COVERED
Outpatient behavioral health services that typically are provided and covered in an office setting by a licensed behavioral health professional provider may be covered in a school setting onsite and via telemedicine as long as the individual being treated is medically stable and does not require 24-hour medical/nursing monitoring or procedures typically provided in a facility setting.
For continuity of care during school holidays and summer vacation, behavioral health services may be covered at a school camp.
Outpatient behavioral health services include one or more of the following:
- Psychotherapy
- Family therapy
- Group Therapy
- Psychiatric evaluation
- Medication management
- Drug and alcohol intervention and support
- Assessment services (excluding psychological testing)
- Crisis response and intervention/suicide prevention
Discontinuation of outpatient behavioral health services in a school setting should be considered in favor of an alternate site of service when one of the following becomes evident and is documented:
The individual and/or parent(s) or caregiver(s) have refused to continue with treatment recommendations.
- Improvement is not seen within a clinically reasonable period of time.
- The individual's mental status declines.
- The individual cannot be safely maintained in the school-based outpatient behavioral health setting.
- Behavioral issues are exacerbated by the treatment.
- The individual is unlikely to continue to benefit or maintain gains from continued care.
NOT COVERED
Behavioral health services, excluding applied behavior analysis services, are not covered in a school site of service if they are part of an Individualized Education Plan (IEP) under the Individuals with Disabilities Education Act (IDEA).
Behavioral health services provided by school staff are not covered and are, therefore, not eligible for reimbursement consideration.
REQUIRED DOCUMENTATION
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Documentation of the performing provider's qualifications must be made available to the Company upon request.
BILLING REQUIREMENTS
Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
When offered face-to-face in the school setting, covered outpatient behavioral health services that are provided on school grounds are to be billed with the place of service code 03 (school) or the place of service code 99 (school camp).
Outpatient behavioral health services that are provided via telemedicine are to be billed with the place of service code 02 (telehealth provided other than in patient's home).
