CurrentBlue Cross Blue Shield - MainePolicy C-11003

Health and Behavior Assessment and Intervention (HBAI) reimbursement

Defines when the health plan allows separate reimbursement for health and behavior assessment and intervention codes and related coding/frequency limits for commercial professional claims; applies to providers submitting claims to Blue Cross Blue Shield - Maine.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyHealth and Behavior Assessment and Intervention (HBAI) reimbursement

Policy CodePolicy C-11003

Change TypeAdded coding frequency limits

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionEnsure services meet authorization and medical necessity guidelines and use proper billing codes and documentation.

SourceLink

POLICY UPDATE CHANGES

Updated Related Coding section comments by adding frequency limits for CPT codes 96158-96159 and 96164-96165.

196158 limit

696159 limit

196164 limit

696165 limit

04/01/2026effective

Coverage Criteria for HBAI Services

HBAI coverage criteria

Covered when ALL of the following are met, unless provider, state, or federal contracts/mandates indicate otherwise:

ALL of the following

Service rendered by a qualified non-physician behavioral healthcare professional
Service reported with a primary medical diagnosis of an acute or chronic physical illness

Not eligible for separate HBAI reimbursement when ANY of the following apply:

Services are reported by a physician or other qualified healthcare professional who is licensed to report evaluation and management or preventive medicine services

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyHealth and Behavior Assessment and Intervention (HBAI) reimbursement

Policy CodePolicy C-11003

Change TypeAdded coding frequency limits

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionEnsure services meet authorization and medical necessity guidelines and use proper billing codes and documentation.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

CPT Codes and Frequency Limits

HBAI CPT codesCPTCovered

96156	Health behavior assessment or re-assessment (health-focused clinical interview, behavioral observations, clinical decision making)
96158	Health behavior intervention, individual, face-to-face; initial 30 minutes
96159	Each additional 15 minutes (in addition to primary service)
96164	Health behavior intervention, group (2 or more patients), face-to-face; initial 30 minutes
96165	Each additional 15 minutes (in addition to primary service)
96167	Health behavior intervention, family (with patient present) face-to-face; initial 30 minutes
96168	Each additional 15 minutes (in addition to primary service)
96170	Health behavior intervention, family (without patient present) face-to-face; initial 30 minutes
96171	Each additional 15 minutes (in addition to primary service)

96158 per-date frequency limit1

Code descriptionHealth behavior intervention, individual, face-to-face; initial 30 minutes

Comment sourceRelated Coding comments specify frequency limit of 1 per date of service

96159 per-date frequency limit6

Code descriptionEach additional 15 minutes (List separately in addition to code for primary service)

Usage noteUse in conjunction with 96158; frequency limit of 6 per date of service

96164 per-date frequency limit1

Code descriptionHealth behavior intervention, group (2 or more patients), face-to-face; initial 30 minutes

Comment sourceRelated Coding comments specify frequency limit of 1 per date of service

96165 per-date frequency limit6

Code descriptionEach additional 15 minutes (List separately in addition to code for primary service)

Usage noteUse in conjunction with 96164; frequency limit of 6 per date of service

Provider Requirements and Billing Restrictions

Documentation Required

Authorization and documentation requirements

Prior authorization is not routinely required for HBAI codes; however services must meet the plan's medical necessity and documentation requirements and may be subject to authorization per the member's benefit plan or state/federal mandates. Ensure claims include medical record documentation supporting the HBAI service, the presenting physical health diagnosis, clinical rationale linking the behavioral intervention to the physical condition, treatment plan, and time spent. Failure to follow applicable authorization or medical necessity rules may result in denial, recovery, or recoupment of payment.

Services must meet member benefit, authorization and medical necessity rules.
Document primary medical diagnosis, clinical rationale, treatment plan, and time units.
Follow state, federal, provider contract and CMS mandates which may supersede this policy.

Billing Rule

Provider and diagnosis restrictions

HBAI services must be furnished and billed by a qualified non-physician behavioral healthcare professional. Physicians or other professionals licensed to report E/M or preventive services should not separately report HBAI for services that overlap with E/M or preventive care. When applicable, use the appropriate practitioner identifier, modifier, or practice-location indicator per billing guidelines to reflect the non-physician behavioral provider.

Only qualified non-physician behavioral healthcare professionals may report HBAI.
Do not report HBAI with a primary mental health or psychiatric diagnosis — primary diagnosis must be an acute or chronic physical illness.
Use applicable modifiers/practice indicators to identify the reporting provider when required.

Denial Risk

Denial risk conditions

Claims for HBAI are at risk for denial or non-reimbursement if any of the following apply: billed by a physician or a provider already eligible to bill E/M or preventive services; billed with a primary mental health/psychiatric diagnosis; insufficient documentation tying the service to the member's physical health condition; or if authorization, coding, or billing guidelines are not followed. The plan may also deny, recover, or recoup payment if state, federal, or contract mandates override coverage.

Reported by a physician or provider licensed to bill E/M or preventive services.
Primary diagnosis is a mental health or psychiatric disorder.
Medical record lacks documentation of primary physical diagnosis, clinical rationale, treatment plan, or time spent.
Authorization, coding, or billing rules not followed, or superseding mandates apply.

OpenPayer

Health and Behavior Assessment and Intervention (HBAI) reimbursement

Coverage Criteria for HBAI Services

CPT Codes and Frequency Limits

Provider Requirements and Billing Restrictions

Definitions