Behavioral Health Services Rendered by Supervised Practitioners

Reimbursement Policy:

Behavioral Health Services rendered by Supervised Practitioners

Effective Date:

January 1, 2023

Purpose:

To expand access to behavioral health services and provide guidance for the reimbursement of behavioral health services rendered by New Jersey provisionally licensed social workers (LSW) and licensed associate counselors (LAC) therapists that must be supervised. This policy applies to in-network professional providers.

Scope:

All Commercial products that are fully insured and ASO are included and the following shall be excluded:

Products where Horizon is secondary to Medicare (e.g. Medigap)
COB
Medicare Advantage
Braven Health

Definitions:

Provisionally licensed practitioner: A provisionally licensed behavioral health practitioner that is practicing under a Plan of Supervised Clinical/Counseling Experience approved by the NJ Board of Social Work Examiners or the Professional Counselor Examiners Committee of the NJ Board of Marriage and Family Therapists

Policy:

Horizon shall expand eligibility for reimbursable services to include certain behavioral health practitioners (LSW and LAC) who are provisionally licensed by the NJ Board of Social Work Examiners or the Professional Counselor Examiners Committee of the NJ Board of Marriage and Family Therapists.

Horizon requires the following for services to be considered eligible for reimbursement:

In network services shall only be considered for payment when the supervising practitioner is credentialed and participating in the plan network for the member being treated.
Out of network services rendered by a provisionally licensed practitioner are out of scope for this reimbursement policy and shall not be considered for reimbursement.
All claims for services delivered by a provisionally licensed practitioner shall be submitted by the supervising practitioner as the rendering service practitioner. No claim shall be submitted by the provisionally licensed practitioner as they are not permitted to practice independently, and they are not credentialed for Horizon's behavioral health network
There must be a Plan of Supervised Clinical/Counseling Experience, approved by the New Jersey Board of Social Work Examiners or the Professional Counselor Examiners Committee of the New Jersey Board of Marriage and Family Therapists in place between the supervising practitioner/rendering service practitioner and the provisionally licensed practitioner.
The host agency, group practice and/or the supervising practitioner must have screening protocols in place to assure that members are screened and assessed and appropriately assigned for treatment with a provisionally licensed practitioner. To assure that the member is receiving proper clinical care, provisionally licensed practitioners should be matched with members based on their individual clinical skill and ability, and the member's care needs.

Any member treated by a provisionally licensed practitioner must:

Be informed of the supervisory relationship,
Be provided with the contact information of the supervising practitioner, and
Provide written consent to treatment with the provisionally licensed practitioner
All of the above must be documented in writing in the patient chart.

Procedure code(s) must be submitted with the modifier “-HO” to identify that the member was treated by another practitioner under supervision of the rendering practitioner.

Services rendered by provisionally licensed practitioners may be subject to audit/review to confirm the validity of the supervisory relationship and the member's informed consent to receive services from provisionally licensed practitioner under this policy. If an audit reveals that services were billed by a practitioner other than the board approved supervisor and/or member consent to be treated by the provisionally licensed practitioner is not documented as noted above, such payments may be retracted by Horizon.

The billing supervisor must comply with all supervisory requirements as outlined in the current licensing and supervision standards of their supervