Covered Services & Billing
Covered Services
Under E2HB1688, covered emergency services include mental health and substance use disorder services that are provided by Mobile Crisis Response Teams and/or by qualified staff in the following Crisis Facilities;
a) Hospital Based Emergency Room with stabilization/post stabilization in an Inpatient Unit
b) Evaluation and Treatment Facility (including Secure Withdrawal Management Services)
c) Crisis Stabilization Unit,
d) Crisis Triage Facility,
e) Withdrawal Management Facility
The above 5 facilities are all considered Behavioral Health Crisis Facilities and any/all of the SERI specified services (procedure / revenue codes) provided in any of those facilities are considered covered Behavioral Health Crisis Services.
The specific Behavioral Health Crisis Services are a subset of those services defined in HCA’s SERI Guide – https://www.hca.wa.gov/billers-providers-partners/program-information-providers/service-encounter-reporting-instructions-seri. That subset of services and related coding guidance is defined in the spreadsheet ‘Crisis Code Guide for Private Insurance Plans’, which is also posted at the above link.
For the scope Behavioral Health Emergency Services, coding requirements for commercial carriers would mirror Medicaid SERI guidance and would be reflected as such on any updates to the SERI spreadsheet. Changes to Medicaid can be triggered by legislation, but also may be triggered by state plan amendments, CMS rule changes, 988 crisis system changes, etc.
The SERI Guide is typically updated once a year by HCA and with a 90-day implementation timeframe. However, not all SERI Guide updates will be applicable to Behavioral Health Crisis Services and, as such, will not appear on the SERI spreadsheet.
Commercial Carriers can sign up to receive updates on the Service Encounter Reporting Instructions (SERI) guide. (An account would need to be created if one does not already exist.) When signing up, select “Service Encounter Reporting Instructions (SERI) updates”, under the “Behavioral Health and Recovery” heading. Once signed up, carriers will receive an email notification any time there are changes to the SERI guide, as well as any changes to the services coding grid related to E2SHB 1688 legislation.
The material in the documents in the table below is an extract from the January 1, 2023 version of the SERI Guide and from the October 2, 2023 version of the Crisis Code Guide for Private Insurance Plans. (The documents posted here below may not be kept current with any future SERI changes. To ensure accuracy over time, the SERI Guide should be referenced via this link https://www.hca.wa.gov/billers-providers-partners/program-information-providers/service-encounter-reporting-instructions-seri so that any/all future changes are not missed.)
| This link contains the a subset of the January 1, 2023 SERI Guide, which are the Behavioral Health Crisis Services (BHCS) along with conditions under which they are covered. | SERI-Defined BHCS |
| This link provides additional detail about BHCS crisis codes, such as the “included” services, that will be used on the 837P or 837I .
Note: For Professional Services (those that are reported on an 837P), the allowable Places of Service for each Behavioral Health Crisis Service will be negotiated between the Carrier and the BH-ASO / Facility at the time of contracting. In the case of ‘out-of-network’ claims, the allowable Places of Service for Behavioral Health Crisis Service will be defined in the Crisis Code Guide for Private Insurance Plans spreadsheet. |
Crisis Code Guide for Private Insurance Plans |
The ‘Crisis Code Guide for Private Insurance Plan’ spreadsheet along with the associated information in the SERI Guide will be used as the ‘Definitive Guidance’ for which codes will be used to identify covered emergency services. Other than E&M codes, only the codes on the spreadsheet should appear on a claim and that code(s) should be considered the complete and exhaustive definition of the relevant covered emergency service.
The use of any different or additional codes may be negotiated between commercial carriers, BH-ASO and facilities, but that would be considered outside the scope of the ‘Definitive Guidance’.
Claims for any/all of the Behavioral Health Crisis Services, i.e., the subset of SERI Guide services specified in the Crisis Code Guide for Private Insurance Plan spreadsheet, that are provided by Agencies, Facilities and Providers who are appropriately certified/licensed by DOH will be processed as emergency services by commercial carriers in compliance with E2HB1688.
Billing Guidance
1) Room and board “per diem” within a facility along with a SERI defined set of “included” clinical services would be included in the payment for the service code that is submitted on a claim, i.e., the “included” services would not be billed separately from the per diem.
2) Required clinical services that are in addition to SERI-defined “included” clinical services” may be provided in the facility by agency providers.
These services, typically E&M codes, may be billed separately from the per diem on an 837P using the provider’s NPI, subject to any specific contract expectations. (Depending upon the location, the associated per diem would be billed on an 837I using the agency’s NPI).
E&M codes on a claim along with a SERI defined covered emergency service are also considered covered emergency services.
These E&M services may be provided by an employee of the Crisis Facility, or a contractor of the Crisis Facility, or an “external” provider who has treatment privileges at the Crisis Facility. For all three situations, AADR reporting requirements are analogous to those of a Hospital ER department, i.e. the goal is that coverage of BH crisis facility services are comparable to those provided in a hospital ER department.
3) For Withdrawal Management Services, clinically managed or medically managed, claims will be submitted on an 837I unless otherwise contractually negotiated between the Carrier and the Facility.
Out-of-network Crisis Facilities for Withdrawal Management will submit claims on an 837I. Any 837P submissions will be denied.
4) Claims submitted by a BH-ASOs of behalf of an Agency or Facility would report the BH-ASO as the ‘Billing Provider’ and report the Agency / Facility as the ‘Rendering Provider’.
5) For a compliant 837-claim transaction WHEN a carrier requires use of a Taxonomy Code: In situations where a provider has a State Taxonomy Code, the BH-ASO will report a) either “101Y00000X” – Counselor or “390200000X” – Student in the Taxonomy Code field on the 837, and b) the state assigned Taxonomy Code in the NTE field on the 837, either at the claim level or line level whichever is most appropriate. The message in the NTE field will be “Wash State Taxonomy Code #xxxxxxxxL”. (for more information – see 10-23-23 Meeting Synopsis item B.1)
The following conditions must be met for using the National Taxonomy Code – “390200000X – Student” on an 837-claim . . . The 837-claim must be submitted:
* For one or more of the procedure codes H2011, S9484, H2019, AND
* The rendering provider
– has a valid NPI, AND
– has a National taxonomy code 390200000X – Student, AND
– is a Master Level Interns with the DOH certification; Registered Agency Affiliated Counselor or Certified Agency Affiliated Counselor, AND
* The claim is otherwise coded as specified in the SERI Guide and the associated worksheet,
THEN the claim will be considered a valid claim for a valid provider and will either be auto-adjudicated OR pended for manual processing.
6) The 835 – Remittance Advice transaction will be used to report the adjudication/ processing of claims by the Commercial Carrier.
7) Involuntary stays at crisis facilities are considered Behavioral Health Emergency Services and thus allowable codes to be covered by commercial carriers. The statutes at 48.43.005 and 48.43.093 require coverage of E&T facility services and make no distinction between voluntary and involuntary stays.
Links to Related Documents (for History and Audit Trail of Changes)
Billing Questions from Association of Washington Health Plans (AWHP)