Behavioral health provider billing

Billable behavioral health services are reimbursed fee-for-service.

Download Behavioral Health commercial fee schedule

In general, follow billing rules for all practitioners using a CMS-1500 claim form.

See CMS-1500 billing guidelines

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.

Psychological testing

When testing is directly provided by an LLP, bill with the supervising LP as the rendering provider.

Organizational providers

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.

Enrollment 

To enroll a new practitioner to an existing organization or group:

  1. Log into your prism account
  2. Click the Enrollments & Requests tab
  3. 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.