HCPCS H0004 is officially defined as "Behavioral health counseling and therapy, per 15 minutes." HCPCS H0004 is referenced in 48 tracked payer policy changes from Ambetter, Arizona Medicaid - AHCCCS, and 10 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS H0004 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Effective January 1, 2027, Ambetter Health of Delaware will stop covering 45 HCPCS H codes (H0003–H0047, H1011, H2001–H2033) and will begin covering HCPCS code H0006. The practice must stop billing the discontinued codes to Ambetter Delaware members and update charge entry and claim submission processes to reflect coverage changes.
Effective 01/01/2027, Ambetter Health will discontinue coverage for 45 HCPC H codes (primarily behavioral health and community support services) and will begin covering HCPC code H0006. Billing teams must update coding practices and prior authorization workflows to reflect these coverage changes.
Ambetter of North Carolina will stop covering a list of HCPCS H codes starting January 1, 2027, and will cover H0006 from that date. Earlier changes are already effective: CPT 80320-80377 drug testing codes were no longer reimbursable from October 1, 2026, and the prior authorization changes effective October 1, 2026 took effect. The newsletter also covers surrogacy diagnosis codes Z33.3 and Z31.7, behavioral health type of bill guidance, and clinical policy updates effective 11/1/2026.
Ambetter of North Carolina's June 2026 provider newsletter says it will stop covering 48 HCPCS H codes beginning January 1, 2027, and will cover H0006 from that date. The newsletter also says drug testing codes G0482 and G0483 are no longer reimbursable under the drugs-of-abuse policy (no date is given), and it lists clinical policy revisions effective August 15, 2026 and a reminder to verify member eligibility by paid-through dates.
Effective January 1, 2027, Ambetter from Coordinated Care Corporation will discontinue coverage for 42 HCPCS H codes (primarily behavioral health and social services codes) while simultaneously adding coverage for H0006. Billing teams must identify all claims currently using the discontinued codes and transition to alternative coding or request prior authorization to determine covered alternatives.
Effective January 1, 2027, Ambetter of Illinois will discontinue coverage for 46 HCPCS H codes (behavioral health and social services codes) while adding coverage for H0006. Billing teams must identify all claims currently using the non-covered codes and implement workflow changes to prevent claim denials after the effective date.
Effective 01/01/2027, Ambetter Health is discontinuing coverage for 52 HCPCS H codes related to alcohol/drug treatment, behavioral health services, and mental health support. Simultaneously, H0006 (Alcohol/drug service, case management) will become newly covered. The billing team must immediately identify affected claims in the system and implement denial protocols for non-covered codes starting January 1, 2027.
Effective January 1, 2027, Ambetter from Buckeye Health Plan will discontinue coverage for 45 HCPCS H codes commonly used for behavioral health and community support services. Simultaneously, H0006 coverage will begin. The practice must identify all affected claims and implement billing workflow changes to avoid denials.
Effective January 1, 2027, Ambetter of Tennessee will discontinue coverage for 46 HCPCS H codes (primarily behavioral health and social services codes) while adding coverage for H0006. The billing team must identify all claims currently using the non-covered codes and transition to alternative billing codes or obtain clarification on approved alternatives before the effective date.
Effective January 1, 2027, Ambetter from Absolute Total Care will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must identify all claims using discontinued codes and transition to alternative codes or obtain patient verification of coverage changes.
Effective January 1, 2027, Ambetter of Oklahoma will discontinue coverage for 46 HCPCS H codes commonly used for behavioral health, substance abuse treatment, and related services. Simultaneously, H0006 coverage begins on the same date. The billing team must identify all affected claims and establish processes to deny or redirect these codes for Ambetter Oklahoma members.
Effective January 1, 2027, Ambetter from SilverSummit Healthplan will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and support services) while adding coverage for H0006. Billing teams must identify all claims using the discontinued codes and implement alternative billing strategies or obtain patient financial responsibility agreements.
Effective January 1, 2027, Ambetter from WellCare of New Jersey will discontinue coverage for 45 HCPCS H codes (behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must identify all claims using the discontinued codes and implement alternative billing strategies or prior authorization processes before the effective date.
Effective January 1, 2027, Ambetter of North Carolina Inc. will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must immediately identify affected claims and update billing systems to prevent denials for these services beginning 2027.
Effective 01/01/2027, Ambetter from Magnolia Health will discontinue coverage for 45 HCPCS H codes (behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must immediately identify affected services, update claim submission logic, and prepare providers for coverage gaps to avoid claim denials.
Effective January 1, 2027, Ambetter from Home State Health will discontinue coverage for 45 HCPCS H codes (behavioral health and social services codes) while adding coverage for H0006. Billing teams must identify all claims currently using the non-covered codes and develop transition plans, as continued billing of these codes will result in denials.
Effective January 1, 2027, Ambetter from Meridian will no longer cover 45 HCPCS H codes (behavioral health and social services codes), while H0006 will begin coverage on that same date. Billing teams must identify all claims using the discontinued codes and implement alternative billing strategies or have claims denied.
Effective January 1, 2027, Ambetter from Louisiana Healthcare Connections will discontinue coverage for 45 HCPCS H codes (behavioral health and social services) while adding coverage for H0006. Billing teams must identify affected claims, update system edits, and establish alternative coding or prior authorization protocols before the effective date.
Effective January 1, 2027, Ambetter from WellCare of Kentucky will discontinue coverage for 46 HCPCS H codes (behavioral health and social services codes), while simultaneously activating coverage for H0006. Billing teams must identify all claims currently using the discontinued codes and establish alternative billing strategies or obtain prior authorization requirements before the effective date.
Effective January 1, 2027, Ambetter from Peach State Health Plan will discontinue coverage for 45 HCPC H codes (H0003-H0047, H1011, H2001-H2033) commonly used for behavioral health, substance abuse treatment, and support services. Simultaneously, H0006 coverage will be newly activated. Practices must identify affected claims, update billing systems, and establish alternative coding or coverage verification processes before the effective date.
Effective January 1, 2027, Ambetter Health will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and substance abuse treatment codes) while simultaneously adding coverage for H0006. Billing teams must immediately identify affected services, audit current patient encounters, and prepare to transition claims to alternative coding or halt billing for these services by the effective date.
Effective January 1, 2027, Ambetter from Arizona Complete Health will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and social services codes) while adding coverage for H0006. Billing teams must identify all claims using the discontinued codes and implement alternative billing strategies to avoid claim denials.
Effective January 1, 2027, Ambetter from Arkansas Health & Wellness will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must identify all claims using the discontinued codes and establish alternative coding or prior authorization strategies to avoid claim denials.
Effective January 1, 2027, Ambetter of Alabama will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and support services codes) while adding coverage for H0006. Billing teams must immediately identify affected claims and update billing software to prevent denials for non-covered codes after the effective date.
Effective January 1, 2027, Ambetter Health will discontinue coverage for 45 HCPCS H codes commonly used for behavioral health, substance abuse treatment, and related services. Simultaneously, HCPCS code H0006 will become newly covered. Billing teams must immediately identify affected claims and update billing logic to prevent denials.
Ambetter from Superior HealthPlan is discontinuing coverage for 46 HCPCS H codes effective January 1, 2027, while adding coverage for H0006. Billing teams must identify claims currently using discontinued codes and establish alternative billing strategies or prior authorization workflows before the effective date.
Effective January 1, 2027, Ambetter from Sunflower Health Plan will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must identify all claims currently using discontinued codes and establish alternative billing strategies or obtain patient notification protocols before the effective date.
Published June 22, 2026: Ambetter Health announced that 46 listed HCPCS H codes will no longer be covered beginning January 1, 2027, while HCPCS H0006 will become covered on that same date. Billing teams should identify claims and scheduled services using the listed H codes for January 2027 dates of service and prepare charge entry and provider notification accordingly.
