Home Provider Home Registration System Provider Handbook Enhanced Care Clinics Find a Provider Bed Tracking System Covered Services/Fees Authorization Schedule Level of Care Guidelines Forms Bulletins Performance Measurement Publications Achieve Solutions FAQs Events/Trainings	Covered Services/Fees Download PDF Version Coverage 1= HUSKY MCO – All diagnoses Responsibility 2= BHP - All diagnoses Legend: 3= BHP for Primary Diagnoses 291-316, HUSKY MCO all other diagnoses   4= Not covered       Note: PSR = Provider Specific Rate Code General Hospital Inpatient Coverage BHP Fee 110 Room & Board- Private 3 PSR 111 Room & Board- Private -Med/Surg/Gyn 3 PSR 112 Room & Board- Private -OB 3 PSR 113 Room & Board- Private -Pediatric 3 PSR 114 Room & Board – Private- Psychiatric 2 PSR 115 Room & Board- Private -Hospice 3 PSR 116 Room & Board – Private - Detox 2 PSR 117 Room & Board- Private -Oncology 3 PSR 118 Room & Board- Private -Rehab 3 PSR 119 Room & Board- Private -Other 3 PSR 120 Room & Board-Semi-Private/2 Bed 3 PSR 121 Room & Board-Semi-Private/ 2 Bed- Med/Surg/Gyn 3 PSR 122 Room & Board-Semi-Private/ 2 Bed -OB 3 PSR 123 Room & Board-Semi-Private/ 2 Bed-Pediatric 3 PSR 124 Room & Board – Semi-Private/2 Bed - Psychiatric 2 PSR 125 Room & Board-Semi-Private/ 2 Bed-Hospice 3 PSR 126 Room & Board -Semi-Private/2 Bed -Detox 2 PSR 127 Room & Board-Semi-Private/ 2 Bed-Oncology 3 PSR 128 Room & Board-Semi-Private/ 2 Bed-Rehab 3 PSR 129 Room & Board-Semi-Private/ 2 Bed-Other 3 PSR 130 Room & Board-Semi-Private/3-4 Bed 3 PSR 131 Room & Board-Semi-Private/3-4 Bed- Med/Surg/Gyn 3 PSR 132 Room & Board-Semi-Private/3-4 Bed-OB 3 PSR 133 Room & Board-Semi-Private/3-4 Bed-Pediatric 3 PSR 134 Room & Board -Semi-Private/3-4 Bed - Psychiatric 2 PSR 135 Room & Board-Semi-Private/3-4 Bed-Hospice 3 PSR 136 Room & Board -Semi-Private/3-4 Bed- Detox 2 PSR 137 Room & Board-Semi-Private/3-4 Bed-Oncology 3 PSR 138 Room & Board-Semi-Private/3-4 Bed-Rehab 3 PSR 139 Room & Board-Semi-Private/3-4 Bed-Other 3 PSR 140 Room & Board-Private-Deluxe 3 PSR 141 Room & Board-Private-Deluxe- Med/Surg/Gyn 3 PSR 142 Room & Board-Private - Deluxe-OB 3 PSR 143 Room & Board-Private - Deluxe-Pediatric 3 PSR 144 Room & Board -Private -Deluxe - Psychiatric 2 PSR 145 Room & Board-Private - Deluxe-Hospice 3 PSR 146 Room & Board – Private – Deluxe – Detox 2 PSR 147 Room & Board-Private - Deluxe-Oncology 3 PSR 148 Room & Board-Private - Deluxe-Rehab 3 PSR 149 Room & Board-Private - Deluxe-Other 3 PSR 150 Room & Board – Ward 3 PSR 151 Room & Board – Ward - Med/Surg/ Gyn 3 PSR 152 Room & Board – Ward – OB 3 PSR 153 Room & Board – Ward – Pediatric 3 PSR 154 Room & Board - Ward - Psychiatric 2 PSR 155 Room & Board – Ward – Hospice 3 PSR 156 Room & Board - Ward - Detox 2 PSR 157 Room & Board – Ward – Oncology 3 PSR 158 Room & Board – Ward – Rehab 3 PSR 159 Room & Board – Ward - Other 3 PSR 160 Other Room & Board 3 PSR 164 Other Room & Board – Sterile Environment 3 PSR 167 Other Room & Board – Self Care 3 PSR 169 Other Room & Board - Other 3 PSR 170 Room & Board- Nursery 3 PSR 171 Room & Board- Nursery – Newborn 3 PSR 172 Room & Board- Nursery – Premature 3 PSR 175 Room & Board- Nursery – Neonatal ICU 3 PSR 179 Room & Board- Nursery - Other 3 PSR 190 Subacute Care 3 PSR 200 Intensive Care 3 PSR 201 Intensive Care – Surgical 3 PSR 202 Intensive Care – Medical 3 PSR 203 Intensive Care – Pediatric 3 PSR 204 Intensive Care – Psychiatric 2 PSR 205 Intensive Care – Post ICU 3 PSR 207 Intensive Care – Burn Treatment 3 PSR 208 Intensive Care – Trauma 3 PSR 209 Intensive Care – Other 3 PSR 210 Coronary Care 3 PSR 211 Coronary Care – Myocardial Infarction 3 PSR 212 Coronary Care – Pulmonary 3 PSR 213 Coronary Care – Heart Transplant 3 PSR 214 Coronary Care – Post CCU 3 PSR 219 Coronary Care – Other 3 PSR 224 Late discharge/Medically necessary 4 N/A Note: MCOs cover alcohol detoxification on a medical floor. Code General Hospital Emergency Department Coverage BHP Fee 450 Emergency Room General Classification 1 N/A 451 EMTALA Emergency Medical Screening Services 1 N/A 452 Emergency Room Beyond EMTALA Screening 1 N/A 456 Urgent Care 1 N/A 459 Other Emergency Room 1 N/A 762 Observation room 3 PSR 981 Professional Fee – Emergency Department 1 N/A Code General Hospital Outpatient Coverage BHP Fee 490 Ambulatory Surgery 1 N/A 762 Observation room 3 PSR 900 Psychiatric Services General (Evaluation) 2 $106.54 901 Electroconvulsive Therapy** 2 $104.41 905 Intensive Outpatient Services – Psychiatric 2 PSR 906 Intensive Outpatient Services – Chemical Dependency 2 PSR 907 Community Behavioral Health Program (Day Treatment) 2 PSR 913 Partial Hospital 2 PSR 914 Individual Therapy 2 $65.52 915 Group Therapy 2 $34.43 916 Family Therapy 2 $78.53 918 Psychiatric Service – Testing 3 $63.96 919 Other - Med Admin 2 $49.06 961 Professional Fees-Psychiatric 4 N/A All others   1 N/A Code General Hospital Outpatient - Enhanced Care Clinic (ECC) Coverage BHP Fee 490 Ambulatory Surgery 1 N/A 762 Observation room 3 PSR 900 Psychiatric Services General (Evaluation) 2 $141.00 901 Electroconvulsive Therapy** 2 $104.41 905 Intensive Outpatient Services – Psychiatric 2 PSR 906 Intensive Outpatient Services – Chemical Dependency 2 PSR 907 Community Behavioral Health Program (Day Treatment) 2 PSR 913 Partial Hospital 2 PSR 914 Individual Therapy 2 $82.03 915 Group Therapy 2 $34.43 916 Family Therapy 2 $98.17 918 Psychiatric Service – Testing 3 $63.96 919 Other - Med Admin 2 $52.76 961 Professional Fees-Psychiatric 4 N/A All others   1 N/A Code Psychiatric Hospital Inpatient (includes state operated hospitals) Coverage BHP Fee 100 All inclusive room and board plus ancillary 4 N/A 124 Room and Board-Psychiatric 2 PSR 126 Room & Board -Semi-Private/2 Bed -Detox 2 PSR 128 Room & Board-Semi-Private/ 2 Bed-Rehab 4 N/A 190 Subacute Care 2 PSR 224 Late discharge/Medically necessary 4 N/A Code Psychiatric Hospital Outpatient Coverage BHP Fee 490 Ambulatory Surgery 1 N/A 762 Observation room 2 PSR 900 Psychiatric Services General (Evaluation) 2 $106.54 901 Electroconvulsive Therapy 2 $104.41 905 Intensive Outpatient Services - Psychiatric 2 PSR 906 Intensive Outpatient Services - Chemical Dependency 2 PSR 907 Community Behavioral Health Program (Day Treatment) 2 PSR 913 Partial Hospital-More Intensive 2 PSR 914 Psychiatric Service-Individual Therapy 2 $65.52 915 Psychiatric Service-Group Therapy 2 $34.43 916 Psychiatric Service-Family Therapy 2 $78.53 918 Psychiatric Service-Testing 2 $63.96 919 Other - Med Admin 2 $49.06 Code Alcohol and Drug Abuse Center (Non-hospital Inpatient Detox) Coverage BHP Fee H0011 Acute Detoxification (residential program inpatient) 2 PSR Code Alcohol and Drug Abuse Center (Ambulatory Detoxification) Coverage BHP Fee H0014 Ambulatory Detoxification 2 $26.50 Code PRTF Coverage BHP Fee T2048 Psychiatric health facility service, per diem 2 PSR Code DCF Residential Coverage BHP Fee N/A DCF Funded residential facility 2 PSR Code Long Term Care Facility Coverage BHP Fee 100 Per diem rate 1 N/A 183 Home reserve 1 N/A 185 Inpatient hospital reserve 1 N/A 189 Non-covered reserve 4 N/A Note: Includes inpatient at special care hospitals. Code MH Clinic Coverage BHP Fee 90801 Psychiatric Diagnostic Interview 2 $106.54 90802 Interactive Psychiatric Diagnostic Interview 2 $112.75 90804 Individual Psychotherapy- Office or other Outpatient (20-30 min) 2 $45.25 90805 Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $50.48 90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $65.52 90807 Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $73.91 90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $96.90 90809 Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $101.78 90810 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) 2 $50.61 90811 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $54.92 90812 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $82.91 90813 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $76.36 90814 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $101.99 90815 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $106.57 90846 Family Psychotherapy (without the patient present) 2 $63.78 90847 Family Psychotherapy(conjoint psychotherapy) (with the patient present) 2 $78.53 90849 Multi-group family psychotherapy 2 $30.79 90853 Group psychotherapy 2 $30.91 90857 Interactive group psychotherapy 2 $33.79 90862 Pharmacologic management 2 $44.82 90887 Interpretation or explanation of results of psychiatric or other medical examinations and procedures or other accumulated data to family or other responsible persons. 2 $52.45 96101 Psychological testing, per hour 2 $71.06 96110 Developmental testing and report, limited 2 $11.95 96111 Developmental testing and report, extended 2 $131.82 96118 Neuropsychological testing battery, per hour 2 $115.79 H0015 Intensive Outpatient-Substance Dependence* 2 PSR H0035 Mental health partial hospitalization, treatment, less than 24 hours (CMHC)* 2 PSR H0037 Community psychiatric supportive treatment program, per diem 4 N/A H2012 Extended Day Treatment 2**** PSR H2013 Partial Hospitalization (non-CMHC)* 2* PSR H2019 Therapeutic Behavioral Services, per 15 minutes (IICAPS, MST, MDFT, FFT, FST, HVS) (Clients under 21 only) 2*** $18.62 J1630 Injection, Haloperidol, up to 5 mg 2 $2.12 J1631 Injection, Haloperidol decanoate, per 50 mg 2 $5.25 J2680 Injection, Fluphenazine decanoate, up to 25 mg 2 $1.49 M0064 Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders 2 $23.91 S9475 Ambulatory setting, substance abuse treatment or detoxification services 4 N/A S9480 Intensive Outpatient-Mental Health 2 PSR S9484 Emergency mobile mental health service, follow-up (Clients under 21 only) 2*** $68.80 S9485 Emergency mobile mental health service, initial evaluation (Clients under 21 only) 2*** $121.73 T1016 Case Management - Coordination of health care services - each 15 min. 2 $15.00 T1017 Case management - home/community, each 15 minutes (part of home-based services only - IICAPS, MST, MDFT, FFT, FST, HVS) (Clients under 21 only) 2 $18.62 *Coverage restricted to providers approved by DSS to provide this service *** Coverage restricted to providers certified by DCF to provide this service ****Coverage restricted to providers licensed by DCF to provide this service Code MH Clinic- Enhanced Care Clinic (ECC) Coverage BHP Fee 90801 Psychiatric Diagnostic Interview 2 $141.00 90802 Interactive Psychiatric Diagnostic Interview 2 $140.94 90804 Individual Psychotherapy- Office or other Outpatient (20-30 min) 2 $56.56 90805 Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $65.12 90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $81.90 90807 Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $94.44 90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $121.13 90809 Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $127.23 90810 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) 2 $63.27 90811 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $68.65 90812 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $102.61 90813 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $95.46 90814 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $127.49 90815 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $133.21 90846 Family Psychotherapy (without the patient present) 2 $79.72 90847 Family Psychotherapy(conjoint psychotherapy) (with the patient present) 2 $98.17 90849 Multi-group family psychotherapy 2 $35.86 90853 Group psychotherapy 2 $34.64 90857 Interactive group psychotherapy 2 $37.98 90862 Pharmacologic management 2 $56.03 90887 Interpretation or explanation of results of psychiatric or other medical examinations and procedures or other accumulated data to family or other responsible persons. 2 $75.25 96101 Psychological testing, per hour 2 $71.06 96110 Developmental testing and report, limited 2 $11.95 96111 Developmental testing and report, extended 2 $131.82 96118 Neuropsychological testing battery, per hour 2 $115.79 99241 Office consult, new/established patient, approx 15 min 2 $50.69 99242 Office consult, new/established patient, approx 30 min 2 $92.71 99243 Office consult, new/established patient, approx 40 min 2 $126.80 99244 Office consult, new/established patient, approx 60 min 2 $184.76 99245 Office consult, new/established patient, approx 80 min 2 $229.59 H0015 Intensive Outpatient-Substance Dependence* 2 PSR H0035 Mental health partial hospitalization, treatment, less than 24 hours (CMHC)* 2 PSR H0037 Community psychiatric supportive treatment program, per diem 4 N/A H2012 Extended Day Treatment 2**** PSR H2013 Partial Hospitalization (non-CMHC)* 2* PSR H2019 Therapeutic Behavioral Services, per 15 minutes (IICAPS, MST, MDFT, FFT, FST, HVS) (Clients under 21 only) 2*** $18.62 J1630 Injection, Haloperidol, up to 5 mg 2 $2.12 J1631 Injection, Haloperidol decanoate, per 50 mg 2 $5.25 J2680 Injection, Fluphenazine decanoate, up to 25 mg 2 $1.49 M0064 Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders 2 $29.89 S9475 Ambulatory setting, substance abuse treatment or detoxification services 4 N/A S9480 Intensive Outpatient-Mental Health 2 PSR S9484 Emergency mobile mental health service, follow-up (Clients under 21 only) 2*** $68.80 S9485 Emergency mobile mental health service, initial evaluation (Clients under 21 only) 2*** $121.73 T1016 Case Management - Coordination of health care services - each 15 min. 2 $15.00 T1017 Case management - home/community, each 15 minutes (part of home-based services only - IICAPS, MST, MDFT, FFT, FST, HVS) (Clients under 21 only) 2 $18.62 *Coverage restricted to providers approved by DSS to provide this service *** Coverage restricted to providers certified by DCF to provide this service ****Coverage restricted to providers licensed by DCF to provide this service Code FQHC Mental Health Clinic Coverage BHP Fee 90801 Psychiatric Diagnostic Interview 2 $- 90802 Interactive Psychiatric Diagnostic Interview 2 $- 90804 Individual Psychotherapy- Office or other Outpatient (20-30 min) 2 $- 90805 Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $- 90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $- 90807 Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $- 90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $- 90809 Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $- 90810 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) 2 $- 90811 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $- 90812 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $- 90813 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $- 90814 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $- 90815 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $- 90846 Family Psychotherapy (without the patient present) 2 $- 90847 Family Psychotherapy(conjoint psychotherapy) (with the patient present) 2 $- 90849 Multi-group family psychotherapy 2 $- 90853 Group psychotherapy 2 $- 90857 Interactive group psychotherapy 2 $- 90862 Pharmacologic management 2 $- 90887 Interpretation or explanation of results of psychiatric or other medical examinations and procedures or other accumulated data to family or other responsible persons. 