Psychiatric and Substance Abuse Facilities
Note: All behavioral health services for HMO members should be arranged through New Directions Behavioral Health, including submission of claims.
The information in this section pertains to members with PPO (BlueChoice, BlueMedicare PPO, and BlueOptions) and Traditional coverage.
Behavioral Health Services
- All types of behavioral health services are eligible for payment when provided under the direction of a physician in:
- Programs accredited by the JCAHO, CARF, or in programs in compliance with equivalent standards.
- Alcohol rehabilitation programs accredited by the JCAHO, CARF or approved by the state of Florida.
- Licensed substance abuse rehabilitation programs (i.e., partial hospitalization program, intensive outpatient program).
- Member benefits and the severity of symptomology, rather than the diagnosis itself, determines whether or not a case will be eligible for payment of level of care requested. Cases are no considered eligible for payment if appropriate treatment can be provided in a less intensive setting of care.
- Eating disorders (anorexia, bulimia) are reviewed under the same criteria as other psychiatric disorders based on member benefits and the severity of symptoms.
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Seven Levels of Behavioral Health Services Provided in PSA Facilities
- Acute Inpatient PSA
Acute inpatient PSA services involve constant medical management and care of a patient 24 hours a day to include, but not limited to: room and board; any outpatient visit that leads to an inpatient admission; psychologist or professional fees of full-time or part-time employees, contractors, consultants, ancillary therapies; routine medical services and testing; history and physical, sequential multiple analysis, electrocardiogram, urinalysis, chest X-rays, and medications.
The behavioral health facility’s license, applicable agreement, and member benefits determine whether a facility is eligible for inpatient payment. Facilities licensed to treat severely ill patients (e.g., suicidal, homicidal, detoxification) are eligible for inpatient payment. If a facility is not licensed to treat severely ill patients, inpatient benefits are not reimbursable.
- Inpatient Detoxification
Inpatient detoxification services are performed inpatient to provide medically safe withdrawal from addictive substances when there is a risk of severe symptoms that cannot be managed in a less intensive setting. Detoxification is limited to the time necessary for the removal of toxic substances from the blood and outpatient follow-up care.
The behavioral health facility’s license, applicable agreement, and the member’s benefits determine whether a facility is eligible for inpatient payment. Facilities that are licensed to treat severely ill patients (e.g., suicidal, homicidal, detoxification) are eligible for inpatient payment. If a facility is not licensed to treat severely ill patients, inpatient benefits will not be paid.
- Substance Abuse Rehabilitation
Inpatient substance abuse services to members who have completed a detoxification program and are need further substance abuse/dependence treatment.
- Psychiatric Residential Treatment
Psychiatric residential treatment services are all-inclusive psychiatric care providing a total of 24-hour therapeutically planned and professionally staffed group living and clinical learning environment to include, but not limited to room and board at a less intensive level. BCBSF defines Department of Children and Families Residential License Level 3-5 as residential services.
Residential treatment is only reimbursable if the member’s benefits cover the services and the facility has an applicable license.
- Partial Hospitalization Program
Partial hospitalization is an ambulatory treatment program that includes the major diagnostic, medical, psychiatric, psychosocial, prevocational treatment, and multi-disciplinary services not provided in an outpatient clinic setting that provides a structural schedule of treatment activities for a minimum of five clinical service hours a day for a minimum of four days per week.
Partial hospitalization benefits may be available for behavioral health diagnoses under BCBSF plans.
- All partial stays must be certified at the time of admission and meet the minimum clinical requirements.
- Submission of partial hospital and inpatient services should be billed on separate claims to ensure appropriate payment.
- Intensive Outpatient Program
Intensive outpatient program is defined as treatment that lasts a minimum of three hours a day for a minimum of three days per week in a structured program.
- Indicate “131” type of bill with revenue code 0905 for psychiatric services and 0906 for substance abuse services. Do not bill revenue codes 0500 or 0914.
- For FEP members, IOP admissions must be certified.
Outpatient services are visits for treatment that do not last longer than 80 minutes per day. Covered outpatient services for behavioral health disorders are eligible for payment based on the terms of the rendering MD, PhD, or licensed masters level clinician’s agreement. No more than one outpatient visit per day will be eligible for payment.
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PSA Facility Transfer
The PSA facility must agree to transfer a member requiring acute care medical or surgical services, in a non-emergency situation, to the nearest participating provider that can furnish covered services.
- Do not bill the member for services that are deemed by Florida Blue as not medically necessary. The facility may bill the member for non-covered services per the member benefits.
- When two or more diagnoses are made for the same case, the primary diagnosis for billing purposes will be the diagnosis that precipitated the admission. The facility must bill the primary diagnosis as substance abuse unless a psychiatric condition is clearly the reason for admission, and can be substantiated by treatment plans, medical records, and psychological evaluations.
- Bill 23-hour observations as an inpatient service with a “111” type of bill, as well as separate admit and discharge dates.
Partial Hospitalization (PHP)
Florida Blue defines revenue code 0169 and 0912 as partial hospitalization for chemical dependency and revenue code 0169 and 0913 as partial hospitalization for psychiatric services.
- Indicate “111” type of bill.
Note: For BlueCard members, you must contact the home plan to identify if the member’s benefit is identified as inpatient or outpatient and bill your claim to Florida Blue accordingly.
For BlueCard members, indicate “111” or “131” type of bill depending on the member’s benefits.
- For inpatient, indicate “111” type of bill with room and board revenue code 0169, and the applicable revenue code 0912 or 0913 on the following line. The days/units must be submitted on the line that contains revenue code 0169.
- If outpatient, indicate “131” type of bill with the applicable revenue code 0912 or 0913. Do not bill revenue code 0169.
For FEP members, indicate “131” type of bill with the applicable revenue code 0912 or 0913. Do not bill revenue code 0169.
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Claims for services will be paid on the per diem rate negotiated with your facility.
- Each per diem represents the allowance for one day of service.
- The per diem rate includes all facility services. This includes services rendered by staff physicians and staff therapists.
- The number of days or visits multiplied by the per diem allowance equals the claims payment allowance.
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