Coverage for Behavioral Health Integration Services

The State of New Hampshire Insurance Department 21 South Fruit Street, Suite 14 Concord, NH 03301 David J. Bettencourt Commissioner Keith E. Nyhan Deputy Commissioner Telephone 603-271-2261 • Fax 603-271-1406 • TDD Access: Relay NH 1-800-735-2964 nh.gov/insurance Bulletin Docket No.: INS 23-038-AB TO: All Health Insurers FROM: Commissioner David J. Bettencourt DATE: November 15, 2023 RE: Coverage for Behavioral Health Integration Services To address the problem of access to mental health services, to implement coordinated, patient-centered care, and improve health outcomes, health systems in the state and nationally are moving toward care models that integrate behavioral health services in primary care settings. The two behavioral health integration (BHI) models currently recognized by the Centers for Medicare & Medicaid Services (CMS) are the Primary Care Behavioral Health model (PCBH) and the Collaborative Care model (CoCM). In recent years and continuing currently, CMS, through development of new Healthcare Common Procedure Coding System (HCPCS) codes, and the American Medical Association (AMA), through development of new Current Procedural Terminology (CPT) codes, have both developed new billing codes that are necessary to support the implementation of BHI service models such as PCBH and CoCM. Behavioral health practitioners and billing practitioners providing care under these models report that they have often had difficulty getting reimbursed by commercial health carriers when they attempt to use the billing codes that are associated with these BHI service models. The Insurance Department conducted its own review of all payer claims data and confirmed that the denial rate for a significant number of these codes is high, with the most frequent denial reason relating to inappropriate use of billing codes. In the 2023 session of the New Hampshire legislature, SB 235 was introduced to address this issue. The bill was retained by the House Commerce Committee with the expectation that the Department would convene a stakeholder group to identify the problem in more detail than can be addressed legislatively and, if possible, devise a solution. The Department has met on several occasions with a stakeholder group in which the various interests were well represented, and the participants were forthcoming and collaborative. Based on the information gathered in these sessions, and through the vehicle of this bulletin, the Department now instructs health insurers doing business in the state as follows. It is incumbent upon Insurers to work closely with their contracted behavioral health providers and with interested behavioral health professional associations to reach a consistent and common understanding on the appropriate use of the various billing codes (CPT and HCPCS) that are in use for BHI services. Insurers shall monitor the denial rates for claims submitted using these billing codes to detect problem areas in the use of these codes and shall take appropriate action to modify their systems and to work with providers as necessary to reduce unnecessary claim denials. Some of the codes associated with BHI that providers have had difficulty using include: • G0323 (Care Management Services for Behavioral Health Conditions) • 99446 (Interprofessional Telephone/Internet/Electronic Health Record Consultations) • 99447 (Interprofessional Telephone/Internet/Electronic Health Record Consultations) • 99448 (Interprofessional Telephone/Internet/Electronic Health Record Consultations) • 99449 (Interprofessional Telephone/Internet/Electronic Health Record Consultations) • 99450 (Basic Life and/or Disability Evaluation Services) • 99451 (Interprofessional Telephone/Internet/Electronic Health Record Consultations) • 99452 (Interprofessional Telephone/Internet/Electronic Health Record Consultations) • 99484 (Care Management Services for Behavioral Health Conditions) Insurers should be sure to address the following specific areas of ambiguity and misunderstanding: • Under what circumstances a behavioral health provider can bill the insurer directly for BHI services provided, and under what circumstances the behavioral health provider may only bill through the “treating (billing) practitioner” • When BHI services will be considered “incident to” the billing practitioner’s services, including: o When an “initiating visit” is required before BHI services can start o The duration of the eligibility of the “initiating visit” o The therapeutic status of the patient, relative to the diagnosis from the “initiating visit” [i.e., worsening, static, new condition/diagnosis] o What kind of supervision is required by the treating practitioner when BHI services are not personally performed by the treating practitioner. • When a Behavioral Health Care Manager is required • When a Psychiatric Consultant is required • Which clinical practitioners are eligible to provide general BHI CMS has provided guidance on billing for BHI services that insurers should make use of in their work to create a common understanding of proper billing practices for BHI services.1 Additionally, the AMA has a Behavioral Health Coding Resource that includes a more complete list of codes associated with BHI than those listed above and that may be useful to distinguish between the PCBH and CoCM delivery of care.2 Insurers are free to perform utilization review and develop fraud prevention safeguards to ensure the appropriate use of these billing codes. Insurers must continue to review and improve provider relations and claims handling systems and procedures for BHI services until such time as the proper use of BHI related billing codes is well understood in the behavioral health provider community and insurers are consistently and correctly processing claims for BHI services. 1 See, for example, the following publication produced by CMS’s Medicare Learning Network: https://www.cms.gov/files/document/mln909432-behavioral-health-integration-services.pdf 2 Behavioral Health Coding Resource, American Medical Association, 2023: Behavioral Health Coding Resource | AMA (ama-assn.org)