For Providers

The codes used by behavioral health providers to bill the Medicaid program are antiquated and in need of updating.

Taking action to modernize the coding system is essential to integration of behavioral and physical health care.

In addition, coverage might be changing for the individuals you serve.

Here, you can learn how to help them understand those changes, and find details on policy and rate changes.

Innovative efforts reward better quality in health care for all Ohioans

 

On July 1, 2017, there will be changes concerning the mental health and substance use disorder treatment services billable to Ohio Medicaid.  

Revised Implementation Schedule

In recognition of the time and technical assistance needed for providers and system stakeholders to thoughtfully transition to the new evaluation and management (E & M) and nursing activity code set, on July 8, 2016, the Departments of Medicaid and Mental Health and Addiction Services announced a revised transition schedule for Behavioral Health Redesign. The coding changes, previously slated to begin January 1, 2017 will now begin July 1, 2017, without a voluntary transition period. The deadline for final transition remains unchanged; all Medicaid behavioral health providers must submit claims using the new behavioral health code set effective July 1, 2017.

Summary of Changes:

1. Replacement of pharmacological management (90863) and medical somatic services (H0016) with primary care office visit code.  Starting July 1, behavioral health providers will be able to bill Evaluation and Management (E&M) Codes. This code set consists of CPT codes 99201 – 99205 and 99211-99215. This change will apply to ALL mental health and substance use disorder treatment providers qualified to bill Ohio Medicaid.  In order to bill for these services, providers must follow the relevant AMA guidance.  

2. New HCPCS codes for rendering RNs and LPNs.   Additional Healthcare Common Procedure Coding System (HCPCS) codes will be available to behavioral health providers to bill Ohio Medicaid for services rendered by Registered Nurses and Licensed Practical Nurses. 

3. Enforcement of Third Party Liability. All Medicaid claims for mental health or substance use disorder services will be edited for third party liability (TPL).  Medicare is the most common third party insurance payer for Medicaid enrollees. That means that behavioral health providers serving Medicare beneficiaries must pursue Medicare enrollment if their agency and/or individual practitioners are not already enrolled. This new requirement is necessary to ensure Medicare payment for services rendered and to allow for Medicare claims to “cross-over” to Ohio Medicaid for co-payment. A similar process is also needed if agency clients have health care coverage through a commercial health insurance plan

4. Registration of Rendering Practitioners. In order to obtain reimbursement, rendering practitioners for behavioral health services must be listed on Medicaid claims. For more information, see the 2/3/16 edition of the 4/19/16 edition of the MITS BITS provider newsletter

5. Specialized Recovery Services (SRS). The Ohio Department of Medicaid is establishing a new specialized recovery services program to further ensure continuity in health care coverage and services for individuals diagnosed with a serious and persistent mental illness. The SRS program, which consists of three new supports under Medicaid, will be available for a subset of individuals who meet certain eligibility requirements. 



Checklist for Provider Agencies:

1. Become familiar with the new behavioral health code set by reviewing documents posted on this web site, MITS BITS newsletters, and information from your Ohio and national provider associations.

2. Use information from the American Medical Association (AMA) coding guidance and the National Correct Coding Initiativ (NCCI) to develop a plan for any necessary changes to your business practice.  

3. If you submit your agency claims via Electronic Data Interchange (EDI), work with your software vendor to update the claims format to match the new mental health and substance use disorder code set and billing requirements (e.g. enforcement of third party liability; inclusion of rendering provider on every claim, etc.). 

4. Make sure that all of your employees who are covered under the rendering provider requirements outlined in the 4/19/16 edition of the MITS BITS provider newsletter are registered with Ohio Medicaid and they are affiliated with your agency. Refer to these step-by-step provider enrollment instructions. If you have any questions regarding enrollment, please email the Behavioral Health Enrollment mailbox at bh-enroll@medicaid.ohio.gov for assistance.

5. Prepare to transition to the new behavioral health code set. All Medicaid behavioral health providers must submit claims using the new behavioral health code set effective July 1, 2017.

Any providers that have not voluntarily changed in July 2017, will be automatically transitioned for services provided on and after July 1, 2017.

Note for Dually Certified Providers: Providers who are dually certified as provider type 84 (mental health) and provider type 95 (substance use disorders) must transition from the old to the new billing code set simultaneously. This is true even though claims may be submitted using different National Provider Identifier (NPI) and Ohio Medicaid Provider Identification numbers.

Register for an NPI on the National Plan and Provider Enumeration System website.


 


NEW LOCATION FOR MANUALS, RATES and RESOURCES

These items have been moved to a dedicated page that can be accessed through the Providers navigation at the top of this website or by clicking here.

The address of the new page is http://bh.medicaid.ohio.gov/manuals.


Medicaid Information Technology System (MITS) newsletter: MITS BITS
The Behavioral Health MITS BITS will contain information on topics directly associated with Ohio Medicaid Behavioral Health Redesign initiatives and related changes going into effect on July 1, 2017. 

Subscribe to the MITS Bits: Visit the OhioMHAS website and use the registration function in the bottom right corner to subscribe to the BH Providers list serv.

Current and past BH MITS Bits are also available on the OhioMHAS website.

Some individuals who previously received Medicaid coverage by spending down may now be eligible for the new Specialized Recovery Services (SRS) program. Eligibility is based upon:

  • Income below $2,199 per month or $26,388 per year.
  • 21 years of age or older.
  • Diagnosed with a severe and persistent mental illness.
  • Needs help with activities such as medical appointments, social interactions and living skills.
  • Not living in a nursing facility, hospital, or similar setting. 
  • Having been determined disabled by the Social Security Administration.

New services available through SRS:

  • Recovery Management
  • Individual Placement and Support (IPS) - Supported Employment
  • Peer Support Services  

Learn more about these new services by visiting the Individuals tab on this site.

Use these resources to learn more about SRS:


HCBS Settings Assessment Tools

  1. HCBS Setting Evaluation Tool (ODM Form 10172) 
    ACF operators can use this tool to help determine their level of compliance with HCBS regulations and develop a plan to come into compliance.

  2. HCBS Setting Verification Checklist (ODM form 10173)
    Recovery Managers will use this tool to gather information about the setting from the individual during the in person assessments.

 

Self-guided HCBS Setting Evaluation Training Series

Module 1 - Provides an overview of current CMS regulations on HCBS settings
Module 2 – Provides information on the requirements that are required for all settings.
Module 3 – Provides additional information on the requirements that are specific to provider-owned or controlled settings, such as ACFs.



 


 

Medicaid Disability Determination Redesign

Ohio is creating a new program to simplify coverage to for thousands of Ohioans who previously dealt with the hassle and anxiety of Medicaid disability determination and spending down every month to keep their Medicaid coverage.

Beginning August 1 2016, individuals eligible for SSI (Supplemental Security Income) will be automatically eligible for Ohio Medicaid coverage. The Spenddown program will end July 31, 2016. 

All Ohioans will have a pathway to coverage without spending down to a more restrictive income limit. 
For more information, visit medicaid.ohio.gov. 

NEW LOCATION FOR TRAINING OPPORTUNITIES

Training opportunities, webinars and slides have been moved to a dedicated page that can be accessed through the Providers navigation at the top of this website or by clicking here.

The address of the new page is http://bh.medicaid.ohio.gov/training.