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Behavioral Health Services _Sect


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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
                                                      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.

      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
                                                      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
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      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

      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
Behavioral Health Services (65) FAQ
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      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.

      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.

      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
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      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

      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

      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

      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
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      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.

      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-

      How often are treatment plans to be                Please see 65-09-3B7A-G.

      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

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