Expedited Psychiatric Inpatient Admission (EPIA)

As health insurance carriers are aware, they are required under managed care provisions in M.G.L. c. 176O and 211 CMR 52.00 to provide communication materials that document whether or not a request for specific health services is to be covered. 

As is noted in Bulletin 2021-07, “[c]arriers will be expected to arrange payments for all medically necessary care for these patients within the inpatient psychiatric facilities, including such care as may be required to enable the facility to accept a patient with specialty needs (such as a 1:1 staff member/patient ratio, payment to convert a double occupancy room into a single, etc.).” 

Bulletin 2021-07 also requires that insurance carriers identify a point person within their companies to assist with finding appropriate inpatient hospitalization for members.

Click to view Carrier Key EPIA Contacts

Further guidance and clarification to health insurance carriers regarding what is described within Bulletin 2018-01 to clarify expectations regarding so-called “specialing” services that may be necessary to facilitate Expedited Psychiatric Inpatient Admissions (EPIA).  

Click to download the EPIA Special Services Coding Grid or scroll to the bottom of this page. 

 

Documentation

The Division reminds carriers that carriers will be expected to provide verbal, as well as written documentation, when a “specialing” service is authorized - with appropriate details, including an authorization number - in order to document that the services are covered by the insured health benefit plan.  Special services are those services that have been identified by the facility or unit as needed to admit a patient and exceed the typical capabilities and competencies of the facility or unit. Since the EPIA process is expected to speed inpatient psychiatric admissions for persons who have been subject to lengthy ER stays, the Division of Insurance requests that all such notifications be made expeditiously based on the presenting symptoms of the patient in order to facilitate patient placement.

• At the time of verbal authorization, plans should be able to provide written authorization, an authorization number, or other identification of services, so that if any issues occur during claims processing, the provider is able to reference that specialing was authorized.
• Plan billing and payment policies should be updated to reflect how the plan’s specialing process works, and also to include the specialing codes established in the coding grid that are required by the plan.
• Finally, we ask that plans provide authorization of specialing as soon as possible as this will help reduce admissions time.

Billing Codes

In order to facilitate reimbursement for “specialing” services, the Division acknowledges the benefits of developing a set of common codes that apply to EPIA “specialing” services.  The Division recognizes that methods and rates of reimbursement are negotiated between carriers and providers; thus, no one method perfectly serves in all situations, especially where carriers and providers may bundle services into one common payment code.  The Division has worked with carriers and providers to develop a standard set of claim codes, which include services that may be considered  EPIA “specialing” services, and which can be used by carriers and providers when negotiating an appropriate development of methods and rates of reimbursement for covered members.  The codes represent a baseline set of codes that may be used as carriers and providers negotiate contracts.    As to the codes and payment policies utilized by an individual carrier’s health plan, network providers will need to refer to provisions included within their contracts with their payer. The Division expects that each health insurance carrier’s billing and payment policies will be updated to reflect a plan’s “specialing” process, including the codes the carrier is using to process approved “specialing” services.

Additional Resources

EPIA Special Services Coding Grid