Currentpriority healthPolicy 054

Behavioral Health Billing and Reimbursement

Billing and reimbursement rules for behavioral health services (residential treatment, ABA, ECT, detoxification, and related services) for commercial, Medicare, and Medicaid lines; governs claim submission, coding, documentation, and place-of-service guidance for providers submitting to Priority Health.

Policy Summary

Payerpriority health

PolicyBehavioral Health Billing and Reimbursement

Policy CodePolicy 054

Change TypeAdministrative (non-material)

Effective Date

Next Review DateFeb 1, 2025

Key ActionDocument and submit medical necessity and required supporting documentation (e.g., InterQual criteria for ECT; psychiatrist order and full documentation for TMS) when requesting authorization or reimbursement.

SourceLink

POLICY UPDATE CHANGES

Added 'Disclaimer' section

one claim per stayResidential claim rule

TOB 86Residential type of bill

Anesthesia bundledECT anesthesia

3TMS codes required

2Major topics covered

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Medical Necessity Criteria

Behavioral health billing and documentation criteria

Billing and medical necessity requirements for behavioral health services.

ALL of the following

Submit one claim for the full period of residential care; separate claims should not be submitted for services included in the period of care.
Residential treatment should be billed using the appropriate type of bill as specified by facility billing guidance (see revenue code guidance).

ALL of the following

Documentation may be required to support medical necessity and must include all services performed.
For applied behavior analysis (ABA): the treatment program must be developed and supervised by a Board-Certified Behavior Analyst (BCBA) and documentation must show measurable progress in the treatment plan to be considered for continuation of treatment.

ALL of the following

Priority Health Behavioral Health department relies on InterQual Behavioral Health criteria to determine medical necessity for ECT.
For ECT codes 0901 or 90870, anesthesia services are considered part of the bundled rate and will not be separately reimbursed.

Operational note

Providers should retain full clinical documentation to substantiate medical necessity and billing claims; documentation requests may be made by the plan for review.

Coverage criteria for detoxification and TMS

Coverage is conditional on documented medical necessity and meeting specific clinical and documentation criteria.

ALL of the following

Medical record must document necessity for inpatient admission to monitor withdrawal symptoms; intoxication alone is not sufficient.
Refer to the Detoxification medical policy (#91104) for additional requirements and guidance.

ALL of the following

A confirmed diagnosis of major depressive disorder.
AND one or more of
- Lack of significant response to treatment with psychopharmacologic agents.

Codes, Revenue Codes, and Reimbursement Notes

ABA CPT CodesCPTCovered

97151	Behavior identification assessment, by a physician or other qualified healthcare professional, per 15 minutes Time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan
97153	Adaptive behavior treatment by protocol, per 15 minutes Administered by technician under the direction of a BCBA, face-to-face with one patient
97154	Group adaptive behavior treatment by protocol, per 15 minutes Administered by technician under the direction of a BCBA, face-to-face with two or more patients
97155	Adaptive behavior treatment with protocol modification, per 15 minutes Administered by BCBA, which may include simultaneous direction of technician
97156	Family adaptive behavior treatment guidance, per 15 minutes Administered by BCBA, with or without patient present, face-to-face with guardian(s)/caregiver(s)
97157	Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes
97158	Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes

ECT codes and anesthesiamixedCovered

90870	Electroconvulsive therapy with monitoring; single seizure
0901	Electroshock Treatment
00104	Anesthesia for electroconvulsive therapy

Revenue codes for residentialRevenueCovered

1001	Behavioral Health Accommodations - Residential - Psychiatric
1002	Behavioral Health Accommodations - Residential - Chemical Dependency
1003	Behavioral Health Accommodations - Supervised Living
0128	Room & Board - Semiprivate (Two Beds) - Rehabilitation

TMS CPT codesCPTCovered

90867	Therapeutic repetitive transcranial magnetic stimulation treatment; initial, including cortical mapping, motor threshold determination, delivery and management
90868	Therapeutic repetitive transcranial magnetic stimulation treatment; subsequent delivery and management, per session
90869	Therapeutic repetitive transcranial magnetic stimulation treatment; subsequent motor threshold re-determination with delivery and management

Revenue codes for inpatient and detoxificationRevenue

0110	Room & Board - Private - General
0116	Room & Board - Private - Detoxification

inv-08: Anesthesia reimbursement — anesthesia for ECT is bundled and not separately reimbursed

Policy statementFor ECT codes 0901 or 90870, the anesthesia service is considered part of the bundled rate and will not be separately reimbursed.

Relevant codes0901 (Electroshock Treatment); 90870 (Electroconvulsive therapy with monitoring; single seizure); 00104 (Anesthesia for electroconvulsive therapy)

Billing implicationDo not submit separate anesthesia reimbursement for ECT when billed with 0901 or 90870 — anesthesia is included in the bundled payment.

inv-09: Psychopharmacologic trial requirement — lack of significant response or intolerance required for TMS consideration

Required documentation for TMS consideration

Authorization, Documentation, and Provider Requirements

Prior Authorization

ECT medical necessity: InterQual criteria

Priority Health’s Behavioral Health department uses InterQual Behavioral Health criteria to determine medical necessity for electroconvulsive therapy (ECT).

Documentation Required

Documentation required; ABA-specific requirements

Documentation may be required to support medical necessity and must include all services performed. For applied behavior analysis (ABA), documentation must include a treatment program developed and supervised by a Board-Certified Behavior Analyst (BCBA) and must show measurable progress in the treatment plan to be considered for continuation.

Documentation Required

Authorization and documentation expectations for detox and TMS

Key Definitions

inv-13: Residential treatment — definition of 24-hour subacute residential treatment

DefinitionResidential treatment: 24-hour care in a subacute facility with structured, licensed healthcare professionals; medically monitored with medical services, licensed nursing and clinical staff onsite and physician emergency on-call availability.

Level of careProvides continuous 24/7 medical monitoring and clinical support in a subacute (non-acute hospital) residential setting.

Staffing requirementsLicensed nursing and clinical staff onsite with physician emergency on-call availability.

inv-14: Applied behavior analysis (ABA) — definition and therapy description

DefinitionApplied behavior analysis (ABA): a style of therapy designed to improve social and emotional skills using interventions based on how people learn.

Therapy focus

Policy Revisions and Administrative Changes

2025-02-14administrativeLatest

Added 'Disclaimer' section clarifying policy precedence and recoupment rights.

Policy Summary

Payerpriority health

PolicyBehavioral Health Billing and Reimbursement

Policy CodePolicy 054

Change TypeAdministrative (non-material)

Effective Date

Next Review DateFeb 1, 2025

SourceLink

On This Page

Intolerance of psychopharmacologic agents.

History of successful TMS.

TMS as a less invasive option to electroconvulsive therapy.

No significant improvement after an adequate duration of psychotherapy.

Order for TMS must be by a psychiatrist who has examined the patient and reviewed their history.

TMS must be administered under the direct supervision of the prescribing physician and the device must be FDA approved/cleared for safe and effective use.

TMS retreatment consideration: Retreatment may be considered for individuals who successfully completed an initial course of TMS and subsequently experience relapse of depressive symptoms; consider on a case-by-case documented basis.

Confirmation of major depressive disorder plus one or more: lack of significant response to psychopharmacologic agents, intolerance to psychopharmacologic agents, history of successful TMS, or TMS as a less invasive option to ECT; AND no significant improvement after adequate psychotherapy; order by psychiatrist who examined the patient.

Psychopharmacologic trial criterionA documented lack of significant response to treatment with psychopharmacological agents is an acceptable prerequisite for TMS.

Alternate prerequisitesIntolerance of psychopharmacologic agents or prior successful TMS may substitute for failed medication trials.

Document medical necessity for inpatient detox: intoxication alone is not sufficient; the record must show the need for inpatient admission to monitor withdrawal symptoms. For TMS, ensure treatment is ordered by a psychiatrist who has examined the patient, administered under the direct supervision of the prescribing physician, and delivered using an FDA‑approved/cleared device.

Inpatient detox: medical record must demonstrate need to monitor withdrawal symptoms (intoxication alone insufficient).
TMS prerequisites: confirmed diagnosis of major depressive disorder and one or more listed reasons (e.g., lack of response to psychopharmacologic agents, intolerance, prior successful TMS, or TMS as less invasive option to ECT), plus no significant improvement after adequate psychotherapy.
TMS order must be by a psychiatrist who examined the patient; device must be FDA approved/cleared; treatment under direct physician supervision.

Targets social and emotional skill development through evidence-based behavioral interventions.

Program oversightDocumentation must include a treatment program developed and supervised by a Board-Certified Behavior Analyst (BCBA) and show measurable progress for continuation of services.

inv-15: Electroconvulsive therapy (ECT) — definition and procedural summary

DefinitionElectroconvulsive therapy (ECT): a procedure performed under general anesthesia in which small electric currents are passed through the brain to intentionally trigger a brief seizure, which can alter brain chemistry and reverse symptoms of certain mental illnesses.

Typical procedure elementsPerformed under general anesthesia with monitoring; may be coded with 90870 (ECT with monitoring; single seizure) and associated anesthesia codes.

Medical necessity determinationPriority Health Behavioral Health department relies on InterQual Behavioral Health criteria to determine medical necessity for ECT.

inv-16: Detoxification — definition (managing acute intoxication and withdrawal)

DefinitionDetoxification: interventions aimed at managing acute intoxication and withdrawal to minimize physical harm from substance use; involves clearing toxins from the body of an acutely intoxicated or dependent patient.

Goal of careMinimize physical harm caused by substance abuse through monitoring and management of withdrawal symptoms.

Admission standardIntoxication alone is not an indication for medical detoxification admission; the medical record must show necessity to monitor and manage withdrawal.

inv-17: Detoxification — alternate/duplicate detox definition

Alternate definitionDetoxification (alternate): a set of interventions to manage acute intoxication and withdrawal, clearing toxins and minimizing physical harm in patients acutely intoxicated and/or dependent on substances.

Care focusEmphasis on medical monitoring and supportive measures to safely manage withdrawal and prevent complications.

Documentation expectationMedical records must document the clinical necessity for inpatient detoxification; mere intoxication is insufficient.

inv-18: Transcranial magnetic stimulation (TMS) — definition and purpose

Definition and purposeTranscranial magnetic stimulation (TMS): a noninvasive procedure using magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression, typically used when other treatments have not been effective.

Regulatory and supervision requirementsTMS must be administered using an FDA-cleared device and under the direct supervision of the prescribing physician.

Indications and prerequisitesUsed for major depressive disorder after failure or intolerance of psychopharmacologic therapy, inadequate response to psychotherapy, or when TMS is a less invasive option to ECT; requires psychiatrist order after examination.