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Mental Health ServicesPart II: Services for Clients Not Enrolled in a BHO, FIMC, or BHSO.89Crisis services .90Provider eligibility .90Who is eligible to provide and bill for these specialized mental health services? . 90Professional services .91Billing . 94How do I bill claims electronically? . 94What are the general guidelines for billing professional services?. 94How do specialized mental health providers bill claims for professional services?. 95Where can I view the fee schedules? . 95Services delivered in an inpatient hospital setting .95Inpatient professional psychiatric services provided to any Apple Health clientwho is not enrolled in FIMC . 96How do I bill freestanding evaluation and treatment services provided to AppleHealth clients who are not enrolled in a BHO, FIMC, or BHSO?. 96How do I bill the professional services in an emergency room setting for a clientwho is transferred to another facility for an inpatient psychiatric admission? . 97When is out-of-state outpatient care covered? . 98Inpatient hospital psychiatric admissions .98Inpatient hospital psychiatric care criteria . 98Provider requirements . 98Voluntary treatment . 99Involuntary treatment . 100Authorization requirements for inpatient hospital psychiatric care .100Medicare/Medicaid dual eligibility and commercial (private) insurance . 101Additional requirements. 101Billing for inpatient hospital psychiatric care .105General billing of institutional claims for inpatient hospital psychiatric care forclients who are not enrolled in a BHO, FIMC or BHSO . 105Claims for psychiatric services when the principal diagnosis falls outside thepsychiatric diagnosis range . 106Splitting claims . 106How do I bill for clients covered by Medicare Part B only (No Part A), or whohave exhausted Medicare Part A benefits prior to the stay? . 106How do I bill for clients when Medicare coverage begins during an inpatient stayor Medicare Part A has been exhausted during the stay? . 107Billing when Medicare Part A benefits are exhausted during the stay . 108Billing for medical admissions with psychiatric principal diagnosis . 109Recoupment of payments . 109Alert! This Table of Contents is automated. Click on a page number to go directly to the page.9

Mental Health ServicesResourcesTopicObtaining prior authorizationor a limitation extensionResourcesFor all requests for prior authorization or limitationextension, submit: A completed, typed General Information forAuthorization form, HCA 13-835. This request formmust be the initial page when you submit your request. A completed Fax/Written Request Basic Informationform, HCA 13-756, and all the documentation listed onthis form and any other medical justification.To download forms, see “Where can I download agencyforms?”Fax your request to: 866-668-1214.Obtaining Apple Health formsSee the agency’s Forms & publications webpage.DefinitionsRefer to Chapter 182-500 WAC for a complete listof definitions for Washington Apple Health.Contacting ProviderEnrollmentSee the Apple Health Billers and Providers Contact Us page.Becoming a provider orsubmitting a change of addressor ownershipFinding out about payments,denials, claims processing, oragency managed careorganizationsSee the Apple HealthBillers and Providers webpage.Electronic billingFinding provider billing guides,fee schedules, and other agencydocumentsThird-party liability other thanagency managed care10

Mental Health ServicesDefinitionsThis list defines terms and abbreviations, including acronyms, used in this billing guide. Refer toChapter 182-500 WAC for a complete list of definitions for Washington Apple Health.Expedited prior authorization (EPA) –See WAC 182-500-0030.Behavioral Health Administrative ServiceOrganization (BH-ASO) – See WAC 182538A-050.Fee-for-service (FFS) – See WAC 182500-0035.Division of Behavioral Health and Recovery(DBHR) - The Behavioral Health andRecovery Division (DBHR) provides supportfor mental health, substance use disorder, andproblem gambling services. The public mentalhealth programs promote recovery andresiliency and reduces the stigma associatedwith mental illness. The substance abuseprevention and substance use disordertreatment programs promote strategies thatsupport healthy lifestyles by preventing themisuse of alcohol, tobacco, and other drugs,and support recovery from the disease ofsubstance use disorder. The problem gamblingprogram mitigates the effects of problemgambling on the family and helps familiesremain economically self-sufficient withoutrequiring assistance from other stateprograms. DBHR brings operational elementslike medical assistance, substance use disorderand mental health into closer workingrelationships that serve clients moreeffectively and efficiently than before.Fully Integrated Managed Care (FIMC) –See WAC 182-538A-050.Hospital – See WAC 182-500-0045.Institution for mental diseases (IMD) –See WAC 182-500-0050.Medically necessary –See WAC 182-5000070.National correct coding initiative(NCCI)" –See WAC 182-500-0075.National provider indicator (NPI) – SeeWAC 182-500-0075.Outpatient – See WAC 182-500-0080.Post stabilization care – Covered servicesrelated to an emergency medical conditionthat are provided after an enrollee isstabilized to maintain the stabilizedcondition, or, to improve or resolve thepatient’s condition. For the purposes of themental health program, emergency servicesend when patient is ready to discharge fromthe emergency room and either be releasedor admitted to an inpatient psychiatricfacility.Behavioral Health Organization (BHO) –See WAC 182-500-0015.Behavioral Health Services Only (BHSO)– See WAC 182-538A-050.Early and periodic screening, diagnosisand treatment (EPSDT) – See WAC 182500-0030.Prior authorization – See WAC 182-5000085.11

