The federal confidentiality law and regulations protect the privacy of substance use disorder (SUD) patient records by prohibiting unauthorized disclosures of patient records except in limited circumstances. Congress enacted the legislation to encourage individuals with SUDs to enter and remain in treatment. Learn more about the regulations implementing the law commonly referred to as “Part 2”.
If a provider treats or diagnoses a patient for SUD or refers patients for treatment of SUD and is subject to the Confidentiality of Substance Use Disorder Patient Records (42 CFR Part 2) as a Part 2 Program, that provider must comply with the terms of their contact with respect to any claim or other information they submit to a health plan that contains patient identifying information. Payment of these claims is contingent upon compliance with these requirements.
For dates of service on or after April 1, 2020, providers must include a Part 2 disclaimer with any claim (or other record) that contains patient-identifying information when submitting the claim (or other information) to Asuris.
When submitting an electronic claim (837 P or I) for Part 2 services on or after April 1, 2020, you must include the information listed below:
- On the CLM09 field, indicate an “I” for obtaining informed consent from the patient to release information governed by a federal statute. See below.
a. Note: This should be familiar with providers, as the field is general – and not specific to Part 2.
- Then, under the NTE01 segment, indicate “CER” for a narrative.
a. Note: Only one CER is permitted per claim.
- Under the NTE02 segment, include in the free-form narrative the Part 2 disclaimer language, as required by federal law. See below.
a. Note: A recent federal rule allowed a short form or long form disclaimer when Part 2 information is shared (e.g. from provider to health insurer).
Here are the two options, though the shorter version is preferable:
- Short form (Preferred version)
a. 42 CFR part 2 prohibits unauthorized disclosure of these records. View a sample form (PDF).
- Long form
a. This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose (see § 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65.
ANSI 837 Field
Informed Consent to release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
Part 2 disclaimer language, as required by federal law. Asuris prefers use of the shorter disclaimer.
Effective January 1, 2019, eight Category I and two modified Category III CPT codes will replace the Category III (temporary) CPT codes for adaptive behavior assessment (ABA) and treatment. The new codes apply to our commercial lines of business. The codes do not apply to our Medicare Advantage products.
The new codes are the result of an application to the American Medical Association CPT Editorial Panel that was developed by the Steering Committee for the ABA Services Work Group, which included representatives of the Association of Professional Behavior Analysts, Association for Behavior Analysis International, Behavior Analyst Certification Board and Autism Speaks, as well as CPT consultants.
Please begin using the new codes for dates of service on and after January 1, 2019. View the crosswalk from the old to the new codes. Crosswalk reimbursement effective January 1, 2019, and source file for length of time units for previously untimed codes is now available on the Availity Provider Portal, under Payer Spaces.
A participating acupuncturist/east Asian medicine practitioner will be reimbursed for acupuncture services provided for chemical dependency treatment when the member's plan includes a benefit for both acupuncture services and chemical dependency treatment.
Acupuncture treatment for chemical dependency is covered in the following instances:
- When the member's plan covers acupuncture
- Diagnosis supports chemical dependency benefits
- When smoking cessation is covered by the member's plan
If required by the member's plan, a referral by the member's primary care physician or by the contracted behavioral health department organization has been filed with us
- All covered services performed during an encounter must be billed in the same electronic claim submission.
- Evaluation and management (E&M) codes are not allowed as a substitute for rehabilitation, acupuncture treatments or spinal manipulation codes.
All licensed providers must bill for any and all services they perform under their own name. A provider may not submit claims for services performed by another licensed provider.
For an initial visit, the office call, cast application and cast materials are allowed. On subsequent visits, the office visit and, if necessary, the charge for recasting and cast material is allowed.
- Casting with a surgical procedure
- Fees for casts or splints applied at the time of surgery are included in the global service package (flat fee) for the surgical procedure.
- Recasting following a surgical procedure
- Recastings are allowed during the flat fee period, including the cast application and cast materials.
- Facility fee
- A facility fee or cast room fee is not covered for casting or recasting.
- When billing for casting materials and casting supplies, please use the appropriate Healthcare Common Procedure Coding System (HCPCS) codes.
Centers for Medicare & Medicaid Services (CMS) no longer reimburses for most consultation codes. With the move to 2010 Relative Value Units (RVUs), we adhere to the CMS determination as it relates to these codes. Therefore, office consultations (CPTs 99241-99245) and inpatient consultations (CPTs 99251-99255) are not accepted as valid codes and will be denied. Please bill with the appropriate codes for all of your patients who are our members.
A fragmented or split professional billing is defined as professional services rendered by the same provider for the same date of service and submitted on multiple professional claim forms.
We require all professional services rendered by the same provider for the same date of service to be submitted on one claim form.
- When a Medicare patient receives services that Medicare specifically requires to be submitted on separate claim forms
Home infusion providers who bill for the initial and subsequent therapy administration code on the same day using modifier SH or SJ
- We use Medicare published fees for injectables and biologicals.
- If a code does not have a Medicare fee, our Pharmacy Services Department will set one.
We will pay only for the amount of the drug that was actually administered to the patient and will not pay for "wastage", or part of a vial that was not administered.
Claims for either injectable or chemotherapy drugs must state the complete name of the drug (do not abbreviate) and the total milligrams, micrograms, units, etc., administered to the member in the narrative comment field of your electronic format. If the comment field of your electronic claim is not completed, the claim will be rejected and must be resubmitted with the correct information.
- Immunizations are covered if the product includes a preventive benefit.
- The administration is covered as well as the vaccines in some cases.
State-supplied vaccines are billed with Modifier SL and reimbursed for the storage and handling.
