CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy N/A
CHAPTER 503 AND LICENSED BEHAVIORAL HEALTH CENTERS (LBHCS) — Appendix 503I.2 Service Codes
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This chapter (503) governs service codes, billing forms, prior authorization notes, and cost-report inclusion for Certified Community Behavioral Health Clinics and Licensed Behavioral Health Centers under the West Virginia Bureau for Medical Services; it affects providers billing Medicaid for CCBHC/LBHC services.
Policy Summary
PayerWest Virginia Bureau for Medical Services (Department of Human Services)
PolicyCHAPTER 503 AND LICENSED BEHAVIORAL HEALTH CENTERS (LBHCS) — Appendix 503I.2 Service Codes
Policy CodePolicy N/A
Change TypeNo material change
Effective DateOct 1, 2024
Next Review Date
Key ActionWhen submitting claims including T1040, ensure any co-reported PPS trigger service that requires prior authorization has that authorization to avoid denial.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
T1040T1040 encounter
Some codesPrior auth needed
ManyPays $0
UB-04Provider claim form
11/25/2024Matrix updated
Coverage and Billing Criteria
Service code billing/coverage criteria
Service-specific coverage and billing criteria (extracted from the service code matrix):
T1040 - CCBHC Encounter code: Claims with T1040 must include the services rendered to the member on the same date of service (except carved-out services); the T1040 itself does not require prior authorization but will deny if an accompanying PPS trigger service lacks required authorization; Included in Cost Report = Yes; Provider Claim Form = UB-04; Prior Authorization Carved-out = No.
H0031 - Mental Health Assessment by Non-Physician: PPS Trigger Included in Cost Report = Yes; Included in Cost Report Provider Claim Form = Yes; Provider Claim Form Prior Authorization field = blank in matrix excerpt; Reimbursement = Pays $0; Bypass 1 = Yes.
90791 - Psychiatric Diagnostic Evaluation (No Medical Services): PPS Trigger Included in Cost Report = Yes; Included in Cost Report Provider Claim Form = Yes; Provider Claim Form Prior Authorization field = blank in matrix excerpt; Reimbursement = Pays $0.
96131 - Testing/evaluation services by qualified health care professional (interpretation, report, feedback): PPS Trigger Service = Yes; Included in Cost Report = Yes; Provider Claim Form = UB-04; Prior Authorization = Required; Carved-out = No; Reimbursement = Pays $0.
96136 - Neuropsychological test administration and scoring, first 30 minutes: PPS Trigger Service = Yes; Included in Cost Report = Yes; Provider Claim Form = UB-04; Prior Authorization = Required; Carved-out = No; Reimbursement = Pays $0.
96146 - Neuropsychological test administration with single automated instrument: PPS Trigger Service = No; Included in Cost Report = Yes; Provider Claim Form = UB-04; Prior Authorization = Required; Reimbursement = Pays $0.
H0032 - Mental Health Service Plan / Mental Health Service Plan Development: PPS Trigger Included in Cost Report = Yes for H0032 (some variants show No); Included in Cost Report Provider Claim Form = Yes (variants may differ); Provider Claim Form Prior Authorization field = blank in excerpt; Bypass 1 = Yes for certain entries; Reimbursement = not specified in excerpt.
Matrix per-code coverage and billing indicators
Coverage/billing indicators present in the matrix (per-code):
Field: PPS Trigger Service Included in Cost Report — indicated as Yes or No per code in the matrix (check per-code entry).
Field: Included in Cost Report / Provider Claim Form — per-code values shown (examples: Yes with UB-04 for many included services; No for CSED waiver codes).
Field: Provider Claim Form Prior Authorization — present in the matrix but frequently blank in the excerpt; some entries explicitly show 'Prior Authorization = Required' for selected testing/evaluation codes.
Field: Reimbursement — many matrix entries in the excerpt show 'Reimbursement = Pays $0' for listed codes; other entries indicate 'MCO' or Medicaid fee schedule where carved out or routed to MCO.
Note: CLIA Certificates as Appropriate column is present for laboratory entries (often 'N/A' or 'Yes' as appropriate).
Coverage criteria and billing rules (matrix-derived)
Summary of coverage and billing rules from the matrix
Laboratory services (e.g., 80061, 82465, 83036, 82948, 82962) — Generally PPS Trigger Included = No; Included in Cost Report Provider Claim Form = Yes for in-house labs; Only laboratory services performed in-house by a CCBHC are included in the cost report; CLIA certificates required 'as appropriate'; many lab entries show Reimbursement = Pays $0 in the excerpt.
Coverage and billing rules (excerpt)
Rules extracted from the service code matrix:
In-house laboratory services provided by a CCBHC are included in the CCBHC cost report (matrix notes: 'Only laboratory services provided by a CCBHC (in-house) are included in the cost report').