2 $- 96101 Psychological testing, per hour 2 $- 96110 Developmental testing and report, limited 2 $- 96111 Developmental testing and report, extended 2 $- 96118 Neuropsychological testing battery, per hour 2 $- H0015 Intensive Outpatient-Substance Dependence* 2 PSR H0020 Methadone service; rate includes all services for which the source of service is the methadone maintenance clinic. 2 $- H0037 Community psychiatric supportive treatment program, per diem 4 N/A H2012 Extended Day Treatment 2**** PSR H2013 Partial Hospitalization (non-CMHC)* 2* PSR J1630 Injection, Haloperidol, up to 5 mg 2 $- J1631 Injection, Haloperidol decanoate, per 50 mg 2 $- J2680 Injection, Fluphenazine decanoate, up to 25 mg 2 $- M0064 Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders 2 $- S9475 Ambulatory setting, substance abuse treatment or detoxification services 4 N/A S9480 Intensive Outpatient-Mental Health 2 PSR S9484 Emergency mobile mental health service, follow-up (Clients under 21 only) 2*** $- S9485 Emergency mobile mental health service, initial evaluation (Clients under 21 only) 2*** $- T1015 Clinic visit/encounter all-inclusive (For use by FQHC MH Clinics) 2 PSR *Coverage restricted to providers approved by DSS to provide this service *** Coverage restricted to providers certified by DCF to provide this service ****Coverage restricted to providers licensed by DCF to provide this service Code Rehabilitation Clinic Coverage BHP Fee 90801 Psychiatric Diagnostic Interview 3 $106.54 90804 Individual Psychotherapy- Office or other Outpatient (20-30 min) 3 $45.25 90805 Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 3 $50.48 90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 3 $65.52 90807 Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 3 $73.91 90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 3 $96.90 90809 Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 3 $101.78 90846 Family psychotherapy (without the patient present) 3 $63.78 90847 Family psychotherapy (conjoint) 3 $78.53 90853 Group psychotherapy 3 $30.91 90857 Interactive Group therapy 3 $33.79 96118 Neuropsychological testing battery, per hour 3 $115.79 All others   1 N/A Code Freestanding Medical Clinic (including non-FQHC School-Based Health Centers) Coverage BHP Fee 90782 Therapeutic or diagnostic injection; subcutaneous or intramuscular 1 N/A 90783 Therapeutic or diagnostic injection; intra-arterial 1 N/A 90784 Therapeutic or diagnostic injection; intravenous 1 N/A 90801 Psychiatric Diagnostic Interview 3 $95.88 90804 Individual psychotherapy (20-30 min) 3 $40.72 90805 Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $45.43 90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $58.97 90807 Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $66.52 90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $87.21 90846 Family psychotherapy (without the patient present) 3 $57.40 90847 Family psychotherapy (conjoint psychotherapy w/patient present) 3 $70.68 90853 Group psychotherapy (other than of a multiple-family group) 3 $27.82 90862 Pharmacologic management 2 $40.34 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. (Typically 5 minutes) 1 N/A 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: problem focused history; problem focused examination; straightforward medical decision-making. (Typically 10 minutes face-to-face) 1 N/A 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: expanded problem focused history; expanded problem focused examination; medical decision making of low complexity. (Typically 15 minutes face-to-face) 1 N/A 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: detailed history; detailed examination; medical decision making of moderate complexity (Typically 25 minutes face-to-face) 1 N/A 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: comprehensive history; comprehensive examination; medical decision making of high complexity (Typically 40 minutes face-to-face) 1 N/A