Substance Use Disorder Evaluation Coverage
Posted on July 13, 2016
In response to the continued impact of the opioid crisis, Health New England is providing substance use disorder evaluation coverage to our plan members.
As part of recently enacted Massachusetts legislation (Chapter 52 of the Acts of 2016, An Act Relative to Substance Use, Treatment, Education and Prevention), Health New England is in compliance with Sections 32 and 39 of the bill. Section 32 requires hospitals to ensure that patients being treated for an opiate-related overdose receive a substance abuse evaluation within 24 hours and allows hospitals to have a “licensed mental health professional” or an emergency services program perform the evaluation. Section 39 of the bill requires MassHealth and its contracted health plans to pay for these evaluations without preauthorization. Sections 32 and 39 are effective as of July 1, 2016.
Billing Details
For MassHealth/Be Healthy™ members: If the substance abuse evaluation is done by an emergency services program (ESP) or a crisis team, they will bill Massachusetts Behavioral Health Partnership (MBHP) directly for our members, as there is already an existing code/process in place. If the evaluation is done by a licensed mental health professional from the emergency room staff, such as a licensed social worker, the medical claim that comes from the hospital directly to Health New England will include an Evaluation & Management code that will be included and paid for out of the existing PAPE (payment amount per episode) rate.
For all other Health New England members (including Health New England Medicare Advantage): Services billed and submitted by facilities as part of an emergency room visit will be reimbursed according to your contract.
If you have questions about this new coverage or billing details, please contact Health New England Provider Relations at (800) 842-4464 ext. 5000.
More information about the Substance Use, Treatment, Education and Prevention Act can be found at
https://malegislature.gov/Laws/SessionLaws/Acts/2016/Chapter52.
