How Do I Become An Enrolled Provider
As a Health First Colorado provider, you have the opportunity to improve the health and well-being of more than a million Coloradans. Health First Colorado is more than health insurance – it is a vital public service, helping almost one in five Colorado citizens stay healthy or move towards better health.
The enrollment process is online and begins on the Provider Enrollment web page.
Enrollment in Managed Care networks is only required if the member being treated is in the Denver Health or Rocky Mountain Health Plan networks.
Demonstration Project To Increase Substance Use Provider Capacity
On October 24, 2018, the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act became law. Under section 1003 of the SUPPORT Act, the Centers for Medicare & Medicaid Services , in consultation with the Substance Abuse and Mental Health Services Administration and the Agency for Healthcare Research and Quality, is conducting a 54-month demonstration project to increase the treatment capacity of Medicaid providers to deliver substance use disorder treatment and recovery services. The demonstration project includes:
- Planning grants awarded to 15 states for 18 months and
- 36-month demonstrations with up to 5 states that received planning grants.
States participating in the 36-month demonstration will receive enhanced federal reimbursement for increases in Medicaid expenditures for substance use disorder treatment and recovery services.
What Original Medicare Doesnt Cover
Your health care provider may recommend you receive services more frequently than Medicare covers, or services that Medicare doesnt cover, and you may end up paying some or all of these costs. Ask your provider why they are recommending such services and whether Medicare will cover them.
You will have to pay for private duty nursing or a private room, unless its medically necessary. Other limits may apply.
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Special Provision: Epsdt Services Can Exceed Policy Limitations For Members Age 20 And Younger
Early and Periodic Screening, Diagnostic, and Treatment is a federal Health First Colorado) program that requires the state Health First Colorado agency to cover services, products, or procedures for Health First Colorado members ages 20 and younger if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition identified through a screening examination . EPSDT covers most of the medical or remedial care a child needs to improve or maintain his/her health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
EPSDT does not require the state Health First Colorado agency to provide any service, product, or procedure that is:
- Unsafe, ineffective, or experimental/investigational.
- Not medical in nature or not generally recognized as an accepted method of medical practice or treatment.
Service limitations on scope, amount, duration, frequency, and/or other specific criteria described in the above screening policies may be exceeded or may not apply as long as the provider documentation shows how the service, product, or procedure will correct, improve or maintain the recipient’s health, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
What Part Of Medicare Covers Mental Health Care
Medicare Part A covers mental health care in an inpatient setting. Part A mental health care is in a general hospital or a psychiatric hospital only for people with mental health concerns. If you get inpatient care in a psychiatric hospital, Part A will cover up to 190 days in a lifetime. There is no limit to the number of benefit periods you can have for mental health care in a general hospital.
Part A covers your room , meals, nursing care , therapy and treatment, lab tests, medications, and other services and supplies you need. Part A does not cover personal items or a phone or TV in your room.
Part B helps pay for these outpatient mental health services:
Part D helps cover self-administered prescribed drugs.
Medicare Advantage plans cover all services offered through Original Medicare Part A, Part B, and usually Part D. Copays and coinsurance amounts vary, depending on your plan. Providers and services must be in-network and typically require referrals and prior authorizations before you can receive services.
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New Funds For Mental Health Services
New Medicaid funds could help schools pay for things like hearing screenings, coordinating care for students, and health services. But advocates see the biggest opportunity in mental health services.
While many necessary health treatments, like physical therapy, are already covered by students IEPs and billed to Medicaid, mental health services are often needed by students without such plans.
Long before the pandemic, schools reported concerns about climbing rates of depression and anxiety among students. But it was hard to find the resources to address those concerns.
A March analysis of federal data by Education Week found that nearly 40 percent of all school districts nationally, enrolling a total of 5.4 million students, did not have a school psychologist in the first full year of the pandemic. Just 8 percent of districts met the National Association of School Psychologists recommended ratio of 1 school psychologist to 500 students.
Federal data show a similar shortage of counselors and social workers in schools. And the student support staff who are in place are often too busy with tasks like special education evaluations and scheduling to provide direct counseling to students.
Everybody is in the same boat I was in, Broome said. Of course I want to provide mental health , but I cant afford it.
But Medicaid could be the solution, Broome said.
That new staff provided individual counseling, group therapy, and intensive trauma therapy.
