Coordination of Benefits : Commercial Health Insurance

Procedure Codes for Claims When Commercial Health Insurance Is the Primary Payer

When a member is enrolled in both a commercial health insurance plan and BadgerCare Plus or Wisconsin Medicaid, the provider is required to submit claims to commercial health insurance sources before submitting claims to ForwardHealth. Even when a member has a known deductible or cost share, primary insurance must process the claim prior to submission to ForwardHealth. The outcome of the primary insurance claim submission, regardless of payment status, is required for secondary claims processing by ForwardHealth.

ForwardHealth recognizes that commercial health insurance policies and procedure codes for behavioral treatment do not always match ForwardHealth policies and procedure codes. For example, some commercial insurers use a single procedure code for billing all behavioral treatment services, regardless of the specific service rendered, the skill level of the renderer, or the number of renderers billed concurrently.

When coordinating commercial health insurance and Medicaid benefits, providers are required to bill the commercial health insurance plan according to the commercial insurer's policies and designated procedure codes, modifiers, and units billed. Do not use modifiers TG or TF when submitting claims to the commercial insurer unless they are required under the commercial insurer's policy. After receiving the claims processing outcome (i.e., RA) from the commercial insurer, the provider may submit a claim to ForwardHealth for consideration of any remaining balance, using the same procedure codes, modifiers, and units billed on the original commercial health insurance claim.

ForwardHealth accepts the following CPT or HCPCS procedure codes when allowed by commercial health insurance companies for reimbursement of behavioral treatment services:

• 90791 (Psychiatric diagnostic evaluation)
• H0031 (Mental health assessment, by non-physician)
• H0032 (Mental health service plan development by non-physician)
• H2012 (Behavioral health day treatment, per hour)
• H2014 (Skills training and development, per 15 minutes)
• H2019 (Therapeutic behavioral services, per 15 minutes)

ForwardHealth does not use billing crosswalks between commercial health insurance procedure codes and ForwardHealth's allowable procedure codes in any benefit areas. COB claims are paid using the procedure code billed to commercial health insurance, based on ForwardHealth's maximum allowable fee schedule, which is the standard, statewide, maximum rate that can be paid for a procedure code.

Note: The requirement for providers to submit claims to commercial health insurance companies according to the commercial insurer's coding guidance does not waive other ForwardHealth program requirements. These requirements (e.g., provider qualifications, medical necessity, documentation requirements) are still in effect. ForwardHealth will not reimburse providers for services that do not meet program requirements.

All units of direct treatment billed against the previously listed CPT codes will be deducted from the total treatment units authorized by ForwardHealth.