CurrentBlue Cross Complete of MichiganPolicy N/A

State of Michigan Residential Mental Health and Substance Use Disorders

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This enhanced benefit policy governs coverage, payment conditions, coding, reimbursement, cost sharing, and billing for residential mental health and residential substance use disorder treatment under the BCN Advantage Medicare Advantage HMO in Michigan. It applies to providers furnishing these services to eligible members.

Policy Summary

PayerBlue Cross Complete of Michigan

PolicyState of Michigan Residential Mental Health and Substance Use Disorders

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 202747d

Next Review DateN/A

Key ActionSubmit claims on a UB-04 or equivalent 837 claim form using BCN Advantage billing requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursResidential mental health treatment duration

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CurrentBlue Cross Complete of MichiganPolicy N/A

State of Michigan Residential Mental Health and Substance Use Disorders

Customize your policy alerts

Sign up for all blue_cross_complete_of_michigan policy alerts

Know when blue_cross_complete_of_michigan releases new policies or updates existing guidance.

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Policy Summary

PayerBlue Cross Complete of Michigan

PolicyState of Michigan Residential Mental Health and Substance Use Disorders

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 202747d

Next Review DateN/A

Key ActionSubmit claims on a UB-04 or equivalent 837 claim form using BCN Advantage billing requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursResidential mental health treatment duration

2Covered residential treatment revenue codes

12ICD-10 code categories listed

086Payable facility location code

N/ABenefit frequency limit

190 daysFreestanding psychiatric hospital limit

Residential Benefit Coverage Criteria

Residential benefit payment conditions

Residential mental health and substance use disorder treatment is an enhanced benefit payable when all applicable payment conditions are met.

Payment conditions

Covered residential service: Residential mental health treatment or residential substance use treatment
Eligible provider: Contracted psychiatric residential treatment facility or substance abuse facility
Payable location: Residential facility086

Original Medicare does not cover residential mental health treatment or residential substance abuse treatment. BCN Advantage provides these services as an enhanced benefit, with coverage subject to the plan’s benefit scope, reimbursement methodology, maximum allowable payment amounts, and applicable member cost sharing.

When a member elects to receive a noncovered service, the member is responsible for the entire charge associated with that service. Providers may not use an Advance Beneficiary Notice of Noncoverage to obtain financial responsibility for noncovered items. If coverage is uncertain, the provider must obtain a coverage determination from BCN Advantage before providing the service; when this determination is not obtained, the member must be held harmless for all charges other than applicable cost sharing.

Billing and Diagnosis Codes

Covered Revenue CodesRevenueCovered

1001	Residential treatment - Psychiatric
1002	Residential treatment - Chemical Dependency

CPT/HCPCS Codesmixed

Not Applicable

CPT/HCPCS codes not applicable

Covered ICD-10 CodesICD-10Covered

F00 - F00.9	Dementia in Alzheimer's disease
F01 - F09	Mental disorders due to known physiological conditions
F10 - F19	Mental and behavioral disorders due to psychoactive substance use
F20 - F29	Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders
F30 - F39	Mood (affective) disorders
F40 - F48	Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders
F50 - F59	Behavioral syndromes associated with physiological disturbances and physical factors
F60 - F69	Disorders of adult personality and behavior
F70 - F79	Intellectual disabilities
F80 - F89	Pervasive and specific developmental disorders

1–10 of 12

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Provider Billing and Coverage Responsibilities

Billing Rule

Submit Claims Using BCN Advantage Requirements

Submit residential mental health and substance use disorder services on the UB-04 or equivalent 837 claim form and follow BCN Advantage’s unique billing requirements.

Report CPT/HCPCS and diagnosis codes to the highest level of specificity.
Include the National Provider Identifier (NPI) on every claim.
Send electronic and paper claims to BCN Advantage. Michigan providers should use the applicable Blue Cross EDI Institutional 837/835 companion documents; providers outside Michigan should contact their local Blue plan for billing instructions.
Mail paper claims to BCN Advantage Claims, Blue Care Network, P.O. Box 68753.

Documentation Required

Residential Treatment Benefit Overview

Residential mental health treatment is a 24-hour, non-hospital, live-in clinical service that provides structured psychiatric, therapeutic, and behavioral care for individuals with severe or complex mental health disorders. Residential substance use treatment is a live-in program providing continuous support, clinical supervision, and evidence-based therapies in a safe, structured environment, with emphasis on behavioral healing, life-skills development, and social reintegration rather than the acute medical management provided in inpatient hospital care.

Residential Treatment Definitions

Residential mental health treatment

Service setting24-hour, non-hospital, live-in clinical service

Care providedStructured psychiatric, therapeutic, and behavioral care

Individuals servedIndividuals with severe or complex mental health disorders

Residential substance use treatment

Service settingLive-in program

Support and supervisionContinuous support and clinical supervision

TherapiesEvidence-based therapies

Residential Level of Care

Benefit Frequency Limits

Residential mental health and substance use disorder treatment

Benefit frequency limitNot applicable

Policy Summary

PayerBlue Cross Complete of Michigan

PolicyState of Michigan Residential Mental Health and Substance Use Disorders

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 202747d

Next Review DateN/A

Key ActionSubmit claims on a UB-04 or equivalent 837 claim form using BCN Advantage billing requirements.

SourceLink

On This Page

Medical Records May Be Required

Providers not contracted with BCBSM or BCN’s Medicare Advantage network may be required to submit documentation supporting billed claims, including applicable medical records. All providers should review applicable BCBSM reimbursement policies before submitting claims; contracted providers should also review the provider manual for additional claim requirements.

Documentation may include medical records and other support for the billed services.
Bill covered services in accordance with applicable BCBSM reimbursement policies.

Note

Verify Benefits and Cost Sharing

Verify member benefits and applicable cost sharing before or at the time of service through the provider portal or by calling 1-800-344-8525. Collect only the appropriate BCN Advantage copayment, coinsurance, or deductible.

Collect applicable cost sharing at the time of service when possible.
BCN Advantage payment is the lesser of Medicare’s allowed amount or the provider’s charge, minus the member’s cost share; this is payment in full and providers may not balance bill the member.

Denial Risk

Use an Eligible Contracted Facility

For residential mental health and substance use disorder services to be payable, the provider must be an eligible contracted psychiatric residential treatment facility or substance abuse facility. Services furnished by an ineligible or noncontracted facility may be denied or not payable.

Confirm the facility’s contracted and eligible provider status before furnishing services.

Denial Risk

Residential Facility Location Required

Residential mental health and substance use disorder services must be furnished at the payable residential-facility location identified by code 086. Services provided in another location may not satisfy the payment conditions and may be denied or not payable.

Report or use location code 086 for the residential facility setting.
Confirm the service location before billing.

Prior Authorization

Obtain a Coverage Determination Before Disputed Noncovered Services

If there is any question whether an item or service is covered, obtain a coverage determination from BCN Advantage before providing it. Providers may not use an Advance Beneficiary Notice of Noncoverage to transfer responsibility for a disputed noncovered item; if the item is provided without a prior coverage determination, the member must be held harmless for all charges except any applicable cost share.

A member who elects to receive a confirmed noncovered service is responsible for the entire charge.
Do not bill the member for disputed noncovered services furnished without first obtaining a coverage determination, except for applicable cost sharing.

Treatment environmentSafe, structured environment focused on behavioral healing, life-skills development, and social reintegration rather than acute medical management