NYS Harm Reduction Services: Medicaid Managed Care Billing Q&A

Updated January 2022

  • Guidance is also available in Portable Document Format (PDF)
1. Are there specific modifiers that should be billed in conjunction with the procedure codes and rates provided?

Modifiers are not applicable to Harm Reduction Services (HRS) billing.

2. Are the rates circulated the Medicaid fee–for–service rates that plans must pay during the first two years of the program?

Yes, see attached table of billing codes. Health Plans will utilize FFS rate codes in conjunction with procedure codes to further define service delivery.

3. What differentiation can be used to distinguish a provider's reimbursement as following the Upstate/Downstate Rates?

The same rate codes are utilized in upstate and downstate regions, service providers in the five boroughs of NYC, Westchester, Nassau and Suffolk counties will be identified as downstate providers by the Syringe Exchange Program's billing provider zip code location.

4. Please advise on the difference in rates circulated in January 2018 versus in April 2018?

The January 2018 document referenced in the question was modified in April 2018 to reflect a required conversion to 15–minute billing units for group level activities.

5. Guidance materials indicate the syringe exchange is not a Medicaid reimbursable service. No rates have been provided, so the service will automatically be denied as non–contracted.

There is a federal prohibition of syringe exchange billing in Medicaid. Syringe Exchange Program (SEP) providers are aware of this.

6. Will the Syringe Exchange Providers (SEPs) be billing on standard claim forms and adhere to standard billing submission requirements, etc.?

Yes, HRS providers will bill using the standard institutional claim.

7. Are these codes under APG?

No. Harm reduction rates are 15–minute FFS billing rate codes established in federal State Plan Amendment (SPA) approval.

8. Should provider bill with a rate code?

Providers bill health plans utilizing the five–digit procedure codes and four–digit rate codes on the attached billing table.

9. Should the claim to be submitted on UB–04 or HCFA 1500?

An electronic 837I claim or a UB–04 is used for HRS claim submissions for managed care plans.

10. CPT procedure codes identified for Harm Reduction Services are currently included on our Medicaid fee schedule and are defined as Health and Behavioral Health Intervention, Are the codes defined as something different for HRS since this is a medical service?

Yes. The combination of procedure codes and FFS rate codes will result in billing for a Harm Reduction Services.

11. What are the allowable settings in which harm reduction services can be provided?

Harm Reduction Services are only provided at NYS DOH authorized and waived Syringe Exchange Programs (SEP) who are Medicaid providers. Health Plans were provided a list of SEPs in October 2017, half of which have established Medicaid Provider IDs. Plans will be notified as additional SEPs establish Medicaid provider IDs. As of July 2018, plans are required to offer contract to each SEP enrolled as a Medicaid provider in the plans service area.

12. Are all harm reduction provider SEPs designated to provide the full range of harm reduction services to enrollees?

Yes. SEPs have the option to provide the full range of approved Medicaid services. We anticipate SEPs will start with a limited menu of services based upon their current grant funded expertise and ramp up over time to provide the more comprehensive list of services.

13. What are the designated rate and revenue codes for HRS?

Rate codes are found on the attached table of managed care billing guidance. SDOH does not restrict the use of revenue codes and allow for the use of any valid revenue code.

14. Please advise on the difference in the Medicaid Managed Care Billing Q&A circulated in May 2018 versus January 2022.

The Medicaid Managed Care Billing Q&A circulated May 2018 was updated to reflect changes to the procedure codes. The billing guidance below details the correct procedure codes.

NYS Medicaid Harm Reduction Services: Managed Care Billing Guidance

Harm Reduction Service Description Units FFS Rate Code MEDS Category of Service Procedure Codes Provider Specialty Code Upstate
Rate per
15 minutes		 Downstate
Rate per 15
minutes
Plan of care development, initial assessment 1 unit per 15 minutes per recipient 3146 0265 96156 283– Counselor $15.99 $22.47
Plan of care development, reassessment 1 unit per 15 minutes per recipient 3146 0265 96156 283– Counselor $15.99 $22.47
Individual supportive counseling 1 unit per 15 minutes per recipient 3146 0265 96158*
+96159*		 283– Counselor $15.99 $22.47
Medication management and treatment adherence counseling 1 unit per 15 minutes per recipient 3146 0265 H0034 283– Counselor $15.99 $22.47
Group supportive counseling 1 unit per 15 minutes per recipient 3147 0265 96164*
+96165*		 283– Counselor $2.52 $3.02
Psychoeducation – support groups 1 unit per 15 minutes per recipient 3147 0265 H2027 283– Counselor $2.52 $3.02
  • The Downstate rate applies to SEP providers in the 5 boroughs of NYC, Westchester, Nassau, and Suffolk counties.
  • SEPs participating with a managed care plan must bill the plan using FFS rate codes and managed care procedure codes listed above. Procedure Codes changed as of January 1, 2020. The asterisk (*) indicates those procedure codes that are used for the initial 30 min. and those used for each additional 15 min. for the primary service.
  • Harm reduction services are a medical benefit to be billed on an institutional claim form. Claims may be submitted on either a UB–04 (paper claim, also known as CMS– 1450) or electronic form 837I (Institutional).
  • Provider Network Data System (PNDS) provider type: Counselor codes: Certified social worker (CSW)–MSW degree–04; counselor–non licensed– Bachelors degree–15, or Other –11
  • Modifiers are not required for FFS or Managed Care billing.
  • Diagnosis Code: SEP providers have discretion over the diagnosis code used on claims. NYSDOH suggests the use of R69: Illness, Unspecified.
  • Medicaid FFS questions may be directed to the eMedNY Call Center at 800–343–9000. Inquires on FFS claim eligibility can also be directed to the eMedNY Call Center.

Prepared by NYSDOH AIDS Institute January 2022