Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 01|01|2024 POLICY LAST REVIEWED: 01|03|2024 OVERVIEW Health and behavior assessment procedures are used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems. The focus of the assessment is not on mental health, but on the biopsychosocial factors important to physical health problems and treatments. MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage and Commercial Products Health and behavior assessment/intervention services are covered when provided by Psychologists (specialty code 062), Clinical Social Worker (LICSW) (specialty code 042), Marriage and Family Therapist (MFT) (specialty code 078), and Mental Health Counselor (MHC) (specialty code 077). If psychiatric services and health and behavior services are rendered on the same date of service, by the same provider, report the predominant service performed.
If a health and behavioral assessment/intervention services and a psychiatric services procedure code are filed by the same provider, for the same date of service, only the first submitted service (or predominant diagnosis) will pay. The second service filed should deny as provider billing error.
COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Evidence of Coverage or Subscriber Agreement for applicable medical benefits/coverage.
BACKGROUND Not applicable CODING Medicare Advantage and Commercial Products: The following codes effective on January 1, 2020 are covered when filed by the providers as noted above: 96156 Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral
observations, clinical decision making)
96158 Health behavior intervention, individual, face-to-face; initial 30 minutes
96159 Health behavior intervention, individual, face-to-face; each additional 15 minutes (List separately in addition to code for primary service) 96164 Health behavior intervention, group (2 or more patients), face-to-face; initial 30 minutes 96165 Health behavior intervention, group (2 or more patients), face-to-face; each additional 15 minutes (List separately in addition to code for primary service) 96167 Health behavior intervention, family (with the patient present), face-to-face; initial 30 minutes Payment Policy | Health and Behavior Assessment

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

96168 Health behavior intervention, family (with the patient present), face-to-face; each additional 15
minutes (List separately in addition to code for primary service) 96170 Health behavior intervention, family (without the patient present), face-to-face; initial 30 minutes 96171 Health behavior intervention, family (without the patient present), face-to-face; each additional 15
minutes (List separately in addition to code for primary service)

Note: When multiple services above are rendered on the same date by the same provider, one co-payment is applied.

Health and behavior assessment/intervention services are invalid procedure codes (not member liability) if the diagnosis is for a psychiatric condition.

RELATED POLICIES None

PUBLISHED Provider Update, March 2024 Provider Update, September 2022 Provider Update, March 2020 Provider Update, April 2018 Policy Update, March 2017 Policy Update, March 2016

REFERENCES Not applicable

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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