The Three Most Often Used Mental Health Cpt Codes
- 90791 Intake session to be billed for your first appointment with that patient exclusively
- 90834 45-55 Minute Individual Therapy Session
- 90837 56+ Minute Individual Therapy Session
Its as straight forward as it seems: bill the intake code for their first session, and bill either a 45 minute or 60 minute session for the rest, depending on the length of their sessions.
Dealing with family therapy, therapy with a family member with the patient not present, group therapy, or other cases? Review our definitive guide to CPT codes to get sorted!
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Early And Periodic Screening Diagnostic And Treatment
8.280.4.E Other EPSDT Benefits
Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:
The following services are covered:
Who Can Provide Mental Health Services
One of the first regulations of mental health billing is the provider of service. This means that insurance will only cover mental health services if they are provided by a certain type of mental health provider.
For example, Medicare allows the following providers to bill for diagnostic and therapeutic treatment:
These providers can only bill for mental, psychoneurotic, and personality disorders.
On the other hand, independent psychologists and non-clinical psychologists can only provide diagnostic services.
What this means is that Medicare will only pay an independent psychologist to diagnose a patient with a mental disorder, and not to continue treating the patient with the mental disorder. If you are a physician or psychiatrist, on the other hand, Medicare will pay for you to diagnose and treat the patient with the mental disorder.
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Does Medicare Pay For Therapy Services
As part of Medicares mental health care benefits, therapy, or counseling is typically covered under Part B as an outpatient service with Original Medicare. MA plans provide the same benefits as Part B does. Therapy generally can be for an individual or a group. Family therapy is covered if it is to support the Medicare beneficiarys mental health treatment goals.
As with all mental health services, you must receive therapy from a provider that accepts assignment for Original Medicare or is in-network with your MA plan. The provider must be licensed in your state. Copay or coinsurance and deductibles apply.
In 2022, for instance, for outpatient mental health care through a UnitedHealthcare MA HMO plan, you pay $25 copay for each Medicare-covered individual therapy session and $15 copay for group therapy. For a similar type of plan with Humana, you pay a $20 copay for mental health services received from a specialist, an outpatient hospital, or intensive therapy that is part of the day program in a hospital. For a similar plan with BCBS/Anthem, you pay $40 for each Medicare-covered visit, group, or individual.
Your copays vary depending on your MA plan. To find out what your out-of-pocket costs will be and precisely what your plan will cover based on Medicare rules, talk with your plans administrator, review your EOC, and talk with your healthcare provider. Allow for the time it takes to get a referral and prior authorization.
Billing For Single Treatments
When one service is provided in a day, billing is fairly straight-forward time-based CPT codes are measured in 15-minute units. Providers shouldnt bill for any service performed for less than 8 minutes. So, if you use 7 minutes for treatment, you wouldnt be able to bill. For a therapeutic service lasting 8 minutes, you can bill for one 15-minute unit of time. At 22 minutes, the time is still counted as one unit of time, but 23 minutes counts as two . Billing is still done in 15-minute increments, and the 8-minute rule is used to determine when the 15-minute time increment shifts for billing purposes.
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Does Medicare Cover Mental Health Services
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Medicare pays much of the cost of a wide range of mental health services, whether provided on an outpatient basis or for inpatients in a psychiatric or general hospital. But you need to be aware of limits on these benefits, including substantial copays, coinsurance and a lifetime maximum.
Mental health issues are common among older adults: Thirty-one percent of Original Medicare beneficiaries are living with mental illness, according to a July 2020 report by the Commonwealth Fund, a private foundation focused on health care. And in a July 2020 survey by the Kaiser Family Foundation, 46% of Americans ages 65 and up said that pandemic-related stress and worry were detrimental to their mental health.
|Annual depression screening 15 mins|
- Includes patient form completion, recording by medical assistant and physician discussion with patient
- Coinsurance and deductible waived
- Furnished by Psychiatrist or Psychologist only with clinical staff-assisted depression care supports in place
- Primary care settings only:
|Face-to-face behavioral counseling for alcohol misuse, 15 minutes|
Top 4 Insurance Companies For Established & High License Level Providers
Best suited for LCSWs, PsyD, PhD, and MDs:
Investigate which companies are paying the most in your State by asking your colleagues.
Tip: You will probably need to establish a separate legal business to work with these companies so expect to create an E-IN for your new practice to get paid the best rates.
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Types Of Covered Mental Health Services
It’s important to know the types of covered mental health services for your patients who may have varying insurance or medical coverage. For example, some insurance will only cover mental health services by specific providers, such as physicians, psychiatrists, clinical psychologists and clinical social workers. Additionally, some independent mental healthcare providers can only diagnose the patient with a mental disorder because insurance will not cover the actual treatment.
If you are part of a private practice, then physicians’ and psychiatrists’ diagnosis and treatment of the mental disorder will most likely be covered by insurance. These services are often some method of counseling, including a general form of:
Medicare Outpatient Mental Health Services
Medicare Part B covers outpatient mental health services, such as care youd get in a health clinic or doctors office. Youll generally pay 20% of the Medicare-approved cost for outpatient care delivered by providers that accept Medicare assignment.
Medicare covers the following types of psychotherapy :
- Psychiatric assessment
- Family counseling, when the primary goal is to treat your condition
- Alcohol misuse counseling, up to four sessions
You may need to meet other criteria to be eligible for therapy coverage, and the doctor, psychologist, or other health-care professional must accept Medicare assignment. Medicare doesnt cover certain types of therapy, such as pastoral counseling or marriage counseling.
If you need more structured or frequent treatment, Medicare Part B also covers partial hospitalization programs, which are outpatient mental health programs where treatment is provided throughout the day and doesnt require an overnight, inpatient stay. The programs are usually run through a community mental health center or a hospitals outpatient department. Services may include therapy with a mental health professional, diagnostic services, and occupational therapy . These programs dont cover meals or transportation to the facility.
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Why Is Medicaid Hard To Bill For Mental Health Providers
For the same reason that Medicare is hard to bill, except that each state has their own contract instead of each region . As such, your states Medicaid policy is up to them.
Each state may have their own system that they have built that might be slow and require many enrollments as well, or they might contract out the insurance coverage to existing commercial insurance companies.
Example: What you think is UHC is actually Medicaid via UHC and while youre in-network with UHC, youre out of network with their Medicaid network your claims get denied.
Make sure you understand exactly which Medicaid panels you are enrolling with, including if youre in-network with their commercial or Medicaid or HMO or PPO or EPO plans.
What Medicare Covers For Inpatient Mental Health Services
Medicare Part A, your hospital insurance, covers mental health services that require your admission to a psychiatric or general hospital. If youre in a psychiatric hospital, youre covered for only up to 190 days of inpatient services over your lifetime. After that, youd need to receive mental health services in a general hospital to be covered.
Your costs will also be substantial: For long hospital stays, they could amount to $10,000 or more in total charges.
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Why Is Medicare Hard To Bill For Mental Health Providers
Medicare subcontracts out to many different subcontractors like Noridian or Palmetto or Novitas or NGS or WPS or FCSO.
Each contractor has their own electronic claims submission enrollment requirements, forms, and process. Each system is clunky and the enrollments take quite some time. Most clients also have a secondary insurance company to bill alongside their Medicare coverage.
We take care of this enrollment process and secondary claims submission and follow-up for our providers at TheraThink.
Telehealth Billing: Quick Guide
With telehealth becoming a popular if not required option for conducting therapy sessions in 2020, keep note of the following four points when billing telemedical therapy appointments:
If you are struggling to find out the place of service code or modifier to use for your insurance claims, this is something we provide as part of our billing service free of charge.
Our beginners guide to mental health billing doesnt make eligibility and benefits verification calls for you, but we do!
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The Role Of Medical Record Documentation
Private practice billing services must include proper documentation. Everything transpiring between a patient and the mental healthcare provider should be in the medical record. But why is mental health documentation important? A patient’s medical record determines what is billed for the mental health service, which means that all required information must be adequately documented. This medical record will help support the diagnosis and procedure code that is billed to insurance.
Essentially, an incomplete or inaccurate medical record would reflect that medical and mental health services are unnecessary for the patient. This error often results in insurance companies not paying for the service, making it difficult for behavioral health providers to do their job and patients to get the treatment they need. Proper note writing and documentation also play a huge role as a communication tool used between mental health providers and professionals.
When you have accurate, up-to-date medical record documentation, the risk of challenges to treatment and administrative litigation and penalties are reduced. Some of the essential things that need to be documented in these clinical records include: