Aetna NC State Health Plan

The North Carolina State Health Plan is introducing three in-network tiers for 2027. Those networks are preferred, access and non-preferred. Please check with Aetna to confirm which tier your practice falls under.

BCBS MI discontinues incident to billing for mental health providers in private practice

Effective March 1, 2027, BCBSM will restrict incident-to billing to facility-based settings only, including psychiatric hospitals, community mental health agencies, and similar institutional environments.2 Private practice offices, regardless of size, will no longer qualify. To help providers adjust, a transition period runs from September 1, 2026, through February 28, 2027. During this window, services rendered by limited license clinicians under supervision can still be billed with the "SA" modifier, but reimbursement will be paid at the submitting provider's applicable rate and they will not be eligible for value-based incentive programs.3 After the transition, any limited licensee attempting to bill incident-to from a private practice will face a penalty: only 80% of the allowed amount will be paid, and the claim remains ineligible for value-based reimbursement. https://www.counselingpsychology.org/articles/bcbsm-billing-change-mental-health-2026-06-14/

Quest Behavioral Healthcare closure

By now you should have heard that Quest Behavioral Health will be closing their business June 30th and will no longer be the behavioral health vendor for UPENN and UPHS. Lyra Health will become the behavioral health vendor for UPHS and IBX (Independence BCBS) will become the behavioral health vendor for UPENN. If you want to continue seeing your current Quest clients as IN network providers you will need to become credentialed with Lyra Health and/or Independence BCBS (IBX). Contact info@ttmedbill.com if you'd like credentialing assistance.

NYCE PPO Bridge Program Network

Effective Jan 1, 2026 NYC employees, pre-Medicare eligibile retirees and their dependents will be offered the New York City Employees PPO plan (NYCE PPO), a health benefit plan delivered through a partnership between EmblemHealth and United Healthcare. The NYCE PPO Bridge Program will offer IN network coverage focused on providers within the 13 lower New York State counties of Bronx, Dutchess, Kings, Nassau, New York, Orange, Putnam, Queesn, Richmond, Rockland, Suffolk, Ulster and Westchester. Historically, all behavioral health services were managed and paid through the Carelon network. The NYCE PPO Bridge Program network replaces Carelon effective Jan 1. 2026. Members with Emblem GHI PPO will receive new insurance cards and providers should request those new cards before scheduling appointments. You can find more information on this new program at: https://www.emblemhealth.com/providers/resources/nyce-ppo/faqs

Medicare IN PERSON behavioral health session visit requirement

Beginning January 1, 2026, Medicare will require a mental health therapy session be conducted IN PERSON within six months of an initial session and then at least one session annually thereafter. This requirement was originally scheduled to begin 10/1/2025 but congress agreed to extend until January 2026.

Carelon EAP

Effective December 2, 2024 Carelon will discontinue the Case Activity Form (CAF) for submitting EAP services provided to Carelon members. Provider's will now be able to submit EAP claims via CMS 1500 forms. The CPT code to use is 99404 and the modifier to use is HJ.

Harvard Pilgrim Changes

Effective Jan. 1, 2025, non-contracted Harvard Pilgrim providers will no longer be considered IN network. Providers were considered participating if the provider was IN network with Optum/United Behavioral Health’s network. Harvard Pilgrim invites Optum/United providers that are seeing Harvard Pilgrim clients to join the Harvard Pilgrim network at https://www.harvardpilgrim.org/provider/resource-center/join-our-network/

BCBS of Michigan network participation changes for 2025

Starting Jan. 1, 2025, Blue Cross Blue Shield of Michigan and Blue Care Network will disenroll health care providers who haven’t submitted any claims for 24 consecutive months. Disenrollments will occur automatically and will be carried out on a quarterly basis. Blue Cross Blue Shield of Michigan and Blue Care Network notify the providers by letter 60 days in advance. Submitting claims regularly will prevent disenrollment from taking place.

NJ Medicaid FFS

Effective January 1st 2025, NJ Medicaid will be shifting behavioral health services from FFS(fee for service) to MCOs(managed care organizations). MCOs will be responsible for coordinating care and managing payments, rather than providers billing Medicaid directly. The main 5 MCOs are Aetna, Horizon NJ, United Healthcare Community Plan, Wellpoint and Fidelis. The process to credential providers through the MCOs has begun. You can get more information and credentialing contacts here: https://www.nj.gov/humanservices/dmhas/information/stakeholder/DMAHS_BHI/MCO%20BH%20Contact%20Resource%20Guide%20for%20Providers_7.22.2024.xlsx

My podcast episode with Leaders in Medical Billing

Updated UBH/United/Optum Supervisory billing policy

Updated Claim Submission Requirements for Optum Patients Receiving Supervisory Services Effective Oct. 1, 2024, Optum will reimburse outpatient supervisory services claims covered by Commercial Behavioral Health plans as follows: California, Colorado, Iowa & Massachusetts – Both network and out-of-network providers and groups ALL other states – Only network providers and groups who have an existing, fully executed participation agreement on or before Sept. 30, 2024.

