CurrentAlliance HealthPolicy 1M-3

Health and Behavior Intervention

Customize your policy alerts

Sign up for Alliance Health Policy 1M-3 alerts

Get alerted when Policy 1M-3 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Medicaid coverage policy governing intensive, focused counseling and related interventions for pregnant and postpartum women with serious psychosocial needs in North Carolina Medicaid. It describes eligibility, coverage criteria, EPSDT considerations, and telehealth applicability.

Policy Summary

PayerAlliance Health

PolicyHealth and Behavior Intervention

Policy CodePolicy 1M-3

Change TypeNo material changes

Effective Date

Last ReviewAug 15, 2023

Next Review Date

Key ActionVerify beneficiary eligibility each time a service is rendered and document medical necessity per EPSDT when applicable.

SourceLink

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentAlliance HealthPolicy 1M-3

Health and Behavior Intervention

Customize your policy alerts

Sign up for Alliance Health Policy 1M-3 alerts

Get alerted when Policy 1M-3 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerAlliance Health

PolicyHealth and Behavior Intervention

Policy CodePolicy 1M-3

Change TypeNo material changes

Effective Date

Last ReviewAug 15, 2023

Next Review Date

Key ActionVerify beneficiary eligibility each time a service is rendered and document medical necessity per EPSDT when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

pregnant/postpartumtarget population

no prior approval requiredprior authorization

60 min/daydaily time limit

11 hrsper pregnancy limit

96158primary CPT

96159addl CPT

Coverage Criteria

General Criteria Covered

Medicaid shall cover the service when medically necessary and the following general conditions are met:

General medical necessity criteria: a. the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary's needs; b. the procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; c. the procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

From general criteria covered

Specific Criteria Covered

Covered for pregnant or postpartum women with one or more of the following conditions:

Covered psychosocial conditions: a. Substance use (alcohol or drugs) or history of substance use with potential negative impact on the current pregnancy; b. Child abuse, family violence, or severe family dysfunction or history of such problems with potential negative impact on the current pregnancy; c. Severe emotional crises associated with situations such as loss of job, divorce, homelessness, death, terminal illness; d. Episodic disorders: severe depression, psychosis, behavior disorders; e. Suicidal tendencies; f. Intense negative feelings about the current pregnancy; g. Intense negative feelings about previous poor pregnancy outcome such as fetal death, stillborn, infant death, or congenital abnormalities; h. HIV infection/AIDS and other life-threatening medical problems; i. Pending incarceration during the pregnancy; j. Major psychological behavioral disorders such as anorexia.one or more present

Specific Medicaid additional criteria covered

Medicaid Additional Criteria Covered

Covered when the beneficiary is pregnant or postpartum and has ONE OR MORE of the following:

Medicaid additional covered conditions: a) Substance use or history of substance use with potential negative impact on the current pregnancy; b) Child abuse, family violence, or severe family dysfunction or history thereof with potential negative impact on the current pregnancy; c) Severe emotional crises (e.g., job loss, divorce, homelessness, death, terminal illness); d) Episodic disorders: severe depression, psychosis, behavior disorders; e) Suicidal tendencies; f) Intense negative feelings about the current pregnancy; g) Intense negative feelings about previous poor pregnancy outcome (fetal death, stillborn, infant death, congenital abnormalities); h) HIV infection/AIDS and other life-threatening medical problems; i) Pending incarceration during the pregnancy; j) Major psychological behavioral disorders such as anorexia.

Medicaid additional criteria covered

Health and Behavior Intervention Coverage Criteria

Covered when billed according to the following rules and documentation supports medical necessity:

Billing order and unit rules: CPT 96158 must be billed for the first 30 minutes; CPT 96159 may be billed for each additional 15 minutes only after 96158 has been billed first.

Telehealth eligible; GT modifier must be appended for interactive audio-visual telehealth

Daily and pregnancy limits: Total reimbursable time per day cannot exceed 60 total minutes; up to 11 hours of Health and Behavior Intervention services are allowed per pregnancy and postdelivery.<=60 minutes/day; <=11 hours/pregnancy

Claims for additional units will be considered for reimbursement through the adjustment process only when coverage conditions are met and documentation supports medical necessity

Place of service and telehealth: Telehealth eligible services may be provided to new and established patients; telehealth claims should append modifier GT for interactive audio-visual delivery and follow Clinical Coverage Policy 1-H requirements.

For beneficiaries under 21, EPSDT (Early and Periodic Screening, Diagnostic and Treatment) rules modify standard policy limits: EPSDT does not require coverage of services that are unsafe, ineffective, experimental or investigational, or not generally recognized as accepted medical practice. Service limitations on scope, amount, duration, frequency, location, and other criteria may be exceeded when provider documentation demonstrates the service is medically necessary to correct or ameliorate a defect, physical or mental illness, or condition, or to prevent worsening or development of additional health problems.

Medicaid shall not cover the procedure, product, or service when the beneficiary fails to meet the eligibility requirements in Section 2.0, does not meet the coverage criteria in Section 3.0, or when the procedure, product, or service duplicates another provider’s service. Additionally, services that are experimental, investigational, or part of a clinical trial are not covered. No further specific Medicaid-only exclusions were listed for this policy.

For telehealth claims delivered via interactive audio-visual communication, append modifier GT to the CPT or HCPCS code. Modifier GT is not appropriate for services delivered as virtual communications alone (non-interactive) or for remote patient monitoring.

A procedure, product, or service is considered not covered when it duplicates another provider’s procedure or service, is experimental or investigational, part of a clinical trial, or when the beneficiary does not meet the eligibility or coverage criteria set out elsewhere in this policy.

Coding and Billing

Covered CPT CodesCPTCovered

96158	Health and Behavior Intervention; first 30 minutes of face-to-face contact with the patient (Telehealth Eligible)
96159	Health and Behavior Intervention; each additional 15 minutes (Telehealth Eligible), billable only after 96158

Referenced ICD-10 Codes (partial list)ICD-10

O09.01	ICD-10-CM code listed in attachment (example group)
Z33.1	ICD-10-CM code listed in attachment (example)

Unlisted Procedure Guidancemixed

unlisted (CPT/HCPCS)

Instructions for Unlisted Procedure or Service and Special Report per current CPT/HCPCS

ModifiersModifier

GT	Modifier GT to indicate service provided via interactive audio-visual communication (telehealth)

inv-13: Total reimbursable time per day

Total reimbursable time per day<= 60 minutes

Billing ruleTotal reimbursable time per day cannot exceed 60 total minutes of service

Adjustment process for excess unitsClaims for additional units considered only via adjustment when coverage conditions and documentation support medical necessity

inv-14: Total reimbursable time per pregnancy/postdelivery

Total reimbursable time per pregnancy/postdelivery<= 11 hours

Policy wording

Provider Actions and Requirements

Prior Authorization

Prior approval requirement for beneficiaries under 21

If the service requires prior approval, beneficiaries under 21 still require prior approval; providers should refer to the NCTracks Provider Claims and Billing Assistance Guide and the EPSDT provider page for details.

Prior Authorization

No prior approval required for Health and Behavior Intervention

Medicaid shall not require prior approval for Health and Behavior Intervention services.

Billing Rule

Treatment Modalities and Settings

Health and Behavior Intervention

Intervention description: Intensive, focused counseling including individualized problem-solving, priority setting, instruction, action planning, and individualized treatment therapies; may involve significant others or other providers.

From description of procedure

Telehealth

Telehealth: Select services within this policy may be provided via telehealth following Clinical Coverage Policy 1-H requirements.

Telehealth allowed for select services

Intensive Psychosocial Counseling / Health and Behavior Intervention

Modality requirements:

Visit Limits and Duration

inv-36: Health and Behavior Intervention

Service durationShort-term; may begin during pregnancy and continue through end of the month in which the 60th postdelivery day occurs

Place of serviceShould be face-to-face in the home or clinic; telephone allowed when life‑threatening situations exist

CoordinationMay be provided in addition to area mental health center services but must not duplicate the same service for the same reason; counseling must be coordinated

inv-37: Health and Behavior Intervention (combined CPT 96158/96159)

Combined CPT 96158/96159 time60 minutes per day when billed as combined 96158 (first 30 min) and 96159 (additional 15-min units)

Billing order96158 billed for first 30 minutes; 96159 billed for each additional 15 minutes and only after 96158 has been billed

Background

Health and Behavior Intervention provides intensive, focused counseling for pregnant and postpartum women with significant psychosocial needs. The service emphasizes individualized problem-solving, priority setting, instruction, action planning, and individualized treatment therapies and may involve significant others or coordination with other providers. Services should generally be face-to-face in the home or clinic, may be short-term (through 60 days postdelivery), and are intended to address conditions that could negatively affect pregnancy or maternal health. EPSDT provisions apply for beneficiaries under 21, which may affect limits when documentation shows the service is necessary to correct or ameliorate a health problem.

Definitions

inv-28: Definitions

DefinitionsNone Apply.

ImplicationNo specific additional definitions are provided within this policy section.

ReferenceSee policy text for standard terminology and usage.

inv-29: Covered conditions (Medicaid additional criteria)

Target populationPregnant or postpartum women with one or more specified psychosocial/behavioral conditions

Examples of covered conditionsSubstance use; child abuse/family violence; severe emotional crises; episodic disorders (severe depression, psychosis); suicidal tendencies; intense negative feelings about pregnancy; prior poor pregnancy outcome; HIV/AIDS and life‑threatening medical problems; pending incarceration; major disorders such as anorexia

Policy Summary

PayerAlliance Health

PolicyHealth and Behavior Intervention

Policy CodePolicy 1M-3

Change TypeNo material changes

Effective Date

Last ReviewAug 15, 2023

Next Review Date

Key ActionVerify beneficiary eligibility each time a service is rendered and document medical necessity per EPSDT when applicable.

SourceLink

On This Page

GT is not appropriate for virtual communications or remote patient monitoring

Eleven hours of Health and Behavior Intervention services is allowed per pregnancy and postpartum

Extra unitsClaims for additional units will be considered for reimbursement through the adjustment process only when coverage conditions are met and documentation supports medical necessity

Billing order, units, and per-date billing

Bill CPT code 96158 for the first 30 minutes of Health and Behavior Intervention and CPT code 96159 for each additional 15 minutes; CPT 96159 may only be billed after CPT 96158 has been billed.

Services must be billed per date of service.
Total reimbursable time per day cannot exceed 60 minutes; up to 11 hours allowed per pregnancy/postdelivery.

Step Therapy

Conservative therapy requirement (medical necessity)

Services must be medically necessary and provided only when no equally effective, more conservative, or less costly statewide alternative is available.

Note

Service duration and coordination; face-to-face preference

These services are intended to be short-term (may begin during pregnancy and continue through the end of the month in which the 60th postdelivery day occurs); refer beneficiaries with long-term counseling needs to other providers to avoid duplication with area mental health center services and coordinate counseling to ensure continuity of care.

Face-to-face in the home or clinic is preferred; telephone only when life‑threatening situations exist.
Services may be provided in addition to area mental health center services but must not duplicate the same service for the same reason.

Denial Risk

Verify Medicaid eligibility at each visit

Providers must verify each Medicaid beneficiary's eligibility at each service encounter and be aware beneficiaries may have service restrictions based on eligibility category.

Documentation Required

EPSDT documentation and prior approval guidance for <21

For beneficiaries under 21, provider documentation must demonstrate that the requested service is medically necessary to correct or ameliorate a condition per EPSDT requirements; the EPSDT and prior approval guidance in NCTracks applies.

Documentation Required

Coding specificity and use current code editions

Report ICD-10-CM and PCS codes to the highest level of specificity that supports medical necessity using the current ICD-10 edition; report the most specific CPT/HCPCS code that accurately describes the service.

Denial Risk

Eligibility verification and potential service restrictions

Providers must verify beneficiary eligibility each time a service is rendered; beneficiaries may have eligibility-based service restrictions that could make them ineligible for this service.

Denial Risk

General denial triggers

Services will be denied if the beneficiary does not meet eligibility in Section 2.0, does not meet the criteria in Section 3.0, duplicates another provider's service, or if the procedure/product/service is experimental, investigational, or part of a clinical trial.

Billing Rule

Additional units require adjustment review and documentation

Claims for additional units beyond allowed totals will be considered for reimbursement only through the adjustment process when coverage conditions are met and documentation supports medical necessity.

Services should be face-to-face in the home or clinic; telephone allowed when life-threatening situations exist; services may be provided in addition to area mental health center services but must not duplicate the same service for the same reason.

through 60 days postdelivery

Short-term service; long-term needs require referral

Health and Behavior Intervention (telehealth eligible)

Health and Behavior Intervention via telehealth: CPT codes 96158 and 96159 are telehealth eligible; interactive audio-visual telehealth claims must append modifier GT; telehealth services may be provided to new and established patients.

GT modifier required for interactive audio-visual services

Telehealth eligibility96158 and 96159 are telehealth eligible (see modifier guidance)

inv-38: Health and Behavior Intervention

Allowed per pregnancy/postdelivery11 hours of Health and Behavior Intervention services allowed per pregnancy and postdelivery

DocumentationClaims beyond allowed totals considered only via adjustment when documentation supports medical necessity

Billing per dateHealth and Behavior Intervention must be billed per date of service

Coverage triggerAt least one of the listed conditions must be present for Medicaid additional criteria to be met

inv-30: postdelivery

Terminology changePostdelivery replaces the term 'postpartum' in policy terminology

Revision dateChange reflected in policy revision dated 05/15/2022

NotePolicy language updated to use 'postdelivery' throughout; see revision history for details