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Medicaid Expansion- Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP) and Residential Treatment Center (RTC) Services

Blue Cross Blue Shield of North Dakota (BCBSND) would like to provide clarification regarding the billing guidelines for psychiatric and/or substance use Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP) and Residential Treatment Center (RTC) services provided to BCBSND Medicaid Expansion members.

To ensure you are accurately billing for behavioral health services review and utilize the Psychiatric and Substance Use Services Guidelines Reimbursement policy. This policy contains information pertaining to coding guidelines, what is included in per-diem rates and what can or cannot be billed separately. Please note that BCBSND does not reimburse RTC and PHP/IOP occurring at the same time. If a member is in RTC and PHP/IOP care at the same time, a pre-authorization is required for residential care and reimbursement will be based on the per diem for residential care. If the member is only in PHP/IOP, a pre-authorization is not required.

Note: Per §1905(a) of the Social Security Act in paragraph (B), Institutions for Mental Diseases (IMD) are not eligible for reimbursement of RTC or inpatient services for the Medicaid Expansion Program. 

BCBSND utilizes Change Health Care® Level of Care Criteria (InterQual) which is based on nationally recognized clinical guidelines to assist clinicians in making informed decisions. InterQual criteria sets are available via InterQual (BCBSND) link on the Availity portal under Authorizations & Referrals section.

Claims received for behavioral health services will follow the BCBSND appropriate fee schedule. Access to the fee schedule portal, as well as additional information regarding fee schedules can be found on the BCBSND website linked here.

For additional questions please contact the BCBS Medicaid Expansion Provider Service Center at 1-833-777-5779.