Commercial Billing Guidance & Resources

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 #1: Commercial Reimbursement Mandate for OMH & OASAS Behavioral Health Outpatient Services Beginning on or after January 1, 2025 (September 30,2024)
Responds to general questions from the field regarding requirements and implementation of Part AA of Chapter 57 of the Laws of 2024.

FAQ #2: Commercial Reimbursement Mandate for OMH & OASAS Behavioral Health Outpatient Services Beginning on or after January 1, 2025 (November 27, 2024)
Responds to commercial insurer questions regarding requirements and implementation of Part AA of Chapter 57 of the Laws of 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.

2025 Commercial Insurance Changes Webinar: For Providers (CTAC-MCTAC login required).

2025 Commercial Insurance Changes Webinar: For Plans (CTAC-MCTAC login required).

Both webinars cover:

• An overview of the scope of the January 1, 2025 Behavioral Health Commercial Rate Mandate
• An overview of reimbursement requirements for commercial plans
• An overview of upcoming rate changes for applicable services
• Guidance and resources, including rates and billing information

Note: The webinar for Commercial Insurers includes APG and Non-APG calculation scenarios.

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.

Exhibit E – MHOTRS APG OMH Outpatient Fee Schedule(November 18, 2024)
Contains fee schedules for OMH outpatient services applicable to Part AA that are priced using APG methodology. This document can be used to determine the final price for every MHOTRS outpatient behavioral health service billed by an OMH-licensed provider, according to Peer Group.

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)