Regulation .02 Behavioral Health Non-Capitated Covered Services.
Regulation .02 Behavioral Health Non-Capitated Covered Services.LinkCopy Citation
A.
An MCO is not responsible for reimbursing for the following substance use disorder services, regardless of diagnosis:
(1)
Services delivered by a community-based provider as described in COMAR 10.09.80 with the following procedure codes:
(2)
Substance use disorder services provided to children in an ICF-A with the revenue code 0100, Residential Services, child and adolescent.
B.
An MCO is not responsible for reimbursing for the following services performed by free-standing laboratories, regardless of diagnosis:
(1)
Presumptive drug tests; and
(2)
Definitive drug tests.
C.
An MCO is not responsible for reimbursing for the laboratory services described in §B of this regulation unless billed by a:
(1)
Primary care provider; or
(2)
Other somatic care provider.
D.
An MCO is not responsible for reimbursing for the following substance use disorder services if the MCO is billed with a primary diagnosis listed in §M of this regulation:
(1)
Services delivered by an inpatient hospital with the following revenue codes:
(2)
Services delivered by an outpatient hospital with the following revenue codes:
(3)
Services delivered by an emergency department with the following revenue codes:
E.
An MCO is not responsible for reimbursing for mental health services with a primary diagnosis listed in §N of this regulation when the services are provided by a hospital and the services are the result of the treatment of mental health diagnosis.
F.
An MCO shall be responsible for reimbursing for behavioral health services delivered by the participant’s primary care provider.
G.
An MCO shall be responsible for reimbursing for somatic services related to gender identity disorder, including gender reassignment surgery.
H.
An MCO is not responsible for reimbursing the behavioral poisoning diagnoses listed in §P of this regulation in an emergency department setting.
I.
An MCO is not responsible for services billed by specialty mental health providers listed in COMAR 10.09.59 when the bill includes the specialty behavioral health diagnoses listed in §M or N in the primary diagnosis field.
J.
An MCO is not responsible for reimbursement of behavioral health crisis services as described in COMAR 10.09.16.
K.
An MCO is not responsible for behavioral health medications.
L.
An MCO is not responsible for reimbursing for services billed by a physician related to prescribing buprenorphine or Vivitrol when the following conditions are met:
(1)
The physician delivering buprenorphine has a DATA 2000 waiver;
(2)
The physician is not the participant’s primary care provider;
(3)
The primary diagnosis is substance use disorder;
(4)
The primary reason for the visit is substance use disorder treatment; and
(5)
The procedure code listed on the claims is one of the following:
M.
Table of substance use disorder diagnoses, for dates of service on or after October 1, 2015:
N.
Table of mental health diagnoses, for dates of service on or after October 1, 2015:
O.
An MCO is not responsible for services billed by a psychiatrist when the claim includes one of the following primary diagnoses:
P.
Table of poisoning diagnoses, for dates of service on or after July 1, 2016: