CurrentOptumPolicy N/A

Preventive Behavioral Health Services Coverage Criteria

Defines coverage and billing rules for up to 8 preventive behavioral health (BH) outpatient sessions for eligible members, including youth under 21 with a positive behavioral health screen, and the documentation and provider requirements to deliver those services.

Policy Summary

PayerOptum

PolicyPreventive Behavioral Health Services Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2021

Next Review DateN/A

Key ActionAdminister and document an age-appropriate behavioral health screen using a MassHealth Appendix W tool and include modifier EP on preventive BH service claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8maximum annual preventive BH sessions covered

Under 21age group eligible with positive screen

EPmodifier required on all claims for preventive BH services

Appendix Wapproved screening tools referenced

Coverage Criteria for Preventive Behavioral Health

Preventive Behavioral Health Outpatient Coverage

Covered when ALL of the following are met:

Eligibility requirements: Member is under age 21 OR other members when applicable; member has a positive behavioral health screen (infants qualify with a positive postpartum depression screening); preventive behavioral health services are recommended by a physician or other licensed practitioner within their scope of practice; provider administers and documents results of an age-appropriate behavioral health screen using a tool from MassHealth Appendix W; services are delivered as outpatient using one of the listed CPT codes; services are received from an in-network provider; a complete Z code is required when no diagnosis is present.

Diagnosis not required; Z code required when no diagnosis

All claims for preventive behavioral health services must be submitted with modifier EP. Note: do not use the EP modifier if you are including a Diagnosis code with the claim per the policy note; however, when EP is billed with a Diagnosis code it still counts toward the 8 total annual preventive sessions.

Members who do not have a positive behavioral health screen and are not otherwise eligible (for example, not under age 21 and not enrolled in the specified Medicaid plans) do not meet the criteria for preventive behavioral health services. Preventive services are intended for members with a documented positive screen and a recommending licensed practitioner; a diagnosis is not required but a complete Z code is required when no diagnosis is present.

Policy Summary

PayerOptum

PolicyPreventive Behavioral Health Services Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2021

Next Review DateN/A

Key ActionAdminister and document an age-appropriate behavioral health screen using a MassHealth Appendix W tool and include modifier EP on preventive BH service claims.

SourceLink

On This Page

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Coding, Modifiers, and Limits

Covered CPT Codes - group or school-based providersCPTCovered

90853

Group psychotherapy (other than multiple-family group)

Covered CPT Codes - primary care with embedded BH clinicianCPTCovered

90832	Psychotherapy with patient and/or family member
90834	Psychotherapy with patient and/or family member
90846	Family psychotherapy (conjoint psychotherapy) (without patient present)
90847	Family psychotherapy (conjoint psychotherapy) (with patient present)
90849	Multiple-family group psychotherapy
90853	Group psychotherapy (other than multiple-family group)

Required claim modifierModifierCovered

EP	Modifier required on all claims for preventive behavioral health services

inv-07: Annual session limit — <= 8 preventive sessions per year

Annual limitUp to 8 preventive behavioral health (BH) sessions per member per year

Prior authorizationNo prior authorization required for up to 8 sessions (effective 09/01/2021)

Counting EP-modified claimsAll services billed with EP count toward the 8-session annual limit

Provider Requirements and Billing Actions

Prior Authorization

No prior authorization up to limit

No prior authorization required for up to eight (8) preventive behavioral health (BH) sessions per member per year effective 09/01/2021. This applies to eligible members under age 21 who meet the screening criteria described below.

Limit: 8 preventive BH sessions per member per year
Effective date: 2021-09-01

Billing Rule

EP modifier billing risk

All claims for preventive behavioral health services must be submitted with modifier EP. Failure to include modifier EP may prevent services from being counted toward the 8-session preventive BH limit and could result in incorrect claim processing or denials. Do not use the EP modifier if you are including a Diagnosis code with the claim (billing with a Diagnosis code may change processing; EP billed with a Diagnosis code still counts toward the 8-session annual limit).

Required on all preventive BH claims: Modifier EP
Do not use EP if including a Diagnosis code on the claim (EP with a Diagnosis code still counts toward the 8-session limit)
Risk: Omitted or incorrect modifier may affect counting toward limit and lead to incorrect processing/denial

Documentation Required

Screening and recommendation documentation

Providers must administer and document an age-appropriate behavioral health screening using a tool from the list of MassHealth-approved screeners (see Appendix W of the MassHealth provider manual). Preventive behavioral health services must be recommended by a physician or other licensed practitioner practicing within their scope of licensure to recommend such services. Document the screening result and recommendation in the medical record; a Z code (complete) is required when a diagnosis is not applicable.

Use a MassHealth Appendix W approved screening tool
Document screening results and the recommending licensed practitioner
When no behavioral health diagnosis is applicable, include a complete Z code in the claim

Note

(blank label)

Members under age 21 enrolled in specified Medicaid plans are eligible if they have a positive behavioral health screen (infants qualify with positive postpartum depression screening). Preventive BH services may be delivered by eligible outpatient or school-based providers or by primary care providers with embedded behavioral health clinicians using the specified CPT codes. Ensure services are delivered by in-network providers when required by the plan.

Eligibility: under age 21, enrolled in eligible Medicaid plan (e.g., MH Standard Commonwealth, MF Family Assistance, MH Care Plus), and positive behavioral health screen
Infants: positive postpartum depression (PPD) screen qualifies
Billing codes: include 90832, 90834, 90846, 90847, 90849, 90853 as applicable
Provider: services must be recommended by authorized licensed practitioner and provided by in-network provider when required

Definitions

inv-13: Preventive BH sessions up to 8 annually for members with positive behavioral health screening, recommended by a licensed practitioner

Covered populationMembers under age 21 (includes infants with positive PPD screening) with a positive behavioral health screen

Recommendation requirementServices must be recommended by a physician or other licensed practitioner within their scope

Screening documentationProvider must administer and document an age-appropriate behavioral health screen using a MassHealth Appendix W tool

Setting and codesOutpatient services using listed CPT codes and delivered by in‑network providers

inv-14: Claim modifier required on all preventive BH service claims (EP) — do not use EP when including a diagnosis code if instructed otherwise; EP still counts toward the 8-session total

Required modifierAll preventive behavioral health service claims must be submitted with modifier EP

Diagnosis noteDo not use the EP modifier if including a diagnosis code with a claim per the note

Counting toward limitEP billed with a diagnosis still counts toward the 8-session annual total

Level of Care

Outpatient

Covered when the following outpatient-level conditions are met:

Outpatient level of care: Services are delivered in an outpatient setting and billed using one of the specified CPT codes for preventive behavioral health services; member requires outpatient services as indicated by screening and/or clinician recommendation; services are provided by an in-network provider.

Refer to CPT code lists for provider type and billing requirements

Authorization and limits: No prior authorization is required for up to 8 preventive behavioral health sessions per member per year (effective 09/01/2021); all claims for preventive behavioral health services must include modifier EP.<= 8 sessions/year

EP modifier counts toward the 8-session limit; do not use EP if including a diagnosis code per billing note, though EP billed with a diagnosis still counts toward the annual total

OpenPayer

Preventive Behavioral Health Services Coverage Criteria

Coverage Criteria for Preventive Behavioral Health

Coding, Modifiers, and Limits

Provider Requirements and Billing Actions

Background

Definitions

Level of Care

Permitted Treatment Modalities

Visit Limits