Effective September 1, 2026, claims submitted by fee-for-service providers that include a referring, ordering, attending or prescribing provider who is not registered with AHCCCS will be denied, and those providers must register or be identified as exception non-registerable providers. Group behavioral health services must have the HQ modifier appended to the service code, and omitting it results in inaccurate billing and may directly affect reimbursement. Intensive Outpatient Program prior authorization requests must use Event Type OP until AHCCCS adds IOP as a selectable event type.
Maryland Medicaid has updated coding guidelines for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), clarifying billing procedures for multiple encounters per day and specifying different trigger codes for MCO versus Fee-for-Service claims. The policy details specific submission requirements for somatic, mental health, substance abuse, and dental services.
Indiana Medicaid is sunsetting several waiver services on Dec. 31, 2025 and adding new behavioral support services and self-directed care options starting Jan. 1, 2026. This includes replacing Basic Behavior Management with a new three-component Behavioral Support Services model and introducing self-directed service options across multiple waivers.
CareSource Georgia Medicaid is implementing updated prior authorization requirements and service frequency limits for behavioral health codes effective January 1, 2026. Session limits reset annually, and claims exceeding limits without prior authorization will be denied. Non-participating providers now require prior authorization at the first session.
A 2% across-the-board Health First Colorado provider rate reduction applies to dates of service beginning July 1, 2026, with exemptions for managed care, pharmacy, RHCs, FQHCs, pediatric behavioral therapy, select NICU and neonatal services, select maternity services, and family planning services. Procedure codes 97535 and 97537 are no longer covered as of July 1, 2026, and CPT 77063 became a covered benefit that must be billed on the same claim as CPT 77067. Effective August 1, 2026, PT 25 and PT 16 claims will be denied when billed for certain behavioral health supportive and team-based services in fee-for-service or to the Regional Accountable Entities.
Maryland Medicaid will now reimburse authorized SUD providers (PT 50) for pre-release Medication-Assisted Treatment (MAT) services delivered via telehealth to incarcerated individuals within 90 days of release as part of the Reentry SUD/SMI Program for Adults. Providers must be contracted with DPSCS, Medicaid-enrolled, and currently licensed. All services require pre-authorization and must use place of service code 09 with GT or UB modifiers.
Indiana Medicaid corrected a system error and added 6 Money Follows the Person (MFP) waiver services to their fee-for-service claim processing system, effective retroactively to January 1, 2026. Providers can now submit or resubmit claims for these behavioral management, employment support, and benefits counseling services within 180 days of June 9, 2026.
Effective for dates of service on or after Dec. 1, 2025, South Carolina Medicaid updated the reimbursement methodology and rates for Medicaid State Plan services rendered by rehabilitative behavioral health (RBHS) providers, Office of Substance Use Services-affiliated organizations and licensed independent practitioners (LIPs). The Department of Alcohol and Other Drug Abuse Services Fee Schedule will be renamed to align with the Office of Substance Use Services. The December 17, 2025 update also changed H0032 from a 15-minute timed unit to a 30-minute encounter for RBHS providers, changed H0002 from a timed unit to an untimed encounter, and corrected the H0038 peer support rate to $14.48 per unit.
Louisiana's School-Based Medicaid Program (SBMP) is adding two new behavioral health procedure codes effective August 29, 2025: H0004 for behavioral health counseling/therapy (per 15 minutes) at $10.00 and H0005 for alcohol/drug group counseling at $10.00. This expansion is part of SBMP's commitment to provide substance abuse coverage services to eligible students.
Effective for dates of service on and after August 11, 2025, schools that provide school-based services can submit claims to ForwardHealth for an expanded set of procedure codes. The new codes cover psychological, counseling, social work, and mental and behavioral health services, therapy and audiology services, nursing and physician services, and dental services. Modifiers are no longer required on school-based services claims for those dates of service, although allowable modifiers are still accepted, and other claims submission requirements have not changed.