Many listed laboratory and presumptive drug testing codes show Reimbursement = Pays $0 when performed in-house by the CCBHC in the matrix excerpt.
CLIA certification is required 'as appropriate' for listed laboratory services (matrix column 'CLIA Certificates as Appropriate').
PPS Trigger Service Included = No for most listed laboratory services and many other services in the excerpt; some services are marked Yes or TBD per code.
Certain behavioral health and CSED waiver services are reimbursed via MCO and claims for those CSED waiver services are submitted to the MCO per current MCO policy (matrix notes indicate MCO reimbursement for multiple CSED entries).
Provider Claim Form varies by service (examples in the matrix: UB-04 for many cost-report included services; CMS 1500 for certain CSED waiver services); the Provider Claim Form Prior Authorization field is often blank in the excerpt and should be checked with the BMS Fiscal Agent when unclear.
Per-code coverage nodes
Per-code coverage and billing instructions from the CCBHC Service Code Matrix:
T1005 (Respite care, HA/HE) — CSED waiver service: PPS Trigger = No; Included in Cost Report Provider Claim Form = No; Provider Claim Form Prior Authorization field = blank in excerpt; Carved-out = (matrix shows claims submitted to MCO); Reimbursement = MCO.
H0038 (Peer Parent Support, HA) — CSED waiver service: PPS Trigger = No; Included in Cost Report = No; Provider Claim Form = CMS 1500; Prior Authorization = Per MCO Policy; Carved-out = Yes; Reimbursement = MCO; Bypass 1 = Yes.
H0004 (Family therapy) — CSED waiver service: PPS Trigger = No; Included in Cost Report = No; Provider Claim Form = CMS 1500; Prior Authorization = Per MCO Policy (matrix excerpts show prior auth guidance tied to MCO for these codes); Carved-out = Yes; Reimbursement = MCO.
A0160 (Non-medical transportation) — Listed among CSED/waiver services: Provider Claim Form = CMS 1500; Prior Authorization = Per MCO Policy; Carved-out = Yes; Reimbursement = MCO (check per-code entry).
Q3014 (Telehealth originating site) — PPS Trigger = No; Included in Cost Report = Yes; Provider Claim Form = UB-04; Prior Authorization = No; Carved-out = No; Reimbursement = Pays $0 (matrix entry).
H2036 (SUD Residential Services) — Residential service: PPS Trigger = No; Included in Cost Report = No; Provider Claim Form = CMS 1500; Prior Authorization = Required; Carved-out = Yes; Reimbursement = Medicaid fee schedule.
Codes, Tables, and Coding Notes
Listed CCBHC/LBHC service codes in Appendix 503I.2CPTCovered
| T1040 | CCBHC Encounter code; must include services rendered same date; does not itself require prior authorization |
| H0031 | Mental Health Assessment by Non-Physician |
| 90791 | Psychiatric Diagnostic Evaluation (No Medical Services) |
| 90792 | Psychiatric Diagnostic Evaluation with Medical Services (Includes Prescribing) |
| 96110 | Developmental Testing: Limited |
| 96112 | Developmental test administration with interpretation |
| 96113 | Developmental test administration each additional 30 |
| 96130 | Testing services by qualified health care professional with interpretation and report |
| 96131 | Testing evaluation services including interpretation, report preparation and feedback |
| 96132 | Testing evaluation services including interpretation and report prep |
1–10 of 15
1/2
Listed covered/required CCBHC service codesmixedCovered
| 99203 | Office or other outpatient visit for the evaluation and management of a new patient 30-44 minutes, low |
| 99204 | Office or other outpatient visit for the evaluation and management of a new patient (longer visit) |
| 99213 | E/M established patient, low complexity |
| 99214 | E/M established patient, moderate complexity |
| H2014 | Psychiatric rehabilitation services / skills training and development |
| H2015 | Comprehensive Community Support Services |
| H2012 | Day treatment |
| H0038 | Peer support services |
| 90839 | Crisis psychotherapy |
| S9485 | Crisis service diem (up to three hours initial crisis) |
1–10 of 16
1/2
CSED waiver / MCO-routed codesmixed
| H0004 | In-home family support (CSED waiver) |
| H2033 | Independent Living/Skill building (CSED waiver) |
| T1016 | Wraparound facilitation (CSED waiver) |
| T2021 | Job development (CSED waiver) |
| T2019 | Supported employment (CSED waiver) |
