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Welcome Behavioral Health Providers!

We appreciate you being a partner in building healthier communities.

With your help, we are setting the standard for progressive community care: holistic, altruistic and most importantly, personal. We are proud of our provider network and value the contribution that each of you make to the quality of our members’ care.
 

Behavioral Health Directed Payment Information (For IHN-CCO/Medicaid Providers Only)

Effective Jan. 1, 2023, the Oregon Health Authority will implement four behavioral health directed payments, also known as BHDPs, within the CCO contracts that will further the goals and priorities of the Medicaid program as follows:

1. Tiered Uniform Rate Increase Directed Payment.

2. Co-occurring Disorder Directed Payment.

3. CLSS Directed Payment.

4. Minimum Fee Schedule Directed Payment.

The following sections include a breakdown of each behavioral health directed payment, frequently asked questions and links to submit more information to the CCO.

Effective Jan. 1, 2023, the Oregon Health Authority will implement a managed care-directed payment arrangement that will provide a uniform percentage increase payment to qualified network, contracted behavioral health providers for services delivered during the contract year. The increase will be in addition to the contracted rates IHN-CCO had in place for qualified behavioral health providers effective Jan. 1, 2022.

The payment increases have two tiers defined by whether the provider is a “Medicaid dominant” or “non-Medicaid dominant” behavioral health provider.

  • 30% increase for Medicaid-dominant: defined as having at least 50% of its total patient service revenue derived from providing Medicaid services in the prior contract year.
  • 15% increase for Medicaid non-dominant: defined as having less than 50% of its total patient service revenue from providing Medicaid services in the prior contract year.

Who Is Eligible?

Qualified participating providers of ACT/SE services, MH non-inpatient and substance abuse services.

What Should You Do?

1. All eligible providers will default to an increase equivalent to the Medicaid Non-dominant tier (15%). No further action is required.  

2. If you feel you or your provider group meets the definition of eligibility for Medicaid-dominant tier (30%), providers should gather financial information* to demonstrate their distribution of prior contract year patient services revenue between Medicaid and non-Medicaid payors and submit it to IHN-CCO prior to March 31, 2023, or as soon as eligibility is met. Initiate the process with IHN-CCO and select “Behavioral Health Directed Payment” in the “Request Type” field.   

*Please track your gathered financial information on the OHA fillable form available at the Oregon Health Authority website by selecting the “Primarily Medicaid Provider Attestation Form” listed under the CCO Rate Increases section.

3. IHN-CCO contracts contain “lesser of billed charges” language. Providers should bill at a rate that takes into account any of the behavioral health-directed payment rate increases they expect to be eligible for to ensure payments can be applied correctly and reduce the need for claim resubmission.

Effective Jan. 1, 2023, the Oregon Health Authority will implement a directed payment arrangement that will provide a uniform payment increase to participating providers of outpatient behavioral health services certified by OHA for integrated treatment of co-occurring disorders, also known as COD, rendered by qualified staff per the forthcoming COD rules. The payment increase(s) equals:

  • 10% of the State Plan Medicaid Behavioral Health Fee-For-Service fee schedule rate effective Jan. 1, 2023, for covered non-residential services provided by providers below a master’s level, including peer service providers.
  • 20% of the Medicaid fee schedule rate in effect on Jan. 1, 2023, for covered non-residential services for master’s level providers.
  • 15% of the Medicaid fee schedule rate in effect on Jan. 1, 2023, for residential services providers.  

The increase(s) will be in addition to your negotiated base rates currently in place for qualified providers delivering services while meeting COD certification standards. The billing entity must be certified under the forthcoming COD rules established by OHA.

The directed payment is limited to services on the Medicaid Fee-For-Service Behavioral Health Rate Increase Fee Schedule and in the A&D Residential, Mental Health Non-Inpatient, Mental Health Children’s Wraparound and SUD categories of service.  

What Should You Do?

1. Become certified by applying for Certification of Approval through your assigned licensing and certification specialist at OHA. Programs will need to have previous and current Behavioral Health Certification of Approval and meet requirements that OHA will add to Oregon Administrative Rule 309-019-0145. OHA has advisory and information groups formed to discuss revisions to this rule. To get involved or receive ongoing information and updates, contact David Corse.  

2. Provider staff rendering services will meet staff training and certification requirements per COD rules.  

3. Certified providers should bill using the appropriate payment modifier when a service is provided to a member with qualifying diagnoses.

  • Master’s level provider: use modifier HO for eligible services to receive the additional 20%.
  • All other providers: use modified HH for eligible services to receive the additional 10%.  


4. For residential providers: To receive the 15% of the Medicaid fee schedule rate increase, a residential CPT code from the following table must be present.

CPT Modifier Other Conditions
H0010 HH Certified SUD program
H0011 HH Certified SUD program
H0018 HH Certified SUD program
H0019 HH None
H2013 Not HK None

5. Providers who obtain COD certification at the organization and rendering provider level should notify IHN-CCO and provide supporting documentation. Initiate the process with IHN-CCO and select “BH Directed Payment” in the “Request Type” field.

6. IHN-CCO contracts contain “lesser of billed charges” language. Providers should bill at a rate that takes into account any of the behavioral health-directed payment rate increases they expect to be eligible for to ensure payments can be applied correctly and reduce need for claim resubmission.  

Effective Jan. 1, 2023, the Oregon Health Authority will implement a directed payment arrangement that will provide a uniform payment increase to qualified participating providers when they deliver culturally and/or linguistically specific services, also known as CLSS, direct services in a language other than English or in an approved sign language.

CLSS are services that are centered on the cultural values of ethnic and minority communities in order to elevate the voices and experiences of those who have been historically oppressed. Their aims are to provide safety, belonging and encourage a shared collective cultural experience for healing and recovery, and are provided by a culturally and/or linguistically specific organization, program or individual provider. The payment increase(s) equals:  

  • 22% of the State Plan Medicaid Behavioral Health Fee-For-Service fee schedule rate in effect on Jan. 1, 2023, for covered services provided by non-rural providers.
  • 27% of the Medicaid fee schedule rate in effect on Jan. 1, 2023, for rural providers.  

The increase(s) will be in addition to your negotiated base rates currently in place for qualified behavioral health providers delivering services while meeting CLSS certification standards.

Who Is Eligible?

1. CLSS Organization Program or individual provider and bilingual service or sign language providers deemed eligible through OHA application process providing the following services:

  • Substance used disorder (non-inpatient).
  • Mental health (non-inpatient).
  • Mental Health Children’s Wraparound.
  • Assertive Community Treatment and Supportive Employment, also known as ACT and SE.
  • Applied Behavioral Analysis, also known as ABA.

2. Once approved as an eligible provider/billing entity by OHA, providers should contact IHN-CCO to submit approval and request for rate enhancement.
3. Providers/billing entities should use the linked template to comply with the required reporting details and must submit a complete template for interpreter services provided to IHN-CCO within 30 days following the end of each calendar quarter starting in 2023. Completed templates can be delivered to SHPprovider@samhealth.org.  

What Should You Do?

1. Providers who deliver a CLSS service, a service in a language other than English or a service in an approved sign language and have met eligibility requirements should bill using the appropriate payment modifier.
2. IHN-CCO contracts contain “lesser of billed charges” language. Providers should bill at a rate that takes into account any of the behavioral health directed payment rate increases they expect to be eligible for to ensure payments can be applied correctly and reduce need for claim resubmission.
3. Initiate the process to submit information and supply approval with IHN-CCO and select “BH Directed Payment” in the “Request Type” field.

 

Effective Jan. 1, 2023, the Oregon Health Authority will implement a directed payment arrangement that will require CCOs to maintain the fee schedule for A&D Residential, Applied Behavior Analysis and Mental Health Children’s Wraparound services at no lower than the OHA State Plan Medicaid Behavioral Health Fee-For-Service fee schedule rate in effect at the date of service.

Impacted Services

The directed payment is limited to services on the Medicaid Fee-For-Service Behavioral Health Rate Increase Fee Schedule and in the A&D Residential, Applied Behavior Analysis and Mental Health Children’s Wraparound Categories of Services.

What Should You Do?

  1. No additional action will be required from providers. IHN-CCO will adopt/maintain the fee schedule for A&D Residential, Applied Behavior Analysis and Mental Health Children’s Wraparound services at no lower than the OHA State Plan Medicaid Behavioral Health Fee-For-Service fee schedule rate in effect at the date of service.
  2. IHN-CCO contracts contain “lesser of billed charges” language. Providers should bill at a rate that takes into account any of the behavioral health directed payment rate increases they expect to be eligible for to ensure payments can be applied correctly and reduce need for claim resubmission.