Payer Guidelines.xlsx

	A	B	C	D	E	F	G	H
1
2	Concurrent Billing
3	Assume you cannot co-bill unless this spreadsheet explicitly says you can
4	Payer	Codes That CAN Be Concurrent Billed	Can you Co-Bill Assessment (97151) and Direct Therapy (97153, 97154)	Can you Co-Bill Protocol Mod (97155, T1026) and Direct Therapy (97153, 97154)	Can you Co-Bill Parent Training (97156) and Direct Therapy (97153, 97154)	Notes	Telehealth

5	Aetna/Molina	97153 & 97155 97155 & 97154 97153 & 97156	NO	YES	YES	(97153 & 97155) may overlap as long as the criteria identified in the descriptors of each code have been met and different qualified health providers (QHPs) are delivering the services. A single QHP may not bill these codes concurrently.
6	Aetna Better health - Medicaid	97153 & 97155 97153 & 97156	NO	YES	tel	(97153 & 97155) may overlap as long as the criteria identified in the descriptors of each code have been met and different qualified health providers (QHPs) are delivering the services. A single QHP may not bill these codes concurrently.	Check your contract	Aetna has an MUE for the 97151 code of 8 units MAX per day. That means they are only paying us for up to 2 hours a day for this code. Aetna may only allow up to 30 direct therapy hours per week; ensure your BCBA is appealing any denials to ensure clients are getting their clinical reocmmendations.
7	Beacon Health Options	97153 & 97155 97155 & 97154	NO	YES	NO	(97153 & 97155) may overlap as long as the criteria identified in the descriptors of each code have been met and different qualified health providers (QHPs) are delivering the services. A single QHP may not bill these codes concurrently.	Check your contract
8	BCBS/Anthem	97153 & 97155 97155 & 97154	NO	YES	NO	(97153 & 97155) may overlap as long as the criteria identified in the descriptors of each code have been met and different qualified health providers (QHPs) are delivering the services. A single QHP may not bill these codes concurrently.	Check your contract	BCBS has an MUE for the 97151 code of 8 units MAX per day. That means they are only paying us for up to 2 hours a day for this code.
9	Cigna/Allegiance/Medical Mutual	97153 & 97155 97151, 97152 & 0362T 97153 & 97156 97151 & 97153 97155 & 97154	YES	YES	YES	(97153 & 97155) direct supervision when the Board Certified Behavior Analyst (BCBA)/Qualified Healthcare Professional (QHP) directs the technician and both are face-to-face with the patient at the same time).	Check your contract	97151 & 97152 Concurrent, 97153 &97155 concurrent
10	Community Health Choice	97153 & 97155 97155 & 97154	NO	YES	NO	(97153 & 97155) may overlap as long as the criteria identified in the descriptors of each code have been met and different qualified health providers (QHPs) are delivering the services. A single QHP may not bill these codes concurrently.	NONE	NO TELEHEALTH
11	Tricare	97155 & 97156 97153 & 97156 97151 & 97153 97151 & 97156 97157 & 97158	YES	NO	Yes		NONE	97151 must be billed within 2 weeks of the first unit being billed or those units will be lost NO TELEHEALTH during first authorizations; 97156 may be provided via telehealth after first auth, but must be specifically requested anda pproved BCaBAs may bill 97155/97156
12	GA Medicaid (Amerigroup)	97153 & 97156 97153 & 97155 97155 & 97154 97151, 97152 & 0362T	NO	YES	YES	(97153 & 97156) those are separate and distinct services delivered to different family members by different providers and may be billed concurrently (97153 & 97155) When supervision is provided, you may bill concurrently for both Supervisors and Behavior Technicians, billing with 97153 and 97155.	Check your contract
13	Humana	97153 & 97155	NO	YES	NO	(97153 & 97155) may overlap as long as the criteria identified in the descriptors of each code have been met and different qualified health providers (QHPs) are delivering the services. A single QHP may not bill these codes concurrently.	Check your contract
14	Line Construcation	97153 & 97155	NO	YES	NO	(97153 & 97155) may overlap as long as the criteria identified in the descriptors of each code have been met and different qualified health providers (QHPs) are delivering the services. A single QHP may not bill these codes concurrently.	Check your contract
15	Magellan	97153 & 97155 97153 & 97156	NO	YES	YES	(97153 & 97155) may overlap as long as the criteria identified in the descriptors of each code have been met and different qualified health providers (QHPs) are delivering the services. A single QHP may not bill these codes concurrently.	Check your contract
16	Mercy Care	97153 & 97155	NO	YES	NO	(97153 & 97155) may overlap as long as the criteria identified in the descriptors of each code have been met and different qualified health providers (QHPs) are delivering the services. A single QHP may not bill these codes concurrently.	Check your contract
17	Molina	97153 & 97155 97155 & 97154 97153 & 97156	NO	YES	YES		Check your contract
18	Optum/UHC	97153 & 97156 97153 & 97155 97155 & 97154 97151, 97152 & 0362T	NO	YES	YES	(97153 & 97156) those are separate and distinct services delivered to different family members by different providers and may be billed concurrently (97153 & 97155) When supervision is provided, you may bill concurrently for both Supervisors and Behavior Technicians, billing with 97153 and 97155.	Check your contract
19	Presbyterian Health Plan	Site wants to concurrently bill everything unless denials begin coming through as it is not clear in payer guidelines or fee schedule				T1026 Can be billed with the client or without - it seems like this can also be billed when the client is absent
20	Sunflower - Medicaid	97153 & 97155 97153 & 97156	NO	YES	YES	(97153 & 97155) may overlap as long as the criteria identified in the descriptors of each code have been met and different qualified health providers (QHPs) are delivering the services. A single QHP may not bill these codes concurrently.	Check your contract
21	Texas Medicaid	97153 & 97156				only allowed to concurrent bill parent trianing if client is not present during 97156	Check your contract
22	Tricare	97155 & 97156 97153 & 97156 97151 & 97153 97151 & 97156 97157 & 97158	YES	NO	Yes		NONE	97151 must be billed within 2 weeks of the first unit being billed or those units will be lost NO TELEHEALTH during first authorizations; 97156 may be provided via telehealth after first auth, but must be specifically requested anda pproved BCaBAs may bill 97155/97156
23	Trillium	97153 & 97155 97152 co-bill w/ 97151	NO	YES	NO	(97153 & 97155) may overlap as long as the criteria identified in the descriptors of each code have been met and different qualified health providers (QHPs) are delivering the services. A single QHP may not bill these codes concurrently.	Check your contract
24	United healthcare community plan -Medicaid	97153 & 97155 97152 co-bill w/ 97151 97153 & 97156	NO	YES	YES	(97153 & 97155) may overlap as long as the criteria identified in the descriptors of each code have been met and different qualified health providers (QHPs) are delivering the services. A single QHP may not bill these codes concurrently.	Check your contract
25	VA Mediciad (anthem health keepers, Molina, UHC VA Medicaid, Aetna Better Health)	97151 & 97152 97151 & 97153 97153 & 97156 97153 & 97155 97154 & 97158	Yes	YES	YES		Check your contract
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