Behavioral health services in the primary care / medical setting

Applies to:

• Commercial employer group and commercial individual MyPriority plans
• Medicare coverage is determined by the Centers for Medicare and Medicaid Services (CMS); if a coverage determination has not been adopted by CMS, this policy applies.

Definition

Psychological evaluation and management services, performed to address difficulties associated with an acute or chronic illness, prevention of a physical illness or disability and maintain health, that do not meet criteria for a psychiatric diagnosis.

Medical policy

• Psychological Evaluation and Management of Non-Mental Health Disorders - 91546

Health and behavioral assessments coverage

Priority Health covers health and behavioral assessments and brief interventions provided by licensed clinicians (LP, LLP, LMFT, LMSW, LPC) when provided as part of a comprehensive medical program approved by Priority Health. Examples include comprehensive spine, weight, feeding disorders, palliative care and advance care planning programs.

It's not covered in the home setting.

See the medical policy for medical necessity criteria and exceptions/limitations to coverage.

Health and behavioral assessments billing

See the medical policy for indications, documentation requirements and coding.