CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Integrated Behavioral Health Services / Collaborative Care Model (CoCM) payment guidelines

Defines BCBSRI reimbursement and program-approval requirements for Collaborative Care Model (CoCM) and other integrated behavioral health services for BlueCHiP for Medicare and Commercial products, and describes when services are covered, billing expectations, and a commercial cost-share waiver for OHIC-designated practices.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyIntegrated Behavioral Health Services / Collaborative Care Model (CoCM) payment guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionProviders must submit a detailed program description to Behavioralhealth@bcbsri.org and receive BCBSRI approval before CoCM or other integrated BHI services will be separately reimbursed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99492–99494, 99484, G0512, 90791–90792Key CPT/HCPCS referenced

Approval requiredSeparate reimbursement

HK modifierCommercial copay waiver

WeeklyConsultation frequency

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Coverage and Program Requirements

Coverage and program requirements for CoCM and BHI care management

Services follow CMS guidelines and are covered; separate reimbursement is allowed only after BCBSRI approval. Program descriptions must demonstrate the following elements.

Program approval required: Providers must submit a detailed program description and receive BCBSRI approval before CoCM or other integrated behavioral health integration (BHI) services will be separately reimbursed; until approval these services are covered but not separately reimbursed.

Submission instructions: Program descriptions must be sent to Behavioralhealth@bcbsri.org and include a cover sheet with provider billing numbers, provider information, and National Provider Identifier (NPI).

Alignment with CMS CoCM requirements: Program must follow the Collaborative Care Model team approach (primary care practitioner, behavioral health care manager, psychiatric consultant) and meet CMS-specified service elements (initial assessment, validated scales, individualized treatment plan, registry use, and weekly caseload consultation with psychiatric consultant).

ALL of the following

Job description for the behavioral health (BH) care manager demonstrating a collaborative integrated relationship with team members and formalized specialized behavioral health training (examples: social work, nursing, psychology).
Initial assessment including administration of validated clinical rating scales and development of an individualized treatment plan.
Plan for patient identification, outreach, and engagement directed by the primary care provider.
Evidence of a compact/contract with a psychiatric consultant and a documented psychiatric consultation/referral process.
Written workflows documenting evidence‑based treatment interventions (e.g., behavioral activation, problem‑solving treatment, motivational interviewing), relapse prevention planning, discharge planning, and coordination with the PCP and other treating providers.
Use of a registry for tracking follow‑up and outcomes monitoring using validated scales, with appropriate documentation of tracking and progress.
Demonstrated evidence of weekly caseload review with the psychiatric consultant.

ALL of the following

Examples (at least one may apply)
- Employment or contract with a dedicated BH care manager (may be non‑licensed but with relevant behavioral health experience, e.g., psychiatric nurse or master’s‑level clinician).
- Capability to provide brief psychosocial interventions, coaching, and support; facilitation and coordination of psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation.
- Ability to provide face‑to‑face and telephonic services during and outside clinic hours, and capability to report on specified quality measures upon request (e.g., alcohol screening and brief counseling, depression remission/response, follow‑up for children on ADHD medication).

Billing and limitations: Until BCBSRI approval, CoCM and other BHI services are covered but not separately reimbursed (exception: primary care providers may bill separately after program approval). Benefits may vary by group—refer to the member's benefit booklet, evidence of coverage, or subscriber agreement for specific group benefits.

Submission, Approval, and Billing Actions for Providers

Prior Authorization

Program approval required for separate reimbursement

BCBSRI follows CMS guidelines: Collaborative Care Management (CoCM) services and other behavioral health integration services are covered but are not separately reimbursed unless the provider submits a detailed program description and receives BCBSRI approval. Providers must submit the program description and receive written approval from BCBSRI before separate reimbursement is allowed.

Program descriptions must include: job description for the behavioral health care manager demonstrating collaborative relationships and relevant training; initial assessment with validated scales and resulting treatment plan; plan for patient identification, outreach and engagement directed by the PCP; evidence of a contract/compact with a psychiatric consultant; psychiatric consultation/referral process; written workflows documenting evidence‑based interventions, relapse prevention and discharge planning; plans for ongoing collaboration and coordination with PCP and other treating providers; demonstrated use of a registry for tracking follow up and progress; evidence of outcome monitoring using validated rating scales; evidence of weekly caseload review with the psychiatric consultant.

Note

How to submit program descriptions

Submit all program descriptions and required supporting documentation to BehavioralHealth@bcbsri.org. Include a cover sheet with: BCBSRI provider number(s), provider billing information, and National Provider Identifier (NPI). The program description should explicitly address the required elements listed by BCBSRI (see program approval callout).

Send to: BehavioralHealth@bcbsri.org
Cover sheet must include: provider billing number(s); provider information; NPI

Billing Rule

Cost‑share waiver billing modifier and eligibility

For commercial plans only, BCBSRI will waive member copayments for eligible behavioral health services when rendered by a BCBSRI‑credentialed behavioral health provider within an OHIC‑designated Qualifying Integrated Behavioral Health Primary Care Practice on the same day as a qualifying primary care visit and when billed with the required modifier. To receive the copay waiver the practice must be designated by OHIC and the service must be one of the eligible codes.

Waiver applies to fully insured individual, small group, and group plans (self‑funded plans may opt in or out); non‑Rhode Island BCBS members are not eligible.
Eligible services must be billed with modifier: HK
Eligible behavioral health CPT codes include: 90791-90792, 90832-90837, 90839-90840, 90846-90847, 90849, 90853, 90863; screening/brief intervention: 99408-99409; health and behavior assessment codes: 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171.
All IRS rules for high deductible health plans apply.

Definitions

Collaborative Care Model (CoCM) — definition and team roles

Model definitionA team-based Behavioral Health Integration approach in which patients are cared for by a primary care practitioner, a behavioral health care manager, and a psychiatric consultant working collaboratively using registries, validated scales, and regular caseload consultation

Team responsibilitiesPrimary care practitioner directs patient identification, engagement, and overall treatment plan; psychiatric consultant provides regular review and treatment recommendations; behavioral health care manager delivers care management and coordination

Operational elementsUse of a registry for tracking follow-up and outcomes, administration of validated rating scales, evidence-based brief interventions, and weekly caseload review with the psychiatric consultant

Behavioral Health (BH) care manager — definition and role

Role summaryDesignated staff member responsible for outreach, assessment, registry maintenance, brief evidence-based interventions, care coordination, and continuous relationship with the patient within the integrated model

QualificationsMay be non-licensed but must have relevant behavioral health experience (e.g., psychiatric nurse, Master’s-level clinician without independent license) and demonstrate training/education in behavioral health

Key activitiesInitial assessment including validated scales; enrollment and tracking in a registry; participation in weekly caseload consultation with psychiatric consultant; facilitation of psychotherapy, pharmacotherapy, counseling, and brief psychosocial interventions

Supervision and directionClinical staff time is directed by a physician or other qualified health care professional; care manager works in collaboration with the PCP and psychiatric consultant and documents workflows for coordination and relapse prevention

OpenPayer

Integrated Behavioral Health Services / Collaborative Care Model (CoCM) payment guidelines

Coverage and Program Requirements

Covered Codes, Billing Rules, and Time Thresholds

Submission, Approval, and Billing Actions for Providers

Definitions