Healthfirst NY online portal retiring

Effective September 30, 2024, member eligibility and benefits verification will retire in Healthfirst’s legacy provider portal (hfproviderportal.org) and should be completed exclusively in Availity Essentials. Eligibility and benefits verification is not the only time-saving tool available to Healthfirst network providers in Availity Essentials: Submit professional and facility claims and gain real-time visibility into the status of a claim. View remittances/explanations of payment with convenient search and filter options. Access additional applications and resources specific to Healthfirst in a dedicated Payer Space, including Member Renewal Roster.

Superior Healthplan copays continue to be waived for outpatient mental health

Effective 10/1/24: Co-pays will Resume for CHIP COVID-19 Services Date: 07/03/24 During the COVID-19 public health emergency, the Texas Health and Human Services Commission (HHSC) waived co-pays for COVID-19 vaccines, testing, and treatment for Children’s Health Insurance Program (CHIP) members. This waiver will end on September 30, 2024. Providers may begin collecting co-pays for COVID-19 vaccines, testing, and treatment rendered to CHIP eligible members for dates of service on or after October 1, 2024. Providers may not charge co-pays for mental health and substance use disorder outpatient office visits. Co-pays have been permanently removed for mental health and substance use disorder outpatient office visits to comply with federal regulations. CHIP co-pays that members must pay are determined based on their income and do not apply to Native Americans, Alaska Natives, CHIP Perinate and CHIP Perinatal newborn members. Providers must adhere to co-pay guidelines outlined in the Superior HealthPlan STAR, CHIP, STAR+PLUS, STAR Health and STAR Kids Provider Manual (PDF), in the Provider Manuals section of Superior’s Training and Manuals webpage. Eligibility and co-pay information may be verified via Superior’s Secure Provider PortalExternal Link.

Front office support for your practice

 For therapist in need of front office support without the physical "front office", S & S Virtual Solutions may be just what you need.  They assist with streamlining new client inquiries, hassle free appointment management, social media management and more.  For more information visit https://snsvsolutions.com/

Change Healthcare Cyber Attack

T & T participated in a zoom conference today regarding the Change Healthcare cyber attack and what the latest updates are.

In case some providers are not aware, the attack occurred 2/21/24.  The group that attacked is called Blackcat Ransomware.  This organization has infiltrated government, healthcare, emergency services and manufacturing systems, to name a few.  Change Healthcare has been working closely with Blackcat and law enforcement to resolve the issue.  

The Blackcat organization has claimed to have 6 TB of data from healthcare organizations which include personal information, health records, payment information and insurance records.  Change Healthcare has not been able to confirm how much data has been breached and what information has been breached.  Change Healthcare has 60 days to report the breach and exactly what information has been compromised.

Since this breach has been in the national news and it hasn't been confirmed exactly what information has been breached and for whom, providers can use their own discretion in alerting patients of the breach.  Again, Change Healthcare has 60 to officially report.

T & T has been advised by our billing software what insurance companies have been compromised.  I have attached a list of the companies we are 100% aware of.  The green shaded companies were compromised and rerouted through a different clearinghouse.  The non green shaded companies are still being worked on to be rerouted.  If a company is not listed, claims are being processed as normal, for now.  T & T has continued submitting claims since 2/21/24 and will continue.  As we receive updates, we will do our best to update you.  Thank you.

Maryland Medicaid makes a behavioral health vendor change

 Maryland Medicaid has announced Carelon Behavioral Health will be the Administrative Service Organization for the Public Behavioral Health System effective January 1, 2025.  Maryland Medicaid will no longer use Optum Maryland as the behavioral health vendor.  The transition process includes transferring authorizations, claims payment processing, participant history, and other information and materials from Optum Maryland to Carelon.  T & T will post further updates as they are released.  

Any questions regarding this announcement can be directed to: mdh.mabehavioralhealth@maryland.gov

Northwell Direct

Northwell Direct updated the network they use for mental health claims.  Claims prior to 2024 were processed and sent to Magnacare.  Starting in 2024 claims will now be sent and processed to HealthComp P.O.Box 2920 Milwaukee WI 53201-2920 Payer ID 36149

Place of service 10

 Medicare will begin accepting claims with place of service 10 for mental health telehealth services when provided while patient is located in their homes.  This place of service goes in effect 1/1/2024.  Applicable modifiers will still be accepted.

Empire BCBS will begin managing behavioral health services through Carelon

If you are a participating BCBS provider, your contract will be merged with Carelon (ie you will now be a participating provider with Carelon for BCBS clients.)  Get more information at:  https://providernews.empireblue.com/article/notice-of-assignment-of-your-empire-provider-agreement-to-beacon

NYS Medicaid approves credentialing for LCSWs, LMHCs and LMFTs

NYS Medicaid has approved credentialing for LCSW, LMHCs and LMFTs.  This will enable NYS providers to be reimbursed for services when patients are covered through Medicare and Medicaid as a secondary or patients who only have Medicaid.   Below is the link to the provider manual.  Please contact T & T for credentialing assistance and fee schedule information at 888.364.3858 or info@ttmedbill.com

 https://www.emedny.org/ProviderManuals/LMHP/PDFS/LCSW_LMHC_LMFT_Policy_Manual.pdf