Billing Behavioral Health (BH) Services Under Managed Care

Mainstream/Health and Recovery Plan (HARP) Billing Guidance | Medicaid BH Rate Updates and Requirements | Medicaid Billing Guidance | Medicaid Provider Enrollment | Medicaid Advantage Plus (MAP) Billing Guidance |  General Medicaid/Medicare Duals Billing Guidance | Commercial BH Billing Guidance

Mainstream/Health and Recovery Plan (HARP) Billing Guidance

• New York State HARP / Mainstream Behavioral Health Billing and Coding Manual (May 18, 2017)


• Mainstream/HARP Coding Taxonomy (October 16, 2020) – This file provides the required coding construct for billing the OMH/OASAS government rates services.

Medicaid BH Rate Updates and Requirements

• Mandated Rate: Billing Guidance for Delivering Services in a Language Other Than English (LOE) Within MHOTRS Programs (October 5, 2023)


• Mandated Rate Update: July 1, 2023 Rate Increase and New APG Rate Codes for School-Based Mental Health Services in Mental Health Outpatient Treatment and Rehabilitative Service (MHOTRS) Programs (September 8, 2023)


• January 2023 Minimum Wage Increase and April 2023 Cost of Living Adjustment (COLA) (August 3, 2023)


• Partial Hospitalization (PH) and Continuing Day Treatment (CDT) Programs Rate Update (June 8, 2023)


• Comprehensive Psychiatric Emergency Program (CPEP) and Mental Health Outpatient Treatment and Rehabilitative Services (MHOTRS) – Peer Rate Update (January 26, 2023)


• Article 31 Clinic Enhanced Federal Medical Assistance Percentage (eFMAP) Rate Increase Notification (September 1, 2022)


• April 2022 Cost of Living Adjustment (COLA) (July 7, 2022)


• Anticipated American Rescue Plan Act (ARPA) Reimbursement (ACT, PROS, CORE, HCBS) (April 20, 2022)


• Enhanced Federal Medical Assistance Percentage (eFMAP) Rate Enhancement for Home and Community-Based Services (HCBS) and Community Oriented Recovery and Empowerment (CORE) Services (February 11, 2022)


• Enhanced Federal Medical Assistance Percentage Rate Enhancement for Personalized Recovery Oriented Services (PROS) and Assertive Community Treatment (ACT) (January 18, 2022)


• Medicaid Reimbursement Rates - Approved Medicaid fee-for-service rates for all OMH programs
  
  
  • HARP BH HCBS Fee Schedule (August 8, 2022)
  
  
  • CORE Fee Schedule (August 8, 2022)


• Office of Mental Health (OMH) Government Rates Table (Updated May 17, 2022)


• Federally Qualified Health Centers (FQHC) Article 31 & Article 32 Payments from Medicaid Managed Care Organizations (July 10, 2020)


• Quick Reference Guide: Protections for BH Government Rates


• Required Managed Care Organization (MCO) Payment of Ambulatory Patient Groups (APGs) and Government Rates (November 2, 2017)
  Contracts for ambulatory behavioral health services that state MCOs may pay “the lessor of APGs or charges” is in violation of law for both APGs or other forms of government rates. DOH is directing MCOs to ensure reimbursement to providers for ambulatory behavioral health services is at the APG rate for behavioral health clinic services or the published government rate for other ambulatory behavioral health services.

Medicaid Billing Guidance

• Integrated Outpatient Services (IOS): Updated Billing for Offsite and Primary Care Services for OMH Host Sites (May 12, 2023)


• 1115 Waiver Mobile Crisis Services Provided by CPEPs (May 4, 2023)


• Behavioral Health Outpatient Revenue Codes (June 2021)


• Billing for Medication Management and Opioid Use Disorders (October 17, 2019)


• Behavioral Health Billing Resource Guide (September 9, 2019)


• Adult BH HCBS Staff Transportation Billing Guidance


• Billing Comprehensive Psychiatric Emergency Programs (CPEP) and Extended Observation Beds (EOB) (August 3, 2016) | Supplemental Guidance (April 26, 2016)


• Claiming Guidance for Clinics, Opioid Treatment (OTP), PROS and ACT for claims that utilize the OASAS or OMH unlicensed practitioner ID

Medicaid Provider Enrollment

• eMedNY Provider Enrollment – Guides, FAQs, and additional information related to the Medicaid Managed Care (MMC) network provider enrollment in New York State Medicaid


• eMedNY What’s New Archives – Information on 21st Century Cures Act and other guidance

Medicaid Advantage Plus (MAP) Billing Guidance

• New York State Medicaid Advantage Plus (MAP) Plans Behavioral Health Billing and Coding Manual (Released July 1, 2022) - This guidance outlines the claiming requirements necessary to ensure proper BH claim submission with respect to MAP Plans.


• MAP Coding Taxonomy for BH Services (Released July 1, 2022) - Provides coding crosswalk from rate codes to procedure codes and modifiers for MAP Plan Behavioral Health Carve-in Services.

General Medicaid/Medicare Duals Billing Guidance

• Billing for Dual Eligible Enrollees - Provides guidance on billing both Medicare and Medicaid via 0Fill process


• Duals Reimbursement in Medicaid Managed Care (Reissued December 1, 2021. Original guidance release date: May 14, 2021)


• Duals Billing FAQ (August 16, 2022) - Responses to Frequently Asked Questions related to billing for enrollees who are dually enrolled in Medicaid and Medicare

Commercial BH Billing Guidance

CPT Revenue Calculator: This tool enables users to calculate the projected revenue for CPT procedures based on current service weights and peer group base rates.

1. 1. CPT Revenue Calculator: Illustrated
2. 2. CPT Revenue Calculator: Blank


3. Department of Health (DOH) Ambulatory Patient Group (APG) Rates This page houses provider-specific base rates for APGs.


4. School-Based Mental Health Clinic Program Site List (October 6, 2023) – A resource for Commercial Plans listing school-based mental health clinic sites with provider IDs, NPIs, rate codes, and rates.


5. School-Based Mental Health Clinic Fee Schedule (October 6, 2023) – A resource for Commercial Plans listing possible combinations of procedures, modifiers, and other elements to determine the final weight. The final weight can be used with the base rate identified in the School-Based Mental Health Clinic Program Site List (above) to calculate reimbursement for school-based mental health clinic services.

* If you are having accessibility issues with the previous documents, please contact Office of Diversity Management, or call (518) 473-4144.