{"id":2063,"date":"2024-12-23T08:32:09","date_gmt":"2024-12-23T16:32:09","guid":{"rendered":"https:\/\/www.qualityhealth.org\/adminsimp\/?page_id=2063"},"modified":"2025-01-10T10:10:06","modified_gmt":"2025-01-10T18:10:06","slug":"covered-services-billing","status":"publish","type":"page","link":"https:\/\/www.qualityhealth.org\/adminsimp\/1688-bh\/covered-services-billing\/","title":{"rendered":"Covered Services & Billing"},"content":{"rendered":"

Covered Services<\/h3>\n

Under E2HB1688, covered emergency services include mental health and substance use disorder services that are provided by\u00a0Mobile Crisis Response Teams<\/strong>\u00a0and\/or by qualified staff in the following\u00a0Crisis<\/strong>\u00a0Facilities<\/strong>;<\/p>\n

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a) \u00a0 Hospital Based Emergency Room with stabilization\/post stabilization in an Inpatient Unit<\/p>\n

b) Evaluation and Treatment Facility (including Secure Withdrawal Management Services)<\/p>\n

c) \u00a0 Crisis Stabilization Unit,<\/p>\n

d) \u00a0 Crisis Triage Facility,<\/p>\n

e) \u00a0 Withdrawal Management Facility<\/p>\n<\/div>\n<\/div>\n

The above 5 facilities are all considered Behavioral Health Crisis Facilities and any\/all of the SERI specified services (procedure \/ revenue codes) provided in any of those facilities are considered covered Behavioral Health Crisis Services.<\/p>\n<\/div>\n

The specific Behavioral Health Crisis Services are a subset of those services defined in HCA\u2019s SERI Guide \u2013\u00a0https:\/\/www.hca.wa.gov\/billers-providers-partners\/program-information-providers\/service-encounter-reporting-instructions-seri<\/a>. That subset of services and related coding guidance is defined in the spreadsheet \u2018Crisis Code Guide for Private Insurance Plans\u2019, which is also posted at the above link.<\/p>\n

For the scope Behavioral Health Emergency Services, coding requirements for commercial carriers would mirror Medicaid SERI guidance \u00a0and would be reflected as such on any updates to the SERI spreadsheet.\u00a0 Changes to Medicaid can be triggered by legislation, but also may be triggered by state plan amendments, CMS rule changes, 988 crisis system changes, etc.<\/p>\n

The SERI Guide is typically updated once a year by HCA and with a 90-day implementation timeframe.\u00a0 However, not all SERI Guide updates will be applicable to Behavioral Health Crisis Services and, as such, will not appear on the SERI spreadsheet.<\/p>\n

Commercial Carriers can\u00a0sign up to receive updates<\/a>\u00a0on the Service Encounter Reporting Instructions (SERI) guide. (An account would need to be created if one does not already exist.)\u00a0 When signing up, select \u201cService Encounter Reporting Instructions (SERI) updates\u201d, under the \u201cBehavioral Health and Recovery\u201d heading.\u00a0 Once signed up, carriers will receive an email notification any time there are changes to the SERI guide, as well as any changes to the services coding grid related to E2SHB 1688 legislation.<\/p>\n

The material in the documents in the table below is an extract from the January 1, 2023 version of the SERI Guide and from the October 2, 2023 version of the Crisis Code Guide for Private Insurance Plans. (The documents posted here below may\u00a0not\u00a0<\/strong>be kept current with any future SERI changes. To ensure \u00a0accuracy over time, the SERI Guide should be referenced via this link\u00a0https:\/\/www.hca.wa.gov\/billers-providers-partners\/program-information-providers\/service-encounter-reporting-instructions-seri<\/a>\u00a0so that any\/all future changes are not missed.)<\/p>\n

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This link contains the a subset of the January 1, 2023 SERI Guide, which are the Behavioral Health Crisis Services (BHCS) along with conditions under which they are covered.<\/td>\nSERI-Defined BHCS<\/a><\/td>\n<\/tr>\n
This link provides additional detail about BHCS crisis codes, such as the \u201cincluded\u201d services, that will be used on the 837P or 837I .<\/p>\n

