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ADAA : Medicaid and MCO Reimbursement

Q:         Can I bill Medicaid directly?

A:         Yes, a provider with an active Medicaid provider number may bill Medicaid/DHMH directly for individuals eligible for Medicaid, but not enrolled in a MCO.  EVS will identify these individuals as “eligible, federal” and no MCO name will be provided.   For PAC enrolled individuals, their coverage does not begin until they have enrolled in a MCO, therefore a provider may only bill a Medicaid MCO for these individuals. 

Q:         How do I bill Medicaid fee-for-service or a Medicaid MCO?

A:         DHMH developed a comprehensive guide to help providers bill Medicaid MCOs or Medicaid Fee-for-service, called the MARYLAND MEDICAID CMS 1500 BILLING INSTRUCTIONS.

Q:         What services will Medicaid MCOs pay for and how much will they pay?

A:         Medicaid will pay for an assessment, individual counseling, group counseling, intensive outpatient and methadone maintenance (as well as other services as outlined in the self-referral protocol .  As of January 1, 2010, PAC will pay for all of these services as long as they are provided outside of a HSCRC-regulated setting.   The individual must meet the ASAM criteria and all the other criteria described in the SAII.

Beginning January 1, 2010, the Medicaid fee schedule for substance abuse services increased.   Please note that substance abuse programs may not bill the Medicaid Program or HealthChoice MCOs for any services that are provided free of charge to patients without Medicaid coverage.  This means that in order to bill Medicaid, providers either need to bill third party insurance for all patients with such insurance or to bill the patients based on a sliding fee scale.  The provider cannot bill more that the provider’s full fee under private insurance or under the sliding fee schedule. 





HCPC Description

Unit of Service


SA Assessment


Alcohol and/or drug assessment

Per assessment


Individual outpatient therapy


Behavioral health counseling and therapy

Per 15 minutes


Group outpatient therapy


Alcohol and/or drug services; group counseling by a clinician

Per 60-90 minute session


Intensive outpatient


Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling, crisis intervention, and activity therapies or education. 

Per diem (minimum 2 hours of service per session)


Maximum 4 days per week


Methadone maintenance


Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program)

Per week



Q:         What are the licensure requirements for a provider to bill Medicaid for substance abuse treatment services?

A:         Federal Medicaid regulations require a licensed profession to provide a substance abuse assessment before services may be billed to Medicaid fee-for service or Medicaid MCOs.   DHMH outlined these requirements in a December 2, 2009 memo

Q:         Do the H codes apply to both Medicaid fee-for-service and MCOs?

A:         Yes.  Medicaid fee-for-service and Medicaid MCOs will be using the same codes and rates.

Q:         May a provider bill Medicaid fee-for-service (straight Medicaid) any CPT codes starting with 9... for substance abuse?

A:         No, Medicaid fee-for service as well as Medicaid MCOs are now only using the H codes. 

Q:         Is it true that all Medicaid clients, not just PAC clients, may be billed at the the new rates (for example $80.00/wk for methadone maintenance)?  

A:         Yes.  The new rates may be used for all Medicaid and PAC clients.  This includes individuals covered by Medicaid MCOs and Medicaid fee-for-service.   

Q:         The new codes do not include a code for our suboxone doctor visit.    This used to be billed as a CPT code 90862, med management.   Please advise what H-code I am to use for this.  

A:         At this point, there is no H code for the physician service.  Medicaid MCOs will reimburse for this if the MCO primary doctor is seeing the patient and prescribing Suboxone.   There is a workgroup that has been convened by ADAA and Medicaid to develop self-referred protocols for buprenorphine treatment.  Depending on the recommendations of the workgroup, a budget initiative may need to approved for funding.  

Q:         Are we allowed to negotiate with the carriers we contract with to bill for the substance abuse assessment or individual counseling? At this time they contract us for both the assessment and the weekly methadone treatment and are sending out amendments to each contract to include the counseling codes H0004 and H0005.  After speaking in detail with each carrier they are under the impression that with the changes for 2010 these services are now separate from H0020.  There are also times when a patient comes in for an Substance Abuse assessment but never returns for treatment.  In those times we can't bill H0020 for the service provided.  (POSTED: 1/19/2010)

A:         Yes, you can negotiate with the MCOs.   Because the H0020 includes the cost of the assessment, you may want to negotiate a separate assessment reimbursement in cases where the patient doesn't return.  

You can only bill for individual/group when the patient is being seen in a non-methadone "slot".  That is, if you're billing H0020, which is a bundled service, you cannot also bill H0004 or H0005.  

Q:         Does the H0020 code (Methadone Maintenance) already include sessions with counselors H0004 and assessment H0001?  May we bill Medicaid or MCOs separately for H004 and H0001 if we are already billing H0020? (POSTED: 1/19/2010)

A:         H0020 is a comprehensive rate that includes individual sessions and assessments.   Providers may not bill H004 and H0001 if they are already billing the comprehensive code H0020. 

Q:         Can I bill the MCO when a client does not show up for an appointment?

A:         No, the Medicaid fee-for-service program and MCOs will not reimburse a provider for missed appointments.   This is not allowed under federal Medicaid rules.

Q:         How long do I have to bill an MCO?

A:         Typically, an MCO will have a filing limit requirement of 180 days from the date of service.  The filing limit will be specifically referenced in the contract and/or provider manual.  The provider should make certain that its contractual agreement stipulates the timelines, since MCOs are free to negotiate their own claim filing guidelines.  See the MARYLAND MEDICAID CMS 1500 BILLING INSTRUCTIONS for more information.

Q:         What is a CMS 1500 and where do I get one?

A:         The CMS-1500 form is the standard Medicare claim form used by non-institutional providers to bill for services.  Providers are required to use this form to bill the Medicaid program and all of the MCOs.  The form will require that you provide a procedure code to bill for services (see question related to MCO payment) and provide the date of service, as well as other information.  A PDF version of the CMS 1500 is available through many websites.   Most billing software packages allow a provider to print a CMS 1500 and some allow them to be electronically filed.  Through an internet search, providers can find basic software packages to help them format and print a CMS 1500 form.  Many MCOs allow CMS 1500 to be electronically filed through their websites.   

Q:         Can I bill the MCO for an assessment of Medicaid or PAC enrolled individuals if I don’t charge sliding scale clients for this service?

A:         Providers cannot bill Medicaid or PAC for a free service.  Therefore, if you want to bill Medicaid or PAC for this service, you either need to bill the uninsured clients on a sliding fee scale or bill the client’s insurance company for the service if the client has third party coverage.   All services supported through ADAA grant funds must also be provided on a sliding scale.

Q:         How do I know my usual and customary charge (required on line 24F of CMS 1500) and how is that different than my sliding scale?   

A:         Your usual and customary charge is the amount you would charge somebody at the top of the sliding fee scale and it is what you would charge the other third party payers. See page 12 of the MARYLAND MEDICAID CMS 1500 BILLING INSTRUCTIONS for more information. 

Q.         If I bill the MCO’s for methadone services, do I need a separate provider number to bill for other levels of care such as Outpatient and Intensive Outpatient? (POSTED: 1/26/2010)

A.         Yes, if you bill for methadone, you must have a separate provider number to bill for other outpatient levels of care.  If you only provide non-methadone outpatient services, then one provider number can be used to bill for all levels of care.

Q.         We sometimes have to bill Methadone for less than a week.  I see Meth is listed per week with no breakdown for less; sometimes we need to bill for 2 or 3 days if we have a transient.  How will this be billed (charge) or can it? (POSTED: 2/1/2010)

A.         You can bill the one week unit. The problem that arises with that is if the patient goes to another methadone program for the remainder of the week, then that provider will not be able to bill since we only allow one unit per recipient per week.

Q.         If  we submit our individual counseling sessions to PAC using the H0004 code, how will the MCO distinguish the length of the visit?  Our individual sessions usually last 1 hour and if they are reimbursing $20.00 per 15 minutes, how will they recognize our length of session and reimburse according? (POSTED 2/4/2010)

A.         Submit one charge for each 15 minutes of individual service.  If the session is 60 minutes in length, then four charges would be submitted.

  Q.         If a client has Medicaid PAC, we cannot bill Medicaid and we cannot bill the client. We only bill after MCO is selected. (POSTED 4/19/2010)

A.         Correct, the patient would be in a grant slot until actually enrolled in an MCO. In that grant slot, the person would be fee assesed based on the sliding fee scale.

Q.     The billing instructions are as follows for billing PAC for Intensive Outpatient Treatment: (Posted 5/6/2010)
Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling, crisis intervention, and activity therapies or education.
Per diem (minimum 2 hours of service per session)
The program description indicates 3 hours/day and at least 3 days/week. Then it states the per diem of a minimum 2 hours of service per session. So, what is a session? How does the two hour minimum relate to the 3 hrs./day & 3 days/wk.?
Please help.

A. Refer to the regs (10.09.80).  We were told that in Maryland, some programs only provide 2 hours per day and that they would not be able to bill if we used language from HCPCs book.  I believe we allow up to 4 sessions per week.  A session has to last at least 2 hours - but more usually lasts 3. 

Q.   I am aware that referrals, diagnostic assessments, and treatment plans must be done by licensed clinicians in order to be reimbursed by PAC/MA. Is that also true for who provides the individual and/or group therapy? Can these clinicians just be at the masters level, without a license or substance abuse certification, to be reimbursed by PAC/MA?  (Posted 5/6/2010)

A.    MA PAC reimbursement requires that a licensed clinician as identified in the memo must sign off on the assessment and treatment. This sign off can occur with or without direct pt contact between the licensed clinician and the pt. If the licensed clinician does not see the pt, a full review of all documentation is required for sign off.   Group and individual counseling notes do not require a sign off by a licensed clinician. COMAR supervision requirements must be followed as per the clinicians' Boards' COMAR. 

Q. Are we allowed to bill an MCO for ASAM Level 0.5 care? (POSTED: 05/24/2010)

A. 0.5 is not a covered service.

Q:  We have an Interim Methadone Maintenance Program in Adult Addictions  Department of Health.  Can we bill using H0020 code MA/MCO's for patients in the Methadone Maintenance Interim Program? (POSTED: 09/22/2010)

A.  Interim Methadone Maintenance is not an MA reimbursable service. The reimbursement is predicated on the patient receiving at least one clinical counseling visit per week.  Since counseling is not a part of the interim maintenance regime, there is no reimbursement available.