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    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyNew Hampshire FQHC SUD Billing Policy Update | Ope…
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    CurrentNew Hampshire Department of Health and Human ServicesPolicy N/A

    FQHC Billing of Substance Use Disorder Services

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    This bulletin governs how New Hampshire FQHCs, FQHC look-alikes, and non-hospital-based rural health centers bill substance use disorder services, including separate-claim, denial, resubmission, and medication-assisted treatment billing rules.

    Policy Summary
    PayerNew Hampshire Department of Health and Human Services
    PolicyFQHC Billing of Substance Use Disorder Services
    Policy CodePolicy N/A
    Change TypeBilling and reimbursement requirements
    Effective DateJanuary 1, 2018
    Next Review DateN/A
    Key ActionBill covered SUD services on a separate claim at the applicable SUD fee-for-service rate, except for SBIRT.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Separate claimRequired billing method for most SUD services
    FFS rateReimbursement basis for separately billed SUD services
    SBIRT

    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.

    Exception to separate billing
    T1015 denialEncounter-code denial risk
    2 plansHealth plans implementing changes

    SUD Billing and Reimbursement Criteria

    SUD Billing and Reimbursement Criteria

    Effective January 1, 2018, FQHCs, FQHC look-alikes, and non-hospital-based rural health centers must bill covered SUD services separately from the FQHC encounter, except for SBIRT services.

    ALL of the following

    • Bill SUD services, except SBIRT, on a separate claim form.
    • Reimbursement is at the SUD service's Fee-for-Service (FFS) rate listed on the SUD fee schedule.
    • Do not bill SUD services as a medical or behavioral health encounter.
    • SBIRT services are included in the FQHC encounter rate and are not subject to the separate-claim requirement.
    • The separately billable SUD services include H0001 (alcohol and/or drug assessment); H0004 with modifiers U1, U2, or U3 (behavioral health counseling and therapy, 30-, 45-, or 60-minute session); H0007 (crisis intervention in the provider office or community); H0047 with modifiers HS/HQ or HR/HQ (family or multi-family group counseling, including family/couple with client present); H0015 (intensive outpatient services); H2036 (partial hospitalization services); H0014 (medically monitored withdrawal management); T1012 with or without HQ/FS (non-peer recovery support, individual or group); H0038 with or without HQ (peer recovery support, individual or group); and H0006 (case management/continuous recovery monitoring).

    Claim Denial and Resubmission Criteria

    Claims that combine the FQHC encounter code with SUD services must be corrected and resubmitted according to the applicable coding combination.

    ONE of the following claim combinations

    • Except for SBIRT codes, if T1015 is billed with a SUD code, the claim will be denied. Resubmit the claim using only the SUD code; the SUD service will be reimbursed at the FFS rate.
    • If T1015 is billed with a SUD code and another non-SUD code, the claim will be denied. Resubmit two claims: one claim with T1015 and the non-SUD code, and a separate claim with the SUD code.

    Same-Day MAT Billing Criteria

    When medication-assisted treatment (MAT) is rendered on the same day as a medical visit, bill the medical and MAT office visits separately; other SUD services may remain with the MAT office visit claim.

    ALL of the following

    • When MAT is rendered on the same day as a medical visit, bill T1015 for the medical visit.
    • On a separate claim, bill the MAT office visit using one of the following E/M codes with modifier HF: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, or 99215.
    • Other SUD services rendered on the same day as a MAT visit may be billed on the same claim as the MAT office visit.

    Billable Code Sets

    Separately billable SUD servicesHCPCSCovered
    H0001Alcohol and/or drug assessment
    H0004-U1Behavioral health counseling and therapy, 30-minute session
    H0004-U2Behavioral health counseling and therapy, 45-minute session
    H0004-U3Behavioral health counseling and therapy, 60-minute session
    H0007-U1Behavioral health counseling and therapy, 60-minute session
    H0047-HS-HQFamily-multi-family group counseling
    H0047-HR-HQFamily/couple counseling with client present, group setting
    H0015Intensive outpatient services
    H2036Partial hospitalization services
    H0014Medically monitored withdrawal management
    1–10 of 15
    1/2
    E&M codes for same-day MAT office visitmixedCovered
    99201-HFE&M MAT office visit with modifier HF
    99202-HFE&M MAT office visit with modifier HF
    99203-HFE&M MAT office visit with modifier HF
    99204-HFE&M MAT office visit with modifier HF
    99205-HFE&M MAT office visit with modifier HF
    99211-HFE&M MAT office visit with modifier HF
    99212-HFE&M MAT office visit with modifier HF
    99213-HFE&M MAT office visit with modifier HF
    99214-HFE&M MAT office visit with modifier HF
    99215-HFE&M MAT office visit with modifier HF

    Billing and Resubmission Actions

    Billing Rule

    Bill SUD services separately

    Bill covered SUD services on a separate claim and use the applicable SUD fee schedule rate. Do not bill these services as a medical or behavioral health encounter.

    Denial Risk

    Do not combine T1015 with a SUD code

    Do not bill T1015 with a non-SBIRT SUD code. The claim will be denied and must be resubmitted using only the SUD code.

    Denial Risk

    Key Billing Terms

    SBIRT
    TermSBIRT
    DefinitionScreening, Brief Intervention, and Referral to Treatment
    Billing treatmentSBIRT services remain included in the FQHC encounter rate and are not billed separately at the SUD fee-for-service rate.
    MAT
    TermMedication Assisted Treatment (MAT)
    Same-day medical visitWhen MAT is rendered on the same day as a medical visit, bill T1015 for the medical visit.
    MAT office visitSubmit a separate claim for the MAT office visit using an applicable E&M code with modifier HF.
    Policy Summary
    PayerNew Hampshire Department of Health and Human Services
    PolicyFQHC Billing of Substance Use Disorder Services
    Policy CodePolicy N/A
    Change TypeBilling and reimbursement requirements
    Effective DateJanuary 1, 2018
    Next Review DateN/A
    Key ActionBill covered SUD services on a separate claim at the applicable SUD fee-for-service rate, except for SBIRT.
    SourceLink
    On This Page
    SUD Billing and Reimbursement CriteriaBillable Code SetsBilling and Resubmission ActionsKey Billing Terms

    Split claims when T1015 includes non-SUD services

    If T1015 is billed with a SUD code and another non-SUD code, the claim will be denied. Resubmit two claims: one with T1015 and the non-SUD code, and a second claim with the SUD code.

    Billing Rule

    Bill same-day MAT separately

    When MAT is rendered on the same day as a medical visit, bill T1015 for the medical visit and submit a separate claim for the MAT office visit with an applicable E&M code and modifier HF.

    Billing Rule

    Include other same-day SUD services with the MAT claim

    Other SUD services rendered on the same day as a MAT visit may be billed on the same claim as the MAT office visit.