Kansas Medicaid (KMAP) is increasing reimbursement rates for Home and Community Based Services (HCBS) effective July 1, 2025, for fiscal year 2026. The policy includes updated rates for Brain Injury services, Technology Assisted services, and Intellectual/Development Disabilities services with specific dollar amounts per procedure code.
Starting July 1, 2025, Kansas Medicaid will allow virtual delivery of HCBS waiver services using HIPAA-compliant audiovisual platforms. Billing teams must use new place of service codes (02 for outside home, 10 for within home) when services are delivered virtually.
AHCCCS has corrected previous guidance and now allows Counseling Facility providers to bill T1016 (case management services) within their scope of practice. This reverses an April 29, 2025 notice that previously indicated T1016 was not covered for counseling facility providers.
Maryland Medicaid's March 3, 2026 FQHC and Rural Health Clinic transmittal reminds billers of existing rules: one encounter per recipient per day for each of somatic, mental health, substance use disorder and dental services, with the trigger code carrying the organization's cost-per-visit rate and other services listed at $0.00. The trigger codes and payer routing differ for MCO, Medicaid fee-for-service, behavioral health and dental claims, so each claim must follow the rule for its payer.
AHCCCS fee-for-service claims with attachments must have the initial claim submitted first, because documentation sent before the claim cannot be matched and will cause delays and denials. The Attachment Control Number (PWK) must be created during the initial claim submission, and all identifiers must match exactly between the claim and the attachment. Behavioral health services delivered to a group require the HQ modifier, dental procedures need two-digit tooth numbers when using JO, and the initial claim must be received within six months of the date of service.
Mental health and substance abuse screening, preventive mental health counseling and substance abuse intervention is a new benefit for pregnant women enrolled in BadgerCare Plus and Wisconsin Medicaid. The screening identifies women at risk for mental health or substance abuse problems, and brief counseling or intervention is provided to women identified as at risk. These services require no prior authorization, are not subject to copayment, and do not count toward other service limitations or prior authorization thresholds.
Relying solely on billing statements, member notification, or collection agencies is not effective, so providers must take appropriate and reasonable action to identify Health First Colorado eligibility within 365 days. Fee-for-service behavioral health codes were rebalanced to 80 to 100 percent of the Medicare benchmark effective April 1, 2021, and Medicaid prescribers of controlled substances must query the Colorado Prescription Drug Monitoring Program before prescribing to Medicaid members effective October 1, 2021, except in the listed situations. Physician-administered drugs on the listed set will require prior authorization no earlier than October 1, 2021.
A provider licensed with ADHS solely as a counseling facility may bill only from six HCPCS codes: H0001 alcohol and/or drug assessment, H0002 behavioral health screening to determine eligibility, H0004 behavioral health counseling and therapy per 15 minutes, H0023 behavioral health outreach service, H0031 mental health assessment by a non-physician, and H2011 crisis intervention service per 15 minutes. Claims for services outside those codes will be denied. Inpatient claims with an admission date equal to the discharge date are paid using the AHCCCS Outpatient Fee Schedule methodology, and a replacement claim is required for processing.
BCBSAZ covers telehealth only as the member's benefit plan provides. Under the BlueCare Anywhere benefit, telehealth is covered when the Telehealth Services Administrator provides the service and determines the condition is appropriate, for a medical, therapy or psychiatry consultation. Under the in-network telehealth benefit, a service is covered when it would be covered in person and can be provided effectively by telehealth, through audio-visual services or limited audio-only services, and out-of-network non-emergency telehealth is not covered. The most recent review, dated 07/29/26, made no revisions.
This is a policy review and restatement of Aetna's existing Clinical Policy Bulletin 0730 for home behavioral healthcare services, last reviewed on 2026-10-21. The policy defines medical necessity criteria for skilled behavioral health services delivered in the home as an alternative to hospitalization or residential treatment. No changes to coverage, billing codes, or requirements are indicated; this appears to be a routine policy maintenance review.
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