Prior authorization request form Form

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 06|01|2025 POLICY LAST REVIEWED: 04|16|2025 OVERVIEW This policy addresses payment guidelines for integrated behavioral health services, including the Collaborative Care Model (CoCM).
MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Collaborative Care Management Services (CoCM) Medicare Advantage Plans and Commercial Products Blue Cross and Blue Shield of Rhode Island (BCBSRI) follows the Centers for Medicare and Medicaid Services (CMS) coverage guidelines for Psychiatric Collaborative Care Services. CoCM is a covered service. Under the Psychiatric Collaborative Care Model, patients are cared for through a team approach typically involving a physician, behavioral health care manager, and a psychiatric consultant. Practices must maintain a program description which include all of the following documentation: • Job description for the behavioral health care manager demonstrating a collaborative integrated relationship with the rest of the team members with formalized training or specialized education in behavioral health (including social work, nursing, or psychology) • Plan for identification, outreach and engagement of patients directed by a physician • Initial assessment, including administration of validated scales and resulting in a treatment plan • Evidence of a compact/contract with a psychiatric consultant • Written workflows documenting: ▪ Psychiatric consultation/referral process ▪ Evidence based treatment interventions to be used in working with patients (i.e.: behavioral activation, problem solving treatment, other focused treatment activities) ▪ plans for ongoing collaboration and coordination with PCP and any other treating providers; ▪ Relapse prevention planning and preparation for discharge from active treatment. • Demonstrated use of a registry for tracking patient follow up and progress • Evidence of weekly caseload review with psychiatric consultant • Evidence of monitoring of patient outcomes using validated rating scales General Behavioral Health Integration Services Medicare Advantage Plans and Commercial Products* Care Management rendered in the context of behavioral health integration is covered. Payment Policy | Behavioral Health Integration Services including the Collaborative Care Model

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

The practice must maintain a program description that indicates the practice is meeting these required elements:
• Initial Assessment • Systematic assessment and monitoring, using applicable validated clinical rating scales. • Care planning by the physician team jointly with the beneficiary, with care plan revision for patients whose condition is not improving • Facilitation and coordination of behavioral health treatment • Continuous relationship with a designated member of the care team Additional elements which support Integrated Behavioral Health as defined by the Centers of Medicare and Medicaid (CMS) maybe included in the program description at your discretion.

Please see the coding section for additional details.

COVERAGE Benefits may vary among groups. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement, for applicable medical services.

BACKGROUND The psychiatric Collaborative Care Model is an approach to Behavioral Health Integration (BHI) shown to improve outcomes in multiple studies. In this model, patients are cared for through a team approach, involving a physician, behavioral health care manager, and psychiatric consultant.

General behavioral health integration care management services are provided face-to-face by clinical staff, under the direct supervision of a physician or other qualified health care professional, to a patient with a diagnosed health care condition, including substance abuse issues requiring care management services.

CODING Medicare Advantage Plans and Commercial Products

Psychiatric Collaborative Care Services (CoCM): The following codes are covered for all physicians:

99492
Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of
behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by
the treating physician or other qualified health care professional, with the following required
elements: outreach to and engagement in treatment of a patient directed by the treating physician or
other qualified health care professional, initial assessment of the patient, including administration of
validated rating scales, with the development of an individualized treatment plan, review by the
psychiatric consultant with modifications of the plan if recommended, entering patient in a registry
and tracking patient follow-up and progress using the registry, with appropriate documentation,
and participation in weekly caseload consultation with the psychiatric consultant, and provision of
brief interventions using evidence-based techniques such as behavioral activation, motivational
interviewing, and other focused treatment strategies

99493
Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: tracking patient follow-up and progress using the registry, with appropriate documentation, participation in weekly caseload consultation with the psychiatric consultant, ongoing collaboration with and coordination of the patient's mental health care with the treating physician or other qualified health care professional and any other treating mental health providers, additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

consultant, provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies, monitoring of patient outcomes using validated rating scales, and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment

99494
Initial or subsequent psychiatric collaborative care management, each additional 30 minutes
in a calendar month of behavioral health care manager activities, in consultation with a psychiatric
consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure)

G0512
Rural health clinic or federally qualified health center (RHC/FQHC) only, psychiatric collaborative care model (psychiatric CoCM), 60 minutes or more of clinical staff time for psychiatric CoCM services directed by an RHC or FQHC practitioner (physician, NP, PA, CNM) and including services furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month

G2214 Initial or subsequent psychiatric collaborative care management, first 30 minutes in a month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional

General Behavioral Health Integration Services The following code is covered for all physicians:

99484
Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements: initial assessment or follow-up monitoring, including the use of applicable validated rating scales, behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes, facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation, and continuity of care with a designated member of the care team

Cost Share Waiver for OHIC Designated Integrated Behavioral Health Primary Care Practice Commercial Products Only: Effective January 1, 2021, in compliance with 230-RICR-20-30-4, BCBSRI will waive member copayments for certain behavioral health services if all the following conditions are satisfied: • The service is rendered by a BCBSRI Credentialed behavioral health provider • The behavioral health provider is practicing within a Qualifying Integrated Behavioral Health Primary Care Practice as designated annually by the Office of the Health Insurance Commissioner (OHIC) • The behavioral health service is rendered on the same day as a primary care visit at the same Qualifying Integrated Behavioral Health Primary Care Practice • The behavioral health service is one that is identified in the coding section below

The following coding guidelines must be followed in order to waive member copayment:

• Codes submitted to BCBSRI must include the modifier HK: Specialized mental health programs for high-risk populations • All IRS rules apply to high deductible health plans.
• Per OHIC, the following codes are eligible for cost share waiver:

CPT Code

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

Behavioral Health
90791-90792, 90832-90837, 90839-90840, 90846, 90847, 90849, 90853, 90863 Screening, Brief Intervention and Referral to Treatment codes

99408-99409

Health and Behavior Assessment Codes

96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171

This waiver applies to all BCBSRI members enrolled in fully insured individual, small group and large group plans. Self-funded accounts have the option to elect or decline this cost share waiver. Members of non-Rhode Island Blue Cross Blue Shield plans are not eligible for the copay waiver.

RELATED POLICIES Health and Behavior Assessment Preventive Services for Commercial Members

PUBLISHED Provider Update, June 2025 Provider Update, July 2024 Provider Update, April 2023 Provider Update, June 2020 Provider Update, May 2019

REFERENCES: None

Pi

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 a greement 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 P CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS