Overview
Under Appendix I and K of the current MassHealth Acute Hospital Request for Applications (as amended from time to time, the “Acute Hospital RFA” or “RFA”) applicable to in-state providers, and as applicable to out-of-state acute hospital providers under regulations at 130 CMR 450.233(D), participating in-state and out-of-state MassHealth acute hospital providers will be paid for BH crisis evaluation services and BH crisis management services, which are in the Acute Hospital RFA.
Crisis Evaluation Services
As described in Appendix I, the hospital may choose to subcontract to appropriately trained and experienced behavioral health providers; however, whether the BH crisis evaluation is provided by hospital staff directly or through subcontracted providers, hospitals must submit claims for these services.
- Any clinical service outside of the scope of BH crisis evaluation can continue to be billed separately, as per applicable billing rules, including, but not limited to:
- Direct psychiatric evaluation of the member by a psychiatrist or advanced practice provider (advanced practice registered nurses or physician assistants) requested by the primary hospital medical team for diagnostic clarification and treatment recommendations (90791, 90792, 99201-99205, 99211-99215, 99241-99245, 99251-99255).
- Intensive, specialized therapies requested by the primary hospital team to support the stabilization efforts of members in the hospital with complex needs, including Applied Behavioral Analysis for members with Autism Spectrum Disorder.
- Initiation of medication for the treatment of opioid use disorder in the emergency department setting and connection to recovery support navigation in the emergency department (G2213 and H2015-TF respectively).
- Any MassHealth payment made to the Hospital for a BH crisis evaluation, based on a claim or invoice submitted by a Hospital, on the same calendar day as a similar service provided and billed by a non-hospital provider is an overpayment as defined by 130 CMR 450.235 and will be subject to recoupment.
- The following services will not be considered inside the scope of a BH crisis evaluation, and therefore can be provided and billed by a non-hospital provider on the same calendar day as a hospital-provided BH crisis evaluation:
- Community-Based MCI services provided to the member on their day of discharge as a warm handoff to facilitate a smooth disposition to the community.
- Children’s BH Initiative services provided to family members/caregivers of youth members throughout the member’s stay in the hospital to help strengthen the resources and capacities of the family to support the member in the community upon discharge.
Crisis Management Services
As described in Appendix K, the Hospital may choose to subcontract to appropriately trained and experienced behavioral health providers; however, whether the BH crisis evaluation is provided by hospital staff directly or through subcontracted providers, hospitals must submit claims for these services.
- Any clinical service outside of the scope of BH crisis management can continue to be billed separately, as per applicable billing rules, including, but not limited to:
- Direct psychiatric evaluation of the member by a psychiatrist or advanced practice provider (advanced practice registered nurses or physician assistants) requested by the primary hospital medical team for diagnostic clarification and treatment recommendations (90791, 90792, 99201-99205, 99211-99215, 99241-99245, 99251-99255).
- Intensive, specialized therapies requested by the primary hospital team to support the stabilization efforts of members in the hospital with complex needs, including Applied Behavioral Analysis for members with Autism Spectrum Disorder.
- Initiation of medication for the treatment of opioid use disorder in the emergency department setting and connection to recovery support navigation in the emergency department (G2213 and H2015-TF respectively).
- Any MassHealth payment made to the Hospital for a BH crisis management service, based on a claim or invoice submitted by a Hospital, on the same calendar day as a similar service provided and billed by a non-hospital provider is an overpayment as outlined in 130 CMR 450.235 and will be subject to recoupment.
- The following services will not be considered inside the scope of a BH crisis management services, and therefore can be provided and billed by a non-hospital provider on the same calendar day as a hospital-provided BH crisis management services:
- Community-Based MCI services provided to the member on their day of discharge as a warm handoff to facilitate a smooth disposition to the community.
- Children’s BH Initiative services provided to family members/caregivers of youth members throughout the member’s stay in the hospital to help strengthen the resources and capacities of the family to support the member in the community upon discharge.
| Date published: | April 30, 2024 |
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