Effective January 1, 2019: Behavioral Health Benefit Updates
Date: 12/26/18
Effective January 1, 2019, Behavioral Health benefits from Superior HealthPlan will be updated due to changes announced by the Texas Medicaid & Healthcare Partnership (TMHP) and the American Medical Association (AMA).
TMHP has announced benefit changes for Texas Medicaid, which includes the addition of peer specialist services and changes to Substance Use Disorder (SUD) services. These updates will impact the following Superior products:
- STAR
- STAR+PLUS
- STAR Health
- STAR Kids
- STAR+PLUS Medicare-Medicaid Plan (MMP)
The American Medical Association (AMA) has issued changes to the family of CPT codes used for psychological and neuropsychological testing. These updates will impact the following Superior products:
- STAR
- STAR+PLUS
- STAR Health
- STAR Kids
- CHIP
- STAR+PLUS MMP
- Allwell from Superior HealthPlan (Medicare)
- Ambetter from Superior HealthPlan (Marketplace)
See below for an overview of each benefit update.
Peer Specialist Services Benefit Addition
Effective January 1, 2019, Peer Specialist services (procedure code H0038) may be a benefit of Texas Medicaid for clients who are 21 years of age and older with a mental health condition and/or substance use disorder, and who have Peer Specialist services included as a component of their person-centered recovery plan.
Peer Specialist services may include the following:
- Recovery and wellness support, which includes providing information on and support with planning for recovery.
- Mentoring, which includes serving as a role model and providing assistance in finding needed community resources and services.
- Advocacy, which includes providing support in stressful or urgent situations and helping to ensure that the member’s rights are respected. Advocacy may also include encouraging the member to advocate for him or herself to obtain services.
Prior Authorization is required once an individual exceeds 104 units of individual or group Peer Specialist services in a rolling 6-month period.
Prior authorization requests for continued services should demonstrate all of the following:
- The member continues to meet eligibility criteria as outlined above, including current DSM diagnosis codes.
- Current person-centered recovery plan and goals.
- Progress made, relative to the goals outlined in the person-centered recovery plan.
- The need for continued services.
Prior authorization requests should also indicate how many additional units of service are being requested (up to 30 units are allowed per request) and which type (individual and/or group), as well as an expected timeframe when services will be delivered.
For additional information, please reference the following announcement located on TMHP’s website: Peer Specialist Services to Become a Benefit of Texas Medicaid January 1, 2019
Substance Use Disorder Benefit Changes
SUD treatment services are individualized, age-appropriate medical and psychosocial interventions designed to treat an individual’s problematic use of alcohol or other drugs, including prescription medication. SUD services may include the following:
- Withdrawal management services.
- Individual and group SUD counseling in an outpatient setting.
- Residential treatment services.
- Medication assisted treatment.
- Evaluation and treatment (or referral for treatment) for co-occurring physical and behavioral health conditions.
Please note: All prior authorization requests must be completed and signed by a Qualified Credentialed Counselor (QCC).
Effective January 1, 2019, prior authorization requests for outpatient treatment services beyond the annual limitation of 135 units of group services and 26 hours of individual services per calendar year will no longer be limited to individuals who are 20 years of age and younger. Requests may be submitted for individuals of any age.
Modifiers HF and HG will no longer be required to identify the SUD services performed.
The following providers will be added as payable for procedure codes H2010 and J2315:
Procedure Code | Place of Service | Provider Type |
|---|---|---|
H2010 | Office setting | Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Physician Assistant (PA) providers |
J2315 | Outpatient setting | Chemical Dependency Treatment Facility (CDTF) |
Many diagnosis codes have been added as payable for procedure codes H0004 and H0005, while on the other hand, some diagnosis codes will no longer be payable for procedure codes H0004 and H0005.
For additional information and full list of diagnosis codes, please reference the following announcement located on TMHP’s website: Substance Use Disorder Benefits to Change for Texas Medicaid January 1, 2019
Psychological and Neuropsychological Testing Coding Changes
The AMA modernized their CPT coding structure to separate evaluation services from testing and administration services only, which will more accurately describe the work performed when multiple hours of technical and professional work are required.
Coding changes impact psychiatrists and psychologists who perform psychological and neuropsychological testing services. Implementation of the new CPT codes are mandatory, and non-compliance is a Health Insurance Portability and Accountability Act (HIPAA) violation.
Effective January 1, 2019, the existing psychological testing CPT codes, 96101-96103, and neuropsychological testing CPT codes, 96118-96120, will retire and be replaced with the following codes:
CPT Codes | Testing Services |
|---|---|
96130, +96131 | Psychological testing evaluation services by physicians or other qualified health care professionals |
96132, +96133 | Neuropsychological testing evaluation services by physicians or other qualified health care professionals |
96136, +96137 | Psychological and neuropsychological test admin and scoring by physicians or other qualified health care professionals |
96138, +96139 | Psychological and neuropsychological test admin and scoring by technicians |
96146 | Psychological and neuropsychological test admin and scoring via standardized instrument via electronic platform |
The switch to the new codes is based on the date of service, not the date the claim is submitted. See below for details:
- For dates of service on or after January 1, 2019: providers must bill with new CPT codes, or the claim will deny. This includes paper and electronic claims. The AMA does not allow for a transition period.
- For dates of service before January 1, 2019: providers can bill with the old codes, and the claim will pay. Timely filing limits apply.
For additional information, please reference the following announcement located on AMA’s website: AMA Releases 2019 CPT Code Set
For questions or more information, please contact Provider Services at 1-877-687-1196.