for substance abuse need different provider further assistance. ID’s? What if an assessment was done by a The member may request the assessment provider and the member is transferred to follow them to the new provider and the new another provider? Does the member get provider may request 4 additional units to do another assessment? an addendum if necessary. Please see 65-08- 5.A. How often are treatment plans to be Please see 65-09-3B7A-G. reviewed? Are MST grandfathered providers? In order to be reimbursed for services delivered, all providers must be currently enrolled, certified and licensed. What if a foster child has a comprehensive Yes, if it is medically necessary. exam and then is referred to a psychiatrist? Is another comprehensive exam allowed? Do we cover collateral contacts for adults? No. Medication Management Services, if they get No, they are separate services. 1 hour and are told they need outpatient therapy does therapy count against the 1 hour of medication management? Do existing individual providers and agencies Please contact Provider Enrollment. need to resubmit information to either MaineCare or APS which connects our IDs with the new codes and rates of reimbursement?
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