CurrentBlue Cross Blue Shield - NevadaPolicy C-11003

Health and Behavior Assessment and Intervention (HBAI) reimbursement

Defines when Blue Cross Blue Shield - Nevada will separately reimburse HBAI services delivered by non-physician behavioral healthcare professionals and lists related CPT codes and frequency limits; applies to commercial members and providers submitting claims to the payer.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyHealth and Behavior Assessment and Intervention (HBAI) reimbursement

Policy CodePolicy C-11003

Change TypeNo material change

Effective DateMay 8, 2024

Next Review DateN/A

Key ActionEnsure services meet authorization and medical necessity guidelines and follow billing/submission requirements using industry-standard codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9 codesRelated HBAI procedure codes listed

MovedFrequency limits relocated

CoveredCovered when primary medical diagnosis

Not coveredNot reimbursed with primary mental health dx

Non-physicianProvider requirement

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.

When HBAI Is Reimbursed

HBAI reimbursement criteria

Conditions under which separate reimbursement for HBAI codes is allowed and not allowed:

ALL of the following

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

Not separately reimbursed when

Services are reported with a primary mental health or psychiatric diagnosis
Services are reported by a physician or other qualified healthcare professional who is licensed to report evaluation and management or preventive medicine services

CPT Codes and Frequency Limits

HBAI related 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 (List separately in addition to code for primary service)
96164	Health behavior intervention, group (2 or more patients): Face-to-face; initial 30 minutes
96165	Each additional 15 minutes (List separately in addition to code for primary service)
96167	Health behavior intervention, family (with the patient present) face-to-face; initial 30 minutes
96168	Each additional 15 minutes (List separately in addition to code for primary service)
96170	Health behavior intervention, family (without the patient present) face-to-face; initial 30 minutes
96171	Each additional 15 minutes (List separately in addition to code for primary service)

Frequency limits

96158Health behavior intervention, individual, face-to-face; initial 30 minutes — frequency limit: 1 per date of service.

96159Each additional 15 minutes (list separately in addition to code for primary service). Use in conjunction with 96158 — frequency limit: up to 6 per date of service.

96164Health behavior intervention, group (2 or more patients) face-to-face; initial 30 minutes — frequency limit: 1 per date of service.

96165Each additional 15 minutes (list separately in addition to code for primary service). Use in conjunction with 96164 — frequency limit: up to 6 per date of service.

Authorization, Billing, and Documentation Requirements

Prior Authorization

Follow authorization, medical necessity, billing and documentation requirements

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence. Providers must follow proper billing and submission guidelines and use industry-standard, compliant codes (CPT, HCPCS, revenue codes); billed services must be fully supported in the medical record or office notes. Failure to follow coding/billing guidelines or current reimbursement policies may result in recovery/recoupment of payment, or claim rejection/denial.

Confirm any required prior authorization and that services meet medical necessity for the procedure, diagnosis, and member’s state of residence.
Bill using industry-standard, compliant codes (CPT, HCPCS, revenue codes) and ensure documentation in the medical record supports billed services.
Be aware Anthem may recover/recoup payment or reject/deny claims if coding/billing guidelines or reimbursement policies are not followed.

Key Definitions

Health and Behavior Assessment

DefinitionThe evaluation of the patient's responses to disease, illness or injury, outlook, coping strategies, motivation, and adherence to medical treatment.

PurposeAssess how a patient is responding to a medical condition and their ability to follow treatment recommendations.

Typical componentsHealth-focused clinical interview, behavioral observations, and clinical decision making (see related CPT 96156 for assessment/re-assessment).

Health and Behavior Intervention

DefinitionThe promotion of functional improvement; minimizing psychological and/or psychosocial barriers to recovery, and management of and improved coping with medical conditions.

GoalsPromote functional improvement and reduce barriers that impede recovery from physical illness or injury.