MedicaidCoverageMedium impact
Clarification on MCO Payment Responsibility for Health Behavior Assessments Administered in an Acute Care Setting
Maryland Medicaid·MD · Psychiatry, Internal Medicine, Family Medicine +1 more·Behavioral Health Administration Services Organization
Effective date
Jan 1, 2025
We identified it
Jun 20, 2026
Summary
MCOs must reimburse for CPT 96156 (health behavior assessments) when performed in acute care hospital settings with a primary somatic diagnosis. This clarifies that these assessments remain MCO-covered services (not carved out to the behavioral health ASO) and establishes the fee-for-service rate at $102.83 effective January 1, 2025. The policy expands eligible provider types and places of service to include inpatient hospitals.
Action Required
By January 1, 2025: Billing team must ensure CPT 96156 claims are routed to MCOs (not the behavioral health ASO) when billed in inpatient hospital settings (place of service 21) with a primary somatic diagnosis. Update billing system to recognize eligible provider types: CC (Certified Professional Counselor), 24 (Nurse Psychotherapist EPSDT), 51 (Therapeutic Behavioral Services), and 94 (Licensed Certified Social Worker). Configure system to reimburse at $102.83 for claims dated on or after January 1, 2025. Train billing and coding staff on the distinction between carved-out behavioral health services (routed to ASO) versus health behavior assessments tied to somatic conditions (MCO-covered). Ensure prior claims incorrectly routed to the ASO are identified and resubmitted to the appropriate MCO.