BEHAVIORAL HEALTH PROVIDERS RE: SCHOOL BASED MENTAL HEALTH CLINICS IN MENTAL HEALTH OUTPATIENT TREATMENT REHABILITATIVE SERVICES (MHOTRS) PROGRAM
IMPACTED PLANS: QHP, GOLD, GOLDCARE
Effective January 1, 2024, OMH has released guidance that is applicable to commercial reimbursement of School Based Mental Health Services (SBMH) covered in the MHOTRS program provided by OMH certified School-Based Mental Health (SBMH) Clinics.
MetroPlusHealth will reimburse SBMH services covered in the MHOTRS program provided to our QHP, Gold and GoldCare members.
Billing Codes and Criteria
To receive the SBMH commercial reimbursement rate, the OMH certified SBMH Clinics must bill with the Medicaid APG rate codes:
- 1030 (Non-Hospital) or
- 1033 (Hospital).
For services delivered outside the school-based satellite operations, SBMH services must be rendered and/or facilitated through the school-based program using the rate codes as follows:
- The provider must bill the regular on-site (e.g.,1504/1516) or off-site base rate (e.g., 1507/1519),
- Utilize the correct zip+4, and
- Attach the appropriate modifier if applicable (e.g., telehealth modifiers).
Note: The zip+4 of the school-based satellite location must be used on the claim(s), to receive the reimbursement rate. This will ensure proper reimbursement.
This memo does not change other requirements outlined in the NYS Office of Mental Health 14 NYCRR Part 599 MHOTRS Billing Guidance with the exception of the rate and rate code changes. The CPT Procedure Weight and Rate Schedule and Rate Schedule and CPT Revenue Calculator will be updated soon to reflect the reimbursement.
Please refer to the OMH Commercial Billing Guidelines and Materials posted at Commercial Billing for Behavioral Health (BH) Services
If you have any questions regarding this memo, please contact MetroPlusHealth at: [email protected].