| T2038 | Community transition (CSED waiver) |
| T2035 | Assistive equipment (CSED waiver) |
| G0176 | Professional services, specialized (CSED waiver) |
| T1005 | Respite care (in-home/out-of-home) (CSED waiver) |
PPS trigger inclusion — per-code flag
DefinitionMatrix flags each service with 'PPS Trigger Service Included in Cost Report' (Yes/No) indicating whether a service counts toward PPS inclusion, per code in the matrix,
Examples (PPS = Yes)T1040 (Encounter) and multiple testing/evaluation codes (e.g., 96131, 96136) are shown with PPS Trigger Included in Cost Report = Yes in the matrix,
Provider implicationServices marked 'Yes' are included in the CCBHC cost report and may affect cost-reporting and payment methodology; verify per-code flag before billing,
Mobile crisis follow-up limit
LimitMobile crisis team follow-up services (T1016) should not continue beyond four weeks after the initial contact/response,
Provider expectationBy four weeks post contact, teams should have provided links and warm handoffs to ongoing care,
Claim formIncluded in Cost Report Provider Claim Form = Yes (UB-04) for mobile crisis follow-up entries in the matrix,
PPS trigger inclusion — laboratory services
General ruleMost laboratory services listed (e.g., 82465, 83036, 82948, 82962, 80305–80307) show 'PPS Trigger Service Included in Cost Report = No' in the matrix,
In-house exceptionOnly laboratory services provided in-house by a CCBHC are included in the CCBHC cost report (not all lab codes),
Reimbursement noteMany laboratory and presumptive drug testing codes display 'Reimbursement = Pays $0' in the matrix when performed in-house or carved-out as indicated,
Telehealth originating site (Q3014) reimbursement
CodeQ3014 (Telehealth originating site)
Prior authorizationPrior Authorization = No for Q3014, per the matrix,
ReimbursementReimbursement = Pays $0 for Q3014 (telehealth originating site) as shown in the matrix,
Included in cost reportIncluded in Cost Report = Yes for Q3014 (despite Pays $0), per matrix entry,
Provider Billing Actions and Authorization Notes
Prior Authorization
T1040 and prior-authorization interaction
The T1040 encounter code itself does not require prior authorization; however, if a PPS trigger service reported on the same date requires authorization and that trigger lacks required authorization, the T1040 claim will deny for no prior authorization.
Billing Rule
Telehealth modifier requirement (modifier 95)
When a service is delivered via telehealth, modifier 95 must be reported alongside the actual service code.
Documentation Required
Provider Claim Form Prior Authorization field in matrix (may be blank)
The service code matrix includes a 'Provider Claim Form Prior Authorization' column; many entries in the excerpt are blank while some codes explicitly list the required claim form or prior-authorization details.
- Matrix column may be blank for many codes — check BMS Fiscal Agent for confirmation
- Some codes explicitly list the provider claim form and prior-authorization indicator (see per-code entries)
Prior Authorization
CMS 1500 indicated for some services; many entries blank
Some services in the matrix specify Provider Claim Form Prior Authorization = CMS 1500, while other services show no prior authorization indicated in the excerpt.
- Example: H0040 and certain CSED waiver services list Provider Claim Form Prior Authorization = CMS 1500
- Many other matrix entries leave the prior-authorization field blank — confirm with BMS Fiscal Agent
Billing Rule
Submit CSED waiver service claims to MCO; follow MCO prior-authorization rules
Claims for Children's Serious Emotional Disorder (CSED) waiver services are submitted to the MCO per current MCO policy; prior authorization and carve-out handling for those codes follow MCO rules.
Prior Authorization
Per-code prior-authorization notes (Per MCO Policy or Required)
Some codes are noted as 'Prior Authorization = Per MCO Policy' or explicitly 'Prior Authorization = Required' in the matrix; for example, H0038 is per MCO policy and H2036 (SUD residential services) is marked Prior Authorization = Required.
Prior Authorization
Telehealth originating site (Q3014) — no prior authorization required
The telehealth originating site code Q3014 is listed with Prior Authorization = No in the matrix (Provider Claim Form = UB-04; reimbursement = Pays $0).
