Billing for Behavioral Health Services in an Outpatient Setting

For behavioral health visits and services performed in the hospital outpatient setting, HMSA commercial plans do not allow split-billing of provider-based behavioral health services as allowed by CMS for its Original Medicare business.

1. This applies whether the behavioral health clinic is located in an on campus outpatient hospital setting or an off campus outpatient hospital, and whether or not the behavioral health clinic uses the hospital tax identification number when billing.
2. Do not split-bill behavioral health clinic-based services, billing part of the service as a facility charge, and part of the service as a professional charge.
3. All behavioral health professional services provided in an outpatient clinic setting are to be billed on a CMS-1500 claim form or electronic equivalent, using an appropriate place of service.
4. Provider-based Behavioral Health Clinic Services may not be billed on facility claims using revenue codes; charges will be denied as a facility provider liability. Participating providers and facilities may not balance-bill the patient. Behavioral health providers should bill all professional services provided in an outpatient clinic on a CMS-1500 claim form or electronic equivalent, using the appropriate place of service.
5. Professional claims will be reimbursed according to the applicable professional fee schedule.

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