Note: For Professional Services (those that are reported on an 837P), the allowable Places of Service for each Behavioral Health Crisis Service will be negotiated between the Carrier and the BH-ASO \/ Facility at the time of contracting.\u00a0 In the case of \u2018out-of-network\u2019 claims, the allowable Places of Service for Behavioral Health Crisis Service will be defined in the Crisis Code Guide for Private Insurance Plans spreadsheet.<\/td>\n

Crisis Code Guide for Private Insurance Plans<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/figure>\n

The \u2018Crisis Code Guide for Private Insurance Plan\u2019 spreadsheet along with the associated information in the SERI Guide will be used as the \u2018Definitive Guidance\u2019 for which codes will be used to identify covered emergency services.\u00a0 Other than E&M codes, only the codes on the spreadsheet should appear on a claim and that code(s) should be considered the complete and exhaustive definition of the relevant covered emergency service.<\/p>\n

The use of any different or additional codes may be negotiated between commercial carriers, BH-ASO and facilities, but that would be considered outside the scope of the \u2018Definitive Guidance\u2019.<\/p>\n

Claims for any\/all of the Behavioral Health Crisis Services, i.e., the subset of SERI Guide services specified in the Crisis Code Guide for Private Insurance Plan spreadsheet, that are provided by Agencies, Facilities and Providers who are appropriately certified\/licensed by DOH will be processed as emergency services by commercial carriers in compliance with E2HB1688.<\/p>\n

Billing\u00a0Guidance<\/h2>\n
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  1. Room and board \u201cper diem\u201d within a facility along with a SERI defined set of \u201cincluded\u201d clinical services would be included<\/strong><\/em> in the payment for the service code that is submitted on a claim, i.e., the \u201cincluded\u201d services would not be billed separately from the per diem.<\/li>\n
  2. Required clinical services that are in addition to<\/strong><\/em> SERI-defined \u201cincluded\u201d clinical services\u201d may be provided in the facility by agency providers.
    \n<\/span>These services, typically E&M codes, may be billed separately from the per diem on an 837P using the provider\u2019s NPI, subject to any specific contract expectations.\u00a0 (Depending upon the location,\u00a0 the associated per diem would be billed on an 837I\u00a0 using the agency\u2019s NPI).
    \nE&M codes on a claim along with a SERI defined covered emergency service are also considered covered emergency services.
    \nThese E&M services may be provided by an employee of the Crisis Facility, or a contractor of the Crisis Facility, or an \u201cexternal\u201d provider who has treatment privileges at the Crisis Facility.\u00a0 For all three situations, AADR reporting requirements are analogous to those of a Hospital ER department, i.e.\u00a0 the goal is that coverage of BH crisis facility services are comparable to those provided in a hospital ER department.<\/li>\n
  3. For Withdrawal Management Services, clinically managed or medically managed, claims will be submitted on an 837I unless otherwise contractually negotiated between the Carrier and the Facility.
    \nOut-of-network Crisis Facilities for Withdrawal Management will submit claims on an 837I. Any 837P submissions will be denied.<\/li>\n
  4. Claims submitted by a BH-ASOs of behalf of an Agency or Facility would report the BH-ASO as the \u2018Billing Provider\u2019 and report the Agency \/ Facility as the \u2018Rendering Provider\u2019.<\/li>\n
  5. For a compliant 837-claim transaction WHEN a carrier requires use of a Taxonomy Code: \u00a0 In situations where a provider has a State Taxonomy Code, the BH-ASO will report a) either \u201c101Y00000X\u201d \u2013 Counselor or \u201c390200000X\u201d \u2013 Student in the Taxonomy Code field on the 837, and b) the state assigned Taxonomy Code in the NTE field on the 837, either at the claim level or line level whichever is most appropriate.\u00a0 The message in the NTE field will be \u201cWash State Taxonomy Code #xxxxxxxxL\u201d. (for more information \u2013 see 10-23 Synopsis <\/a>item B.1)<\/span><\/li>\n
  6. The following conditions must be met for using the National Taxonomy Code \u2013 \u201c390200000X \u2013 Student\u201d on an 837-claim . . .\u2002The 837-claim must be submitted.\n