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    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyDell Children's CoCM Prior Auth Update | OpenPayer
    Ask Trek AI about this page
    CurrentDell Children's Health PlanPolicy N/A

    CoCM Services Provided by FQHCs and RHCs

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    This document describes Texas Medicaid reimbursement and prior authorization requirements for Collaborative Care Model (CoCM) services furnished by Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs). It applies to enrolled Texas Medicaid members of all ages with a mental health or substance use condition and to providers billing these services.

    Policy Summary
    PayerDell Children's Health Plan
    PolicyCoCM Services Provided by FQHCs and RHCs
    Policy CodePolicy N/A
    Change TypeMaterial coverage and authorization update
    Effective DateMarch 1, 2025
    Next Review DateN/A
    Key ActionBill CoCM services furnished by an FQHC or RHC using procedure code G0512; do not bill this code from another provider type because the claim will be denied.
    SourceLink
    POLICY UPDATE CHANGES

    Effective March 1, 2025, Texas Medicaid adds FQHCs and RHCs as eligible provider types for CoCM services billed with procedure code G0512.

    FFS Medicaid does not require prior authorization for the first six calendar months of CoCM services and requires prior authorization for an additional six calendar months.

    03/01/2025Effective date
    G0512Required procedure code
    60 minutesMinimum monthly service time

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    1 per monthMonthly service limit
    6 monthsNo prior authorization
    6 monthsPrior authorization period

    FQHC and RHC CoCM Coverage Requirements

    FQHC and RHC CoCM coverage requirements

    Coverage and reimbursement require all applicable provider, service, documentation, time, frequency, and authorization conditions.

    ALL of the following

    • Member is enrolled in Texas Medicaid and has a mental health or substance use condition, including a pre-existing or suspected condition.
    • Service is furnished by an FQHC or RHC provider using procedure code G0512.
    • At least 60 minutes of qualifying CoCM services are furnished within the initial or subsequent calendar month; administrative and clerical duties do not count toward the time threshold.≥ 60 minutes per calendar month
    • No more than one G0512 service is billed per calendar month during an episode of care for the same person from the same provider.1 service per calendar month
    • Required CoCM elements are documented in the electronic medical record or electronic health record, including outreach and engagement; an initial assessment with a validated rating scale and person-centered plan of care; registry entry and tracking; weekly psychiatric consultation; evidence-based brief interventions; care coordination; and relapse-prevention planning.
    • For FFS Medicaid services during the first six calendar months, prior authorization is not required; prior authorization is obtained for services furnished during an additional six calendar months beyond the initial six-month period.

    CoCM Billing Parameters

    Covered HCPCS CodesHCPCSCovered
    G0512Collaborative Care Model services furnished by an FQHC or RHC in an initial or subsequent calendar month
    Minimum monthly CoCM service time
    Minimum timeAt least 60 minutes of CoCM services must be furnished within each initial or subsequent calendar month.
    Applicable periodThe 60-minute threshold applies to each calendar month of services, whether initial or subsequent.
    Excluded timeAdministrative and clerical duties do not count toward the 60-minute threshold.
    Monthly service frequency
    Monthly limitOne CoCM service is allowed per calendar month.
    Episode of careThe limit applies during an episode of care.

    Provider Billing and Documentation Actions

    Denial Risk

    Use G0512 for FQHC and RHC CoCM Services

    Bill initial and subsequent CoCM services furnished by an FQHC or RHC using procedure code G0512. Claims submitted by any other provider type will be denied.

    • Eligible providers: FQHCs and RHCs
    • Denial risk: G0512 is restricted to FQHCs and RHCs
    Billing Rule

    Meet the Monthly Time Threshold

    Provide at least 60 minutes of qualifying CoCM services within each initial or subsequent calendar month. Administrative and clerical duties do not count toward the threshold.

    CoCM Terms

    Collaborative Care Model (CoCM) services
    Service timingCoCM services are provided in the first calendar month or a subsequent calendar month of services.
    Care managerThe services are provided by a behavioral health care manager.
    Direction and recipientThe behavioral health care manager works under the direction of an FQHC or RHC practitioner— a provider, physician assistant, or nurse practitioner — for the person receiving CoCM services.
    Behavioral health care manager (BHCM)
    RoleA behavioral health care manager provides CoCM activities.
    DirectionThe BHCM performs those activities under the direction of an FQHC or RHC practitioner.
    Policy Summary
    PayerDell Children's Health Plan
    PolicyCoCM Services Provided by FQHCs and RHCs
    Policy CodePolicy N/A
    Change TypeMaterial coverage and authorization update
    Effective DateMarch 1, 2025
    Next Review DateN/A
    Key ActionBill CoCM services furnished by an FQHC or RHC using procedure code G0512; do not bill this code from another provider type because the claim will be denied.
    SourceLink
    On This Page
    FQHC and RHC CoCM Coverage RequirementsCoCM Billing ParametersProvider Billing and Documentation ActionsCoCM Terms
    Person and provider
    The limit applies to the same person receiving services from the same provider.
    FFS Medicaid prior authorization-free period
    Prior authorization-free periodFFS Medicaid does not require prior authorization for the first six calendar months of CoCM services.
    Initial monthThe first six-month period includes the initial calendar month.
    Subsequent monthsThe first six-month period also includes five subsequent calendar months.
    Extended FFS Medicaid service period
    Extended periodAn additional six calendar months of CoCM services may follow the first six calendar months.
    Prior authorizationFFS Medicaid requires prior authorization for services furnished during the additional six calendar months.
    TimingThe authorization requirement applies beyond the first six calendar months of CoCM services.
  1. Minimum threshold: 60 minutes per calendar month
  2. Applies to both the initial and subsequent months
  3. Exclude administrative and clerical duties
    4. Billing Rule

    Apply the Monthly Frequency Limit

    Limit billing to one G0512 service per calendar month during an episode of care for the same person from the same provider.

    • Applies to the initial or any subsequent calendar month
    • One service per month for the same person and provider
    Prior Authorization

    First Six Months Do Not Require Prior Authorization

    Under FFS Medicaid, prior authorization is not required for the first six calendar months of CoCM services, including the initial month and five subsequent months.

    • Covers the initial month plus five subsequent months
    • Applies to CoCM services provided by an FQHC or RHC
    Prior Authorization

    Prior Authorization Required Beyond Six Months

    Under FFS Medicaid, obtain prior authorization for an additional six-month period when CoCM services continue beyond the first six calendar months.

    • Authorization is required after the initial six-month period
    • The additional period covers six calendar months
    • Applies to CoCM services provided by an FQHC or RHC
    Documentation Required

    Document Required CoCM Elements

    Document the required CoCM service elements in the electronic medical record or electronic health record. The FQHC or RHC practitioner or behavioral health care manager must maintain documentation supporting the services.

    • Conduct outreach and engagement; complete an initial assessment with a validated rating scale and person-centered care plan
    • Enter information in the registry and track follow-up activities and progress with appropriate documentation
    • Participate in weekly caseload consultation with the psychiatric consultant and modify treatment when needed
    • Provide evidence-based brief interventions, such as motivational interviewing or problem-solving treatment
    • Track progress using validated rating scales and coordinate care with treating FQHC and RHC providers
    • Plan for relapse prevention as the person prepares for discharge
    Directing practitionersThe directing FQHC or RHC practitioner may be a provider, physician assistant, or nurse practitioner.