Behavioral Health Billing Quick Tips
Date: 11/14/24
This document offers tips for proper billing of behavioral health (BH) claims to Meridian for Illinois HFS HealthChoice Illinois (YouthCare) programs. It is not all inclusive. Please utilize the Illinois Association of Medicaid Health Plans (IAMHP) Billing Manual (PDF) for complete claims billing guidance.
Illinois Department of Healthcare and Family (HFS) Fee Schedules
There are four behavioral health billing fee schedules. Reimbursement is determined by the credentials of the provider delivering the service.
- Practitioner Fee schedule: Outlines reimbursement for billing CPT® codes including the base fee and psych add on rates—used for Psychiatrist and Nurse Practitioner billing.
- Community Mental Health Provider Fee Schedule: Outlines reimbursement for billing HCPCS codes approved for CMHC and BH clinics.
- Licensed Practitioner of the Healing Arts: Outlines reimbursement for independently practicing Licensed Clinical Social Worker (LCSW), Licensed Clinical Psychologist (LCP), Licensed Marriage and Family Therapist (LMFT), or by a Licensed Clinical Professional Counselor (LCPC)
- SUPR Fee Schedule: Outlines reimbursement for billing HCPCS codes approved for Substance Use Prevention & Recovery (SUPR) providers
Note, HFS does not allow Licensed Professional Counselors (LPC) to be reimbursed for services. All HFS fee schedules.
Correct Claim Form and Diagnosis Codes
Utilize the correct claim form when billing different services.
- CMHC, SUPR OP, practitioner billing, RH/FQHC are all billed on a CMS1500
- Inpatient and outpatient hospital services, RH/FQHC DUALs eligible encounter services, and IP SUPR service are billed on a UB04
All behavioral health claims must be billed with a behavioral health diagnosis as the primary diagnosis regardless of the service setting. SUPR claims must have a diagnosis in the range of F10-F19.99.
Claims billed with incorrect diagnosis will deny EXDW – Inappropriate diagnosis billed, correct, and resubmit.
Claims billed on the incorrect claim form will deny EXUZ - Services billed on incorrect form, please rebill on UB04 when billed on a CMS1500 or EXPF – Professional fee must be billed on a HCFA when billed on a UB04.
Taxonomy and IMAPCT Category of Service
Covered codes and services are reimbursable based on how your organization and/or providers are enrolled with HFS.
Please remember the following requirement for the billing NPI in Box 33b of the CMS 1500
- HCPCS codes H0002, 90791, H2010, H004, H005, H006 and H2014 claims must be billed with taxonomy 261QR0405X for CMHC billing and 276400000X for Rehabilitation, Substance Abuse
- HCPCS code H0020 must be billed with billing taxonomy 261QM2800X
- HCPCS codes H0047, H2036, H0010 and H0012must be billed with billing taxonomy 32450000x or 325S0500X
- CPT® codes on the practitioner and LPHA fee schedules may only be billed when rendered by a practitioner and must have the practitioner NPI and taxonomy in the rendering loop of the CMS1500 (Box 24J)
Providers (organization/billing) NPI must be enrolled at HFS with the following provider types
036 – Community Mental Health Center | 027 – Behavioral Health Clinic |
A full list of codes and allowed taxonomies can be found in Chapter XIII of the IAMHP Billing Manual and on HFS Fee Schedules.
Licensed Clinical Psychologist vs Psychologist
When submitting an enrollment request for providers to be loaded in the Meridian claim system the correct taxonomy for the provider must be on your roster. Meridian often sees enrollment requests for Psychologist (taxonomy 103T00000X) that submits claims for psychotherapy services. As psychotherapy cannot be billed by a psychologist, claims deny EXZE – service is inappropriate for provider specialty. Psychotherapy codes may be billed by a Licensed Clinical Psychologist (LCP), which requires the provider to be enrolled with taxonomy 103G00000X, 103GC0700X, 103TC0700X or 103TC2200X.
Modifier Billing
A significant number of behavioral health services require a modifier. Missing or incorrect modifiers are one of the main reasons for Meridian behavioral health claims denials. Required modifiers are outlined in Chapter XIII of the IAMHP billing manual. If you receive a denial for EX86 – this is not a valid modifier for this code or EXIM – missing or invalid modifier, please review the modifier billed against the requirement in the IAMHP Billing Manual (PDF) to make corrections and send a correct claim.
Telehealth
- Telehealth claims require a location of 02 telehealth provided in other than the patient’s home, or
- 10 – telehealth services provided when patient is home AND a modifier of GT- session was administered via a telecommunication system or,
- 93 – audio only telemedicine code.
- Common denials occur when claims are received with an office location and a telehealth modifier or a telehealth location and no telehealth modifier.
- Claims will deny either EXIM – missing or invalid modifier or EX4B - Service Not Reimbursable for location billed.
- Please note that for MMP claims the appropriate telehealth location and modifier combination is POS 02 and modifier 95.
Corrected claims
Please remember that if you have submitted a claim and then must make a correction to the claim, you must send a corrected claim referencing the original claim number or the claims will deny EX18 – Duplicate claim. The easiest way to correct a claim is to access the YouthCare Secure Provider Portal and select the “correct a claim” function.
If submitting a corrected claim, on the UB04, via EDI or on paper, please remember to use frequency code 7 in Box 4 [FL4] – fourth digit of the UB04 Type of Bill [0xx7] and include the original claim number of Box 64 [FL64].
If submitting a corrected claim, on the CMS1500, via EDI or on paper, please remember you must utilize a resubmission code of 7 and include the original claim number in box 22.
For questions, please contact YouthCare Provider Services at 844-289-2264, Monday through Friday, from 8 a.m. to 6 p.m.