Behavioral health provider billing
Billable behavioral health services are reimbursed fee-for-service.
In general, follow billing rules for all practitioners using a CMS-1500 claim form.
Behavioral health practitioner requirements
In order to be reimbursed for in-network services, practitioners must be credentialed by Priority Health and licensed as follows:
- Commercial HMO/EPO/POS/PPO plans: MDs/DOs, LPs, LMSWs, LPCs and LLPs
- Medicaid plans: MDs/DOs, LPs, LMSWs, LPCs and LLPs
- Medicare Advantage plans: MDs/DOs, LPs and LMSWs
Limited license practitioners
LLMSWs, LLPCs and TLLPs cannot be credentialed and cannot bill directly for in-network or out-of-network services.
LLMSWs, LLPCs and TLLPs may provide only services within their respective scope of licensure to Priority Health Commercial and Medicaid Members (cannot provide services to Medicare Advantage Members) and only when supervised by a fully licensed and credentialed provider, as follows:
- For services provided by an LLMSW, an LMSW must supervise and bill with the LMSW’s NPI using AJ modifier.
- For services provided by an LLPC, an LPC must supervise and bill with the LPC’s NPI using HO modifier.
- For services provided by a TLLP, an LP must supervise and bill with the LP’s NPI using HO modifier.
Field 24J (“rendering provider”) of the 1500 claim form must list the Type 1 NPI of the supervising provider (do not use the NPI of the LLMSW, LLPC or TLLP), and field 24D must include the AJ or HO modifier as noted above.
Services will be reimbursed at the corresponding supervisor’s licensure level rate specified in the Behavioral Health Fee Schedule.
Supervision must, at a minimum, include documentation by the supervising/billing provider in the Member’s medical record that they have reviewed the limited license practitioner’s medical record notes within one week of each visit.
Exceptions to the credentialing and supervision requirements
Exceptions to the above credentialing and supervision/rendering provider billing rules are as follows:
Psychotropic medication management services
Psychiatric advanced practice providers, e.g., NPs and PAs, directly providing these services do not require credentialing by Priority Health. Bill with their supervising/collaborating psychiatrist as the rendering provider.
When testing is directly provided by an LLP, bill with the supervising LP as the rendering provider.
When working in an accredited organization that’s credentialed with us as an Organizational Provider, appropriately licensed behavioral health practitioners (other than MDs/DOs) don’t require individual credentialing.
To enroll a new practitioner to an existing organization or group:
- Log into your prism account
- Click the Enrollments & Requests tab
- Select the appropriate option for your enrollment request
We’ll notify you through prism when we’ve added the provider. Claims with dates of service before the notification date will be denied.
Provider record and billing reviews
Priority Health reviews claims data to identify and monitor suspect patterns as part of our fraud, waste and abuse program.
Providers may be flagged for reviews for:
- Excessive billing of high-level codes
- Exclusive use of one code level billed
- Excessive units for a time-based code
Submitting electronic claims
Mailing paper claims
Priority Health Claims
P.O. Box 232
Grand Rapids, MI 49501
- Status claims
- Claims Inquiry tool guide
- Edits Checker tool guide
- Claim deadlines
- Set up electronic payments
- BH provider billing
- Facility billing
- Advanced practice professional billing
- Professional billing
More billing topics:
- ACA non-payment grace period
- Ambulatory surgery center billing
- Balance billing
- Clinical edits
- Check reissue procedure
- COB: Coordination of benefits
- Correcting claims
- Correcting overpayments & underpayments
- Diagnosis coding
- Dual-eligible members
- Front-end rejections
- Gender-specific services
- Medicaid billing
- NDC numbers on drug claims
- Office-based procedures billing
- Risk adjustment
- Unlisted codes, drugs & supplies