Important notification: New APG rate codes for SBMH Services in MHOTRS Programs

On November 17, 2023, the state of New York received the needed approval and notified plans of a 25 percent increase to Ambulatory Patient Group (APG) peer group base rates for School-Based Mental Health (SBMH) Services in Mental Health Outpatient Treatment and Rehabilitative Services (MHOTRS) Programs.  The enhanced rates for SBMH Services in MHOTRS Programs were effective July 1, 2023.

To receive the enhanced rate, services should have been rendered and/or facilitated through the school-based program, and services must be billed using new rate codes 1030 (non-hospital) and 1033 (hospital). Anthem will accept claims with these new rate codes for dates of service July 1, 2023, starting February 17, 2024.

Providers seeking to submit claims outside the 90-day timely filing window must do so by
May 31, 2024. In addition, claims previously billed to the plan for services should be submitted as corrected claims with the new rate codes 1030 (non-hospital) and 1033 (hospital) as applicable.

Helpful links:

• New York State billing guidance: MHOTRS billing guidance
• Rate codes: Clinic rate codes

If you have questions or need more information, contact Health Care Networks team at 866-231-0847.