For Providers

BH Redesign, implemented January 1, 2018, made major changes to the Medicaid billing codes, rates, claims requirements.
 

The resources below and Manuals, Rates & Resources will help you and your staff understand those changes and find details on policy and rate changes.

 

On January 1, 2018, changes were made concerning the mental health and substance use disorder treatment services billable to Ohio Medicaid.

Summary of Changes:
1. Replacement of pharmacological management (90863) and medical somatic services (H0016) with primary care office visit code. Starting January 1, 2018, 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.

5. Specialized Recovery Services (SRS). The Ohio Department of Medicaid has established a 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. For more information, visit ODM's SRS web page.

 

 

Checklist for Provider Agencies:

1. Become familiar with the 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 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. Refer to the new Provider Network Management (PNM) module for information about enrolling as a Medicaid provider.

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

 

 

July 23 Stakeholder Resources

May 29 Stakeholder Resources

These resource documents are in preparation of the Behavioral Health Stakeholder meeting taking place May 29, 2019. Please review prior to the meeting. Hard copies will not be provided onsite, but please feel free to bring your own copies if you prefer. Thank you for your participation and we look forward to the meeting.

The Ohio Revised Code grants rule-making authority to the Ohio Departments of Medicaid and Mental Health and Addiction Services. These agencies may adopt new rules, and amend or rescind current rules, as needed, to reflect changes and alignment through Behavioral Health Redesign. Rules become part of the Ohio Administrative Code.

The final rules, effective January 1, 2018, are posted on Lawriter: codes.ohio.gov/oac.

 

Ohio Medicaid is undergoing a Disability Determination Redesign. To check if you are impacted, click HERE.