- Use CPT 90476-90749 for the actual vaccine/toxoid.
- When multiple immunizations are given, use both CPT 90471 and 90472.
- CPT 90471 and 90472 must be submitted with the vaccine and toxoid code(s).
- Indicate the number of units of service that were given on the same line as CPT 90472.
Use Modifier 25 on well visit and/or evaluation and management (E&M) services, if billing CPT 90471 or 90472.
The provider actually performing the analysis of the specimen may bill for laboratory services. Laboratory services are reimbursed according to our medical policy and are paid based on a fee schedule.
The following billing activities are not allowed:
- Billing for services not rendered.
Billing for services performed by another provider or laboratory.
Use Modifier -90 when laboratory specimens are sent to reference laboratories. Note: This service is not eligible for additional reimbursement.
Services not covered:
Conveyance or stat fees
Members receive the highest level of benefits when they receive services from participating providers. Benefits are reduced when services are provided by a non-participating or non-network provider. Note: If it is necessary to refer your patient to a non-participating or non-network provider, please communicate this to your patient to avoid subjecting him or her to unexpected bills.
We reimburse you for the cost of duplicating medical records when we have requested the records for utilization management purposes including:
- Medical necessity
- Prior authorization
- Discharge planning
When requesting reimbursement, please submit a bill or invoice along with the duplicated records. All bills for medical records must be submitted along with the requested records to be eligible for reimbursement.
Duplicate records reimbursement rates are as follows:
- 25 pages or less: $5.00
More than 25 pages: $5.00 for the first 25 pages, plus .10 cents for each additional page
Please do not submit invoices for an outside vendor who is providing you with copying services. Our policy states that we do not reimburse this type of vendor for duplication of medical records. In addition, any X-rays and/or pictures that are submitted with the records will be returned to you as we do not reimburse for duplication of X-rays and pictures. Please include the following information with the bill or invoice:
- Copy of original claim
- Total amount of charges
- Number of pages duplicated
- Member's name and member identification number
- To whom the check should be made out (for example, clinic or medical group)
Provider's name, address, telephone number and tax identification number
Please do not include a CPT code on the invoice.
Please submit routine colonoscopy and sigmoidoscopy claims to us following these Federal Reform guidelines to ensure that these claims are processed and paid correctly.
- Routine colonoscopies or sigmoidoscopies and all associated claims for screening (for example, pathology and anesthesia) must be billed with one or more of the appropriate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes:
- Z800 Family history of malignant neoplasm of digestive organs
- Z8371 Family history of colonic polyps
- Z1212 Encounter for screening for malignant neoplasm of rectum
- Z1211 Encounter for screening for malignant neoplasm of colon
- Routine screenings that become diagnostic (i.e., due to detection of a suspected pathology) should be billed with Modifier 33 Preventive Service or Modifier PT Colorectal Cancer Screening test, converted to diagnostic test or other procedure to indicate the original intent of the procedure was for preventative screening. (For example, during a scheduled routine screening colonoscopy several suspicious lesions are discovered and multiple biopsies of the lesions are obtained by the surgeon. The surgeon would bill 45380 PT.)
- For members under 50 years of age, the appropriate diagnosis code should be used in the primary field. If polyps are removed, the diagnosis code should be used in the primary field and 211.3 diagnosis code should be used in the secondary field. Please refer to MLN Matters Number: SE0746 (PDF) (see page 2).
For more information about Modifier PT, please refer to MLN Matters Number: MM7012 (PDF) (see page 3).
The following will not be paid under Federal Reform and the member will incur cost-sharing amounts according to his or her medical benefits.
- Screenings services billed with other diagnoses codes (for example, personal history) or is outside of the age or frequency guidelines
A procedure that is diagnostic and not a screening will not be paid at 100%; it will be covered as a regular medical benefit. For example, if a physician orders the procedure due to a medical condition or orders any subsequent diagnostic colonoscopies, these procedures are not routine screenings and will not be paid at the Federal Reform benefit level of 100%.
When CPT 41899 Unlisted procedure, dentoalveolar structures is billed with a primary diagnosis of ICD-10-CM Z418 Encounter for other procedures for purposes other than remedying health state by a medical Primary Care Provider (PCP), the charge for the fluoride application is not eligible for benefit consideration.
For program criteria, including eligibility for the MDPP benefit and services covered by Medicare, review the:
Effective January 1, 2020, Medicare added coverage for OTPs for all beneficiaries. OTPs provide medication‑assisted treatment (MAT) for people diagnosed with an opioid use disorder.
Nonresidential opioid treatment facilities must submit claims for OTP services with a place of service (POS) 58 on an 837P electronic claim. CMS has published the following resources for providers to learn more about the OTP benefit, provider enrollment and coding and billing requirements:
Providers are responsible for submitting accurate and complete claims for all medical and surgical services, supplies and items rendered to members using industry standard coding guidelines. Please refer to our Correct Coding Guidelines policy in the Reimbursement Policy Manual.
If you provide services at a facility that are billed separate from the facility claim, the claim for the services you provided must include the service facility NPI where the service was rendered.
When appropriate, the service facility NPI should be included in loop 2310, segment NM109 on an ANSI 837p claim.
To ensure accurate reimbursement, claims should include:
- Contracted per diem codes—one line per date of service (i.e. line level “from” date equals “to” date) with 1 unit of service
Hourly codes—one line per date of service (i.e., line level “from” date equals “to” date) with the total units (hours) rendered
Do not use:
- Date ranges (e.g., 01/01/2020 – 01/03/2020) on a single line
- Multiple lines with the same date of service for the same code