Annual Mental Health Wellness Exams, Temporary Waiver of Auth for Post-Acute Facilities

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In this issue:

• Annual Mental Health Wellness Exams
• Home health care - prior authorization requirements
• Temporary waiver of authorization for post-acute facilities
• Commercial rate adjustment for telehealth services provided by non-PCP providers
• NOC/Unlisted code process for Medicare Advantage
• Response to ED Boarding Crisis
• Update - InterQual for Providers
• Medical policy updates
• Medicare provider notification
• Drug code and code updates
• New codes summary

Annual Mental Health Wellness Exams

Per MA DOI Bulletin 2024-02, we will cover an annual Mental Health Wellness Exam when billed under the medical benefit effective 4/1/2024 as follows: 
 
Diagnosis Code: Z13.30, Encounter for screening examination for mental health and behavioral disorders, unspecified
Service Code: 90791, Psychiatric diagnostic evaluation
Modifier: 33, Preventive Services: When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.
 
Frequency Limit: Annual
 
Services are provided at no member cost sharing except if the member is enrolled in an HSA qualified health plan (plan name includes the word ‘HSA’).
 
Mass General Brigham Health Plan’s Behavioral Health partner, Optum, will update our behavioral health providers via Provider Express. 

Home health care - prior authorization requirements 

Mass General Brigham Health Plan reimburses contracted Home Health Care agencies for home health care service provided to a member with an approved home health care plan. Various services and procedures require referral and/or prior authorization.

To determine if a service or procedure requires a referral and/or prior authorization, please refer to the referral and prior authorization guidelines.

Additional resources

• The medical policy for home health care can be found here. 
• Provider payment guidelines for home health care can be found here. 

Temporary waiver of authorization for post-acute facilities

Mass General Brigham Health Plan is waiving prior authorization requests from January 9, 2024 until April 1, 2024 for patient transfers from acute care hospitals to sub-acute care facilities and rehabilitation facilities. This applies to initial admission to the sub-acute and/or rehabilitation. This is in support of the recent directive from the Massachusetts Executive Office of Health and Human Services (EOHHS).

Notice of Admission (NOA)

Notifications should be submitted by the respective Skilled Nursing and Acute Rehabilitation facilities within 24 hours of admission and updates provided a minimum of every 5 days to support discharge planning. 

Concurrent review and retrospective review will proceed (if notification occurred) to determine appropriateness of level of care.

Included in this waiver

• Medicaid, Commercial and Medicare lines of business
• INN providers
• OON providers within Massachusetts

Excluded from this waiver

• Long Term/custodial care
• Out of network providers outside of Massachusetts

Commercial rate adjustment for telehealth services provided by non-PCP providers beginning January 1, 2024 

 
At the beginning of the COVID-19 pandemic, we implemented a temporary change to reimburse telehealth services on parity with in-person visits, in alignment with public health emergency recommendations and regulatory guidance.
 
On January 1, 2024, we returned to the pre-pandemic practice of a rate differential for services rendered through telehealth versus in-person. Services delivered via telehealth will pay at 85% of in-person rates, with exceptions for primary care and behavioral health. Primary Care services will continue to be reimbursed at 100% of in-person rates. Our behavioral health network is managed by Optum Behavioral Health. Optum BH applies rate parity for services delivered via telehealth. The MA DPH establishes rates for Early Intervention and Early Intensive Behavioral Intervention.
 
As we return to pre-pandemic operations and policies, we make these changes in accordance with MA 211 CMR 52.00, which implements MA Chapter 260 of the Acts of 2020 and related guidance. We will continue to communicate with you as more information becomes available.

NOC/Unlisted code process for Medicare Advantage

For Medicare Advantage, claims with an NOC/Unlisted code requires a member's medical record(s). An email with the subject line, UNLISTED CODE MEDICAL RECORD REQUEST, will be sent to the provider with instructions on how to submit documentation. Please submit medical records via the Plan's secure portal: 

https://mft.nhp.org/Web/Account/Login.htm
user name: unlistedcodes
password: nhp

Response to ED Boarding Crisis

Mass General Brigham Health Plan complies with regulatory guidance to ensure Hospitals are reimbursed for behavioral health crisis evaluations and stabilization services provided in the Emergency Department in response to the ED Boarding crisis.

This applies to:

• Commercial members, for dates of service 11/01/2022 and forward per MA DOI Bulletin 2022-08.
  
  
• Medicaid members, for dates of service 01/03/2023 through 09/30/2023, per Mass Health guidance including MCE Bulletin 93 published November 2022.
• Medicaid members, for dates of service 10/01/2023 and forward, per the MA Inpatient Acute General RFA effective 10/01/2023.

Mass General Brigham Health Plan complies with regulatory guidance to ensure Hospitals are reimbursed for behavioral health crisis evaluations and stabilization services, crisis management, recovery support navigators and the initiation of medication treatment for Opioid Use Disorders in the ED per the MA Inpatient Acute General RFA effective 10/01/2023.  

Provider payment guidelines | Mass General Brigham Health Plan

Update - InterQual for Providers  

On February 5, 2024, Mass General Brigham Health Plan updated their InterQual to the October 2023 Release. To learn more about this update, please visit: https://chciqrc.mcoutput.com/interqual/Content/CR-2023-LOC.htm 

Medical policy updates

Eight (8) medical policies were reviewed and passed by the Mass General Brigham Health Plan’s Medical Policy Committee. These policies are now posted to MassGeneralBrighamHealthPlan.org. The table below is a summary.

For more information or to download our medical policies, go to https://www.massgeneralbrighamhealthplan.org/providers/medical-policies and select the policy under the medical policy listings.

2024 Medicare provider notification

View the Medicare Provider Notification here.

Drug code and code updates

View code updates for February 2024 here. 

New codes summary

View the January new codes summary here.