- Q3014: Prior Authorization = No; Provider Claim Form = UB-04; Included in Cost Report = Yes; Reimbursement = Pays $0
Definitions and Key Terms
PPS Trigger Service — definition
DefinitionA PPS Trigger Service is any service flagged in the CCBHC Service Code Matrix as triggering inclusion in the Payment Prospective Services (PPS) component of the CCBHC cost report,
Matrix fieldThe matrix column 'PPS Trigger Service Included in Cost Report' indicates whether the flagged service is counted in the cost report (Yes/No),
Provider impactServices designated as PPS triggers should be tracked for cost-reporting and may affect encounter aggregation and reimbursement methodology,
T1040 — encounter code and prior authorization
CodeT1040 — CCBHC Encounter code (must include services rendered same date)
Prior authorizationT1040 itself does not require prior authorization, per the matrix,
Interaction noteIf a PPS trigger code reported with the T1040 encounter requires authorization and that authorization is missing, the T1040 claim may deny,
PPS Trigger — short definition
Short definition'PPS Trigger' denotes the matrix field 'PPS Trigger Service Included in Cost Report' used to mark services that trigger PPS inclusion,
UsageUsed across the service code matrix to indicate per-code inclusion status in the CCBHC cost report,
ActionConfirm per-code PPS Trigger status in the matrix before preparing cost-report submissions,
Provider Claim Form Prior Authorization — matrix column
Column meaning'Provider Claim Form Prior Authorization' is the matrix column indicating whether a prior authorization is required and which provider claim form (e.g., UB-04, CMS 1500) applies,
ObservationMany entries in the matrix leave this field blank or vary by code; some entries explicitly list UB-04 or CMS 1500,
Provider guidanceVerify per-code prior-authorization form requirements in the matrix and with the BMS Fiscal Agent when the field is blank,
PPS Trigger Service — duplicate reference
DefinitionPPS Trigger Service — a service marked in the matrix as triggering inclusion in the PPS component of the cost report (duplicate reference),
Matrix useThe document repeats this designation for specific codes to indicate cost-report inclusion,
Provider implicationTreat duplicate references as confirmation to check the matrix for per-code details when preparing claims and cost reporting,
Included in Cost Report — laboratory services
PolicyOnly laboratory services provided in-house by a CCBHC are included in the CCBHC cost report (matrix additional information),
Matrix entriesLaboratory codes (82465, 83036, 82948, 82962, 80305–80307) show 'PPS Trigger Service Included in Cost Report = No' but 'Included in Cost Report Provider Claim Form = Yes' reflecting in-house inclusion rules,
CLIA requirementCLIA Certificates as Appropriate = Yes for listed laboratory services where indicated, consistent with in-house lab inclusion,
Included in Cost Report — indicator
Field meaning'Included in Cost Report' indicates whether the service (typically in-house laboratory services or other in-house services) is counted in the CCBHC cost report, per the matrix,
Typical valuesMatrix values are Yes or No per code; many lab codes show 'No' for PPS trigger but may be 'Yes' for included-in-cost-report when performed in-house,
Provider actionConfirm per-code inclusion status when preparing cost-reporting and claims, especially for in-house services,
Bypass 1 — system routing flag
DefinitionBypass 1 is a system routing flag in the matrix indicating whether a service bypasses standard processing (Yes/No depending on service),
ExamplesSome screening/assessment codes and crisis-related services show varying Bypass 1 settings (Yes/No) in the matrix entries,
Operational noteCheck the per-code 'Bypass 1' value in the matrix to understand routing behavior for claims processing,
CLIA Certificates as Appropriate — laboratory requirement
Meaning'CLIA Certificates as Appropriate' indicates whether CLIA certification is required for the laboratory service, as shown in the matrix (often 'Yes' for lab/presumptive testing codes),
ExamplesLaboratory and presumptive drug testing codes (e.g., 82465, 83036, 80305–80307) list CLIA requirement = Yes where applicable,
Provider requirementEnsure CLIA certification is in place 'as appropriate' before performing in-house laboratory services, per matrix guidance,
Carved-out — matrix carve-out indicator
Definition'Carved-out' indicates whether a service is excluded from CCBHC reimbursement and handled by an MCO or other arrangements (Yes/No), as shown in matrix entries,
ExamplesCSED waiver services (H0038, H0004) show Carved-out = Yes with reimbursement via MCO; some residential services are carved out,
Provider actionWhen 'Carved-out = Yes' submit claims per MCO policy and confirm prior-authorization requirements with the MCO,
PPS Trigger Service — No indicators
PPS trigger statusThe matrix lists multiple services with 'PPS Trigger Service = No' across entries (especially many laboratory codes and select service codes),
Use in cost report'PPS Trigger Service = No' indicates the code does not trigger PPS inclusion for per-patient-per-day PPS calculation in the cost report,
Provider recommendationVerify each code's 'PPS Trigger Service' value in the matrix before counting services for PPS cost-reporting,
Policy Summary
PayerWest Virginia Bureau for Medical Services (Department of Human Services)
PolicyCHAPTER 503 AND LICENSED BEHAVIORAL HEALTH CENTERS (LBHCS) — Appendix 503I.2 Service Codes
Policy CodePolicy N/A
Change TypeNo material change
Effective DateOct 1, 2024
Next Review Date
Key ActionWhen submitting claims including T1040, ensure any co-reported PPS trigger service that requires prior authorization has that authorization to avoid denial.
SourceLink
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