MedicaidCoverageHigh impact
Updated Clarification on MCO Payment Responsibility for Health Behavior Assessments Administered in an Acute Care Setting
Maryland Medicaid·MD · Psychiatry, General Practice, Internal Medicine·Behavioral Health Administration Services Organization
Effective date
Jan 1, 2025
We identified it
Jun 20, 2026
Summary
MCOs in Maryland are now responsible for reimbursing CPT 96156 (health behavior assessment) when performed in acute inpatient hospital or outpatient hospital settings by eligible providers (psychologists, nurse psychotherapists, licensed certified social workers). This policy supersedes previous guidance (PT 80-25) and clarifies that behavioral health assessments related to treating somatic conditions are covered by MCOs, not carved out to fee-for-service. The reimbursement rate is $102.83 with no time limits for assessment length.
Action Required
By January 1, 2025 (or immediately if claims are being submitted): (1) Billing team must update system configuration to recognize CPT 96156 as MCO-reimbursable (not fee-for-service only) when billed from Place of Service 21 (inpatient hospital) or 22 (outpatient hospital campus). (2) Verify that provider credentials in billing system reflect eligible provider types: 15 (Psychologist), 24 (Nurse Psychotherapist EPSDT), or 94 (Licensed Certified Social Worker). (3) Update claims submission logic to route CPT 96156 claims to MCOs for acute care settings instead of to Medicaid FFS. (4) Update internal billing workflows and provider education materials to reflect that MCOs cover this code in hospital settings per PT 09-26. (5) Communicate this change to all hospital-based behavioral health providers in your network. Failure to bill to the correct payer will result in claim denials and payment delays. This policy supersedes PT 80-25, so archive old guidance.