Behavioral health provider billing
Billable behavioral health services are reimbursed fee-for-service. Review the appropriate fee schedule below to identify which practitioner can bill for specific services. All fee schedules are updated quarterly.
- Select the appropriate Behavioral Health fee schedule and date of service from the drop-down menu.
- Note: the non-physician Behavioral Health fee schedule identifies all practitioner levels, along with services that can only be rendered by a psychologist or social worker.
- All professional services are listed within the Medicare physician fee schedule localities and behavioral health is not separately identified.
- Michigan localities:
(01 = Macomb, Oakland, Washtenaw and Wayne Counties, 99 = all other counties)
In general, follow billing rules for all practitioners using a CMS-1500 claim form. Field 24J (rendering provider) on the CMS-1500 claim form must show the individual NPI number of the practitioner who directly provides the service being billed. Exceptions to this are noted below.
Behavioral health practitioner requirements
In order to be reimbursed for in-network services, practitioners must be credentialed by Priority Health and licensed as follows:
- Commercial HMO/EPO/POS/PPO plans: MDs/DOs, LPs, LMSWs, LPCs, LLPs, LMFTs and LBAs
- Medicaid plans: MDs/DOs, LPs, LMSWs, LPCs, LMFTs and LLPs
- Medicare Advantage plans: MDs/DOs, LPs and LMSWs (and starting Jan. 1, 2024, LMFTs, LPCs and LLPs. We’ll begin accepting changes to network participation to add Medicare Advantage on Dec. 1, 2023. If you’re a new provider to Priority Health, submit an enrollment application at that time. If you’re already a participating provider, submit an individual change request.)
Limited license practitioners
LLMSWs, LLCs and TLLPs cannot be credentialed and cannot bill directly for in-network or out-of-network services.
LLMSWs, LLCs and TLLPs may provide only services within their respective scope of licensure to Priority Health Commercial and Medicaid Members (cannot provide services to Medicare Advantage Members) and only when supervised by a fully licensed and credentialed provider, as follows:
- For services provided by an LLMSW, an LMSW must supervise and bill with the LMSW’s NPI using AJ modifier.
- For services provided by an LLC, an LPC must supervise and bill with the LPC’s NPI using HO modifier.
- For services provided by a TLLP, an LP must supervise and bill with the LP’s NPI using HO modifier.
Field 24J (“rendering provider”) of the 1500 claim form must list the Type 1 NPI of the supervising provider (do not use the NPI of the LLMSW, LLC or TLLP), and field 24D must include the AJ or HO modifier as noted above.
Services will be reimbursed at the corresponding supervisor’s licensure level rate specified in the Behavioral Health Fee Schedule.
Supervision must, at a minimum, include documentation by the supervising/billing provider in the Member’s medical record that they have reviewed the limited license practitioner’s medical record notes within one week of each visit.
Exceptions to the credentialing and supervision requirements
Exceptions to the above credentialing and supervision/rendering provider billing rules are as follows:
Psychotropic medication management services
Psychiatric advanced practice providers, e.g., NPs and PAs, directly providing these services do not require credentialing by Priority Health. Bill with their supervising/collaborating psychiatrist as the rendering provider.
When testing is directly provided by an LLP, bill with the supervising LP as the rendering provider.
When working in an accredited organization that’s credentialed with us as an Organizational Provider, appropriately licensed behavioral health practitioners (other than MDs/DOs) don’t require individual credentialing.
To enroll a new practitioner to an existing organization or group:
- Log into your prism account
- Click the Enrollments & Requests tab
- Select the appropriate option for your enrollment request
We’ll notify you through prism when we’ve added the provider. Claims with dates of service before the notification date will be denied.
Provider record and billing reviews
Priority Health reviews claims data to identify and monitor suspect patterns as part of our fraud, waste and abuse program.
Providers may be flagged for reviews for:
- Excessive billing of high-level codes
- Exclusive use of one code level billed
- Excessive units for a time-based code
Submitting electronic claims
Mailing paper claims
Priority Health Claims
P.O. Box 232
Grand Rapids, MI 49501
- Status claims
- Claims Inquiry tool guide
- Edits Checker tool guide
- Claim deadlines
- Set up electronic payments
- BH provider billing
- Facility billing
- Advanced practice professional billing
- Professional billing
More billing topics:
- ACA non-payment grace period
- Ambulatory surgery center billing
- Balance billing
- Clinical edits
- Check reissue procedure
- COB: Coordination of benefits
- Correcting claims
- Correcting overpayments & underpayments
- Diagnosis coding
- Dual-eligible members
- Front-end rejections
- Gender-specific services
- Medicaid billing
- NDC numbers on drug claims
- Office-based procedures billing
- Risk adjustment
- Unlisted codes, drugs & supplies