Commercial Billing Guidance

Part AA of Chapter 57 of the Laws of 2024 requires insurers to reimburse covered outpatient mental health and substance use disorder services provided by in-network OMH and OASAS facilities. The rates cannot be less than the Medicaid rates for those services.

Resources below can be used to support commercial insurers and mental health providers with systems configurations needed for the implementation of Part AA, effective on or after January 1, 2025.

FAQ: Commercial Reimbursement Mandate for OMH & OASAS Behavioral Health Outpatient Services Beginning on or after January 1, 2025 (September 30,2024)

Calculating APG Rates for OMH-Licensed and OASAS-Certified Facilities(October 8, 2024) A support for commercial insurers to configure their billing systems for implementation of Part AA of Chapter 57 of the Laws of 2024. Provides instructions on how Medicaid determines APG rate reimbursement for outpatient behavioral health services.

Fee Schedules & Rate Tools

Exhibit A – APG Base Rates for MHOTRS Providers (September 17, 2024)
Contains provider-specific APG Base Rates (including School-Based Mental Health Clinic services), with associated rate codes.

Exhibit B – MHOTRS APG Weight Schedule (May 8, 2024)
For Commercial Plans listing possible combinations of procedures, modifiers, and other elements to determine the final APG weight.

Exhibit C – Non-APG OMH Outpatient Services Fee Schedule (August 29, 2024)
Contains fee schedules for OMH outpatient services applicable to Part AA that are not priced using APG methodology. Includes: applicable rate codes, procedure codes, modifiers and units of service.

Exhibit D – Non-APG OMH Provider-Level Fee Schedule (September 17, 2024)
Contains provider-specific rates for non-APG OMH outpatient services applicable to Part AA.

APG CPT Revenue Calculators

• APG CPT Revenue Calculator: Illustrated
• APG CPT Revenue Calculator: Blank

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

Office of Addiction Services and Supports (OASAS) Ambulatory Providers
This page houses the reimbursement rates for OASAS ambulatory programs.

School-Based Mental Health Clinic Resources

Department of Financial Services (DFS) Insurance Circular Letter No. 9 (2023)
Reimbursement for Treatment Provided by School-Based Mental Health (SBMHC) Clinics

Commercial Coverage for Services Provided by OMH-Licensed SBMH Clinics FAQs (July 12, 2024)
Responds to questions received from providers.

School-Based Mental Health (SBMH) Clinic FAQs for Commercial Billing (March 1, 2024)
Responds to questions received from commercial insurers.

Webinar: Reimbursement for Services provided by OMH-licensed School-Based Mental Health Clinics for Commercial Plans (CTAC-MCTAC login required).

This webinar covers:

• School-Based Mental Health Clinic reimbursement requirements.
• Guidance and resources, including rates and billing information.

Contact Information

• For questions regarding commercial billing for OMH licensed services, please contact: commercial-billing@omh.ny.gov
• For provider complaints regarding behavioral health services billed under commercial insurance, please go to: File a Complaint | Department of Financial Services (ny.gov)