CurrentBeacon-Health-OptionsPolicy PT 71-24

Medicaid Coverage for Collaborative Care Model Services: HealthChoice and Fee-for-Service

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This policy governs Maryland Medicaid HealthChoice managed care and full-benefit Fee-for-Service reimbursement, provider participation, billing, coverage criteria, and coordination requirements for Collaborative Care Model services delivered by primary care-led teams.

Policy Summary

PayerBeacon-Health-Options

PolicyMedicaid Coverage for Collaborative Care Model Services: HealthChoice and Fee-for-Service

Policy CodePolicy N/A

Change TypeExpanded and clarified coverage and reimbursement guidance

Effective DateOctober 1, 2023

Next Review DateNot specified

Key ActionDo not obtain prior authorization for Collaborative Care Model services billed under HealthChoice or full-benefit Fee-for-Service Medicaid.

SourceLink

POLICY UPDATE CHANGES

Maryland Medicaid expanded Collaborative Care Model coverage to all Medicaid participants.

The guidance establishes and clarifies reimbursement methodology, monthly billing limits, and minimum payment requirements for HealthChoice, Fee-for-Service, FQHC, and RHC Collaborative Care Model services.

The guidance clarifies that the primary care provider is the only provider who bills Medicaid for Collaborative Care Model services.

The guidance clarifies required coordination with the behavioral health administrative services organization before enrolling a participant in Collaborative Care Model services.

This guidance supersedes prior guidance identified as PT 47-24, PT 35-24, and PT 26-24.

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CurrentBeacon-Health-OptionsPolicy PT 71-24

Medicaid Coverage for Collaborative Care Model Services: HealthChoice and Fee-for-Service

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Sign up for Beacon-Health-Options Policy PT 71-24 alerts

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Policy Summary

PayerBeacon-Health-Options

PolicyMedicaid Coverage for Collaborative Care Model Services: HealthChoice and Fee-for-Service

Policy CodePolicy N/A

Change TypeExpanded and clarified coverage and reimbursement guidance

Effective DateOctober 1, 2023

Next Review DateNot specified

Key ActionDo not obtain prior authorization for Collaborative Care Model services billed under HealthChoice or full-benefit Fee-for-Service Medicaid.

SourceLink

POLICY UPDATE CHANGES

Maryland Medicaid expanded Collaborative Care Model coverage to all Medicaid participants.

The guidance clarifies that the primary care provider is the only provider who bills Medicaid for Collaborative Care Model services.

The guidance clarifies required coordination with the behavioral health administrative services organization before enrolling a participant in Collaborative Care Model services.

This guidance supersedes prior guidance identified as PT 47-24, PT 35-24, and PT 26-24.

3Core CoCM service components

4Covered billing codes

1 + 2Monthly PCP billing structure

$161.28CPT 99492 payment

$145.08HCPCS G0512 payment

NonePrior authorization

Participant, Provider, and Coordination Requirements

Participant eligibility

The participant must meet all of the following eligibility conditions:

ALL of the following

The participant receives Medicaid benefits through a HealthChoice managed care organization (MCO) or is enrolled in full-benefit Fee-for-Service (FFS) Medicaid.
The participant’s behavioral health diagnosis is clinically appropriate for the primary care setting.
A validated tool is available to monitor symptoms and quantify outcomes.

Provider and billing requirements

Covered reimbursement requires compliance with the applicable provider, billing, time, and reimbursement pathway requirements:

ALL of the following

The billing provider is an eligible Maryland Medicaid primary care provider, and CoCM services are billed under the PCP’s name and provider number. Behavioral health care managers and psychiatric consultants may not bill Medicaid directly for CoCM services.
Claims use the applicable CoCM billing code and are based on the cumulative time spent by the behavioral health care manager on clinical activities for the individual during the month, with the monthly minutes distributed across the month and documented in the medical record.
For the standard PCP billing pathway, bill either CPT 99492 or CPT 99493 once per month and CPT 99494 up to twice per month. These limits may be exceeded based on medical necessity.
ONE of the following billing pathways applies
- The standard PCP pathway is used: bill one applicable 60- or 70-minute base code per month, with up to two additional 30-minute codes per month, as supported by the patient’s needs and evidence-based model requirements.
- The FQHC or RHC pathway is used: bill HCPCS G0512 once per month when at least 60 minutes of care are provided to the individual during the month; do not bill CPT 99492, 99493, or 99494. The service minutes may be distributed across multiple episodes of care and must be documented in the medical record.

ASO coordination

The following coordination requirements apply before engaging a participant in CoCM:

ALL of the following

Contact the behavioral health administrative services organization (ASO) to determine whether the participant is receiving specialty behavioral health services reimbursed by the ASO.
CoCM and specialty behavioral health services may both be provided when the services address appropriate separate conditions or needs, such as CoCM for depression and ASO-reimbursed substance use disorder treatment.
Use a Release of Information (ROI) that meets the requirements of 42 CFR Part 2 when consent is needed to coordinate care with the ASO.

Covered Codes and Billing Frequencies

Initial-month psychiatric collaborative care managementCPTCovered

99492

Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional.

Subsequent-month psychiatric collaborative care managementCPTCovered

99493

Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional.

Additional CoCM timeCPTCovered

99494

Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month; may only be used with 99492 or 99493 in the same month.

FQHC/RHC psychiatric CoCMHCPCSCovered

G0512

For FQHCs or RHCs only: psychiatric CoCM, 60 minutes or more of clinical staff time for psychiatric services directed by an FQHC practitioner and including behavioral health care manager services and psychiatric consultant consultation, per calendar month.

Telehealth and telephonic modifiersModifier

-GT	Telehealth modifier permitted for CoCM providers when the service is provided via telehealth.
-UB	Modifier required with the appropriate service code to identify an audio-only telephonic service.

Examples of diagnoses suitable for CoCM considerationICD-10

F32.1	Major depressive disorder, single episode, moderate.
F33.0	Major depressive disorder, recurrent, mild.
F41.0	Generalized anxiety disorder.
Z73.3	Stress, not elsewhere classified.

PCP base-code frequency

Base codesCPT 99492 or 99493

FrequencyOnce per month

ExceptionThe monthly limit may be exceeded based on medical necessity

Additional-time code frequency

Additional-time codeCPT 99494

FrequencyUp to twice per month

Operational and Billing Actions

Prior Authorization

Prior Authorization Not Required

Prior authorization is not required for Collaborative Care Model (CoCM) services under either HealthChoice managed care or Fee-for-Service (FFS) Medicaid.

Note

Verify Eligibility and Diagnosis Suitability

Before billing CoCM services, verify that the enrollee receives HealthChoice benefits or is enrolled in FFS Medicaid with full benefits, and confirm that the behavioral health diagnosis is clinically appropriate for primary care and can be monitored with a validated symptom and outcomes tool.

Eligible conditions include, but are not limited to, depression, anxiety, and substance use disorder (SUD).
Examples of diagnosis codes include F32.1, F33.0, F41.0, and Z73.3.

Collaborative Care Model Roles and Benchmarks

Collaborative Care Model care team

Primary care providerLeads the care team and coordinates care

Behavioral health care managerProvides behavioral health coordination and intervention

Psychiatric consultantProvides psychiatric consultation to the team

Primary care provider

Eligible practitioner typesPhysician, advanced practice nurse, physician assistant, pediatrician, or practitioner who delivers obstetric or gynecological services

RolePrimary coordinator of care who provides accessible, continuous, comprehensive, and coordinated health services

Policy Summary

PayerBeacon-Health-Options

PolicyMedicaid Coverage for Collaborative Care Model Services: HealthChoice and Fee-for-Service

Policy CodePolicy N/A

Change TypeExpanded and clarified coverage and reimbursement guidance

Effective DateOctober 1, 2023

Next Review DateNot specified

Key ActionDo not obtain prior authorization for Collaborative Care Model services billed under HealthChoice or full-benefit Fee-for-Service Medicaid.

SourceLink

On This Page

Billing conditionMay only be used with 99492 or 99493 in the same month

FQHC/RHC G0512 frequency

CodeHCPCS G0512

FrequencyOnce per month

Applicable providersFederally Qualified Health Centers and Rural Health Clinics

FQHC/RHC minimum monthly time

Minimum timeAt least 60 minutes of care for an individual in the month

Billing consequenceIf less than 60 minutes is provided in the month, the FQHC or RHC may not bill G0512

DocumentationThe service time must be documented in the medical record

Monthly PCP billing structure

Base monthly serviceEither one 60-minute or 70-minute code per month

Additional servicesUp to two additional 30-minute codes per month

Billing basisThe combination is contingent upon patient needs and evidence-based model requirements

Documentation Required

Coordinate With the Behavioral Health ASO

Before engaging a Medicaid participant in CoCM, contact the behavioral health administrative services organization (ASO) to determine whether the participant is receiving specialty behavioral health services reimbursed by the ASO.

Contact the ASO at 1-800-888-1965.
Use a Release of Information that satisfies 42 CFR Part 2 to coordinate care with the ASO.
CoCM and specialty behavioral health services may both be appropriate when they address different conditions, such as CoCM for depression and ASO-funded treatment for SUD.
If the ASO has an open authorization, it may confirm only that information when contacted by the participant’s PCP, even if the participant signed a release.

Documentation Required

Maintain Provider Enrollment and Model Compliance

Maintain Maryland Medicaid enrollment and comply with the evidence-based CoCM model. Only an eligible enrolled PCP may seek Medicaid reimbursement for CoCM; the behavioral health care manager and psychiatric consultant may be employees or contractors of the PCP.

PCPs must be enrolled as an eligible primary care provider type under COMAR 10.67.05.05; providers not yet enrolled must apply through ePREP.
Eligible PCP types include physicians, advanced practice nurses, physician assistants, pediatricians, and practitioners providing obstetric or gynecologic services who coordinate the enrollee’s primary care.
By billing, providers attest that they reviewed standard CoCM guidelines, implemented CoCM consistently with those guidelines, and provide services in accordance with them.
The behavioral health care manager must be a qualified behavioral health professional working under the PCP’s general supervision and supports treatment initiated by the PCP, including medication monitoring.
The treating PCP who bills need not be onsite when the behavioral health care manager delivers services.
The psychiatric consultant is typically a psychiatrist, psychiatric nurse practitioner, addiction medicine specialist, or other federally permitted behavioral health specialist; direct patient contact, prescribing, and direct treatment are not required, and the consultant need not be an enrolled Medicaid provider.
The CoCM team establishes treatment and measurable benchmarks for the patient’s next six months.

Billing Rule

Apply Monthly Billing and Time Documentation Rules

For office-based CoCM, only the treating PCP may bill. Submit the applicable monthly code combination and base billing on the behavioral health care manager’s cumulative clinical time for the individual patient, with the month’s minutes distributed across the month rather than delivered in a single episode.

Bill either CPT 99492 (initial month, first 70 minutes) or 99493 (subsequent month, first 60 minutes) once per month.
Bill CPT 99494 for each additional 30 minutes, up to twice per month; it may be billed only with 99492 or 99493 in the same month.
The stated limits may be exceeded when supported by medical necessity.
The behavioral health care manager and psychiatric consultant may not bill CoCM services directly.
MCO reimbursement must be no lower than the applicable FFS rate.

Billing Rule

Use the FQHC and RHC Billing Pathway

FQHC and RHC CoCM providers must use HCPCS G0512 as the monthly billing pathway and may bill it only once per month. Document the required clinical time in the medical record and apply the code only when the minimum monthly threshold is met.

G0512 requires at least 60 minutes of clinical staff time in a calendar month; 60 minutes or 70 minutes for a new patient may be distributed across multiple episodes of care during the month.
Do not bill G0512 when fewer than 60 minutes of care are provided in the month.
FQHCs and RHCs may not bill 99492, 99493, or 99494 for CoCM.
Bill FQHC services under the rendering PCP’s name and provider number; reimbursement is at the FFS rate and is not included in the all-inclusive cost base rate.
A routine medical care visit may be reimbursed in addition to CoCM services when rendered on the same day.

Billing Rule

Report Telehealth Services

For CoCM services delivered via telehealth, submit the appropriate service code with the -GT modifier.

The -GT modifier indicates that the service was provided via telehealth.

Billing Rule

Report Audio-Only Telephonic Services

For audio-only telephonic CoCM services, submit the appropriate service code with the -UB modifier to identify the service as telephonically delivered.

Use the -UB modifier with the applicable CoCM service code for audio-only telephonic delivery.

Billing responsibility

The PCP is the only provider who seeks Medicaid reimbursement under the model

Behavioral health care manager

QualificationsNurse, licensed social worker, psychologist, or other licensed professional with formal education or specialized training in behavioral health coordination and intervention

SupervisionWorks under the general supervision of the primary care provider

RoleSupports and implements treatment initiated by the PCP, such as medication monitoring

Psychiatric consultant

Typical specialist typesLicensed psychiatrist, psychiatric nurse practitioner, addiction medicine specialist, or other behavioral health medicine specialist allowed under federal regulations

Patient contactTypically is not expected to have direct contact with the patient

Direct treatment and enrollmentIs not expected to prescribe medication or deliver treatment directly to the patient and is not required to be an enrolled Medicaid provider

CoCM treatment benchmarks

Established byThe Collaborative Care Model care team

PurposeSet measurable benchmarks for the patient to reach

Time frameThe next six months