Information For Dates of Service On and After October 1, 2015

Revenue Codes

Refer to following table or the UB-04 Uniform Billing Manual for a list of allowable revenue codes for the outpatient mental health benefit for services provided by outpatient mental health clinics. However, outpatient mental health services, other than group therapy and medication management (which are not separately billable for inpatient hospital members), provided by a psychiatrist or psychologist to a hospital inpatient member must be billed on the 1500 Health Insurance Claim Form. Providers should refer to the maximum allowable fee schedule for maximum allowable fees and copayment rates.

The following table lists the revenue code that providers are required to use when requesting PA and submitting claims for outpatient mental health services. Not all providers may be reimbursed for all mental health services. Consult the following table to determine which enrolled providers may be reimbursed for a particular service.

Outpatient Mental Health Services Revenue Codes^*

(Submitted Only on the UB-04 Claim Form)

For the following revenue codes, the $825 limit allowed without PA is applied per billing provider in a calendar year.