Mental Health ServicesProvider – See WAC 182-500-0085.Psychiatric hospital – See WAC 182-5501050.Psychiatric residential treatment facility(PRTF) – A nonhospital residentialtreatment center licensed by DOH, andcertified by the agency or the agency'sdesignee to provide psychiatric inpatientservices to Medicaid-eligible individuals agetwenty-one and younger. A PRTF must beaccredited by the Joint Commission onAccreditation of Health care Organizations(JCAHO) or any other accreditingorganization with comparable standardsrecognized by Washington State. A PRTFmust meet the requirements in 42 C.F.R.483, Subpart G, regarding the use ofrestraint and seclusion.Third-party liability (TPL) – See WAC182-503-0540.12

Mental Health ServicesProgram Overview(WAC 182-531-1400)This billing guide describes mental health benefits administered through the Health CareAuthority (the agency) and the Department of Social and Health Services (DSHS) that areavailable to Apple Health clients.This billing guide is divided into two parts:Part I of this guide describes the set of lower-acuity mental health services covered by managedcare organizations (MCOs) or fee-for-service (FFS) and the higher-acuity mental health servicescovered by a behavioral health organization (BHO), fully integrated managed care (FIMC), orbehavioral health services only (BHSO) for clients enrolled in these programs. (A BHSOprovides behavioral health services to clients who enroll in an FIMC managed care plan forbehavioral health services only.)Part II of this guide describes the set of specialized mental health services available to FFS orMCO-enrolled clients that are not enrolled in a BHO, FIMC, or BHSO for mental health servicesand have one of the recipient aid categories (RACs) listed in that section. These specializedservices are in addition to the lower-acuity mental health services covered by the client’s MCOor FFS program. Specialized mental health services include inpatient services as well asoutpatient services that are classified as above the ACS.Note: To find the BHO offering mental health coverage for each region, see theBHO Contacts sheet.To determine which services are covered by which payer and who to bill, see How do providersidentify the correct payer?What services are covered?Apple Health clients in all regions have coverage for: Mental health services, including crisis, outpatient and professional services Mental health services provided by DOH-licensed behavioral health agencies Psychiatric inpatient hospitalization13

Mental Health ServicesNational correct coding initiativeThe agency continues to follow the National Correct Coding Initiative (NCCI) policy. TheCenters for Medicare and Medicaid Services (CMS) created this policy to promote nationalcorrect coding methods. NCCI assists the agency to control improper coding that may lead toinappropriate payment. The agency bases coding policies on the following: The American Medical Association’s (AMA) Current Procedural Terminology (CPT)manualNational and local policies and editsCoding guidelines developed by national professional societiesThe analysis and review of standard medical and surgical practicesReview of current coding practicesProcedure code selection must be consistent with the current CPT guidelines, introduction, andinstructions on how to use the CPT coding book. Providers must comply with the codingguidelines that are within each section (e.g., E/M services, radiology, etc.) of the current CPTbook.Medically Unlikely Edits (MUEs) - Part of the NCCI policy are MUEs. MUEs are themaximum unit of service per HCPC or CPT code that can be reported by a provider under mostcircumstances for the same patient on the same date of service. Items billed above the establishednumber of units are automatically denied as a “Medically Unlikely Edit.” Not all HCPCS or CPTcodes are assigned an MUE. The agency adheres to the CMS MUEs for all codes.The agency may have units of service edits that are more restrictive than MUEs.The agency may perform a post-pay review on any claim to ensure compliance with NCCI.NCCI rules are enforced by the ProviderOne payment system.Partnership Access Line for prescribingpractitionersThe Partnership Access Line (PAL) is a telephone-based child mental health consultation systemfor Washington State. PAL employs child psychiatrists, child psychologists, and social workersaffiliated with Seattle Children’s Hospital to deliver its consultation services.The PAL team is available to any primary care provider throughout Washington State.Washington’s primary care providers are encouraged to call the PAL toll free number (866) 5997257 as often as needed. PAL provides rapid consultation responses during business hours(Monday-Friday, 8:00 a.m. to 5:00 p.m.) for any type of children’s mental health issue that ariseswith any child. For more information, see the Partnership Access Line webpage.14

Mental Health ServicesAdditional mental-health-related servicesThe following covered services are explained in other agency billing instructions and rules: Applied Behavior Analysis (ABA) Program Billing Guide Alcohol or substance misuse counseling (screening, brief interventions, and referral totreatment) (SBIRT)(See the Physician-Related Services/Health Care Professional Services Billing Guide) Collaborative Care Model Guidelines(See the Physician-Related Services/Health Care Professional Services Billing Guide) Screening children for mental health and caregiver depression screening(See Early and Periodic Screening

for mental health services? North Central Washington Behavioral Health removed from the list of BHOs. Outdated information Provider requirements Language added to the headings and text to clarify that provider requirements in this section of the guide apply to lower-acuity mental health services. Outpatient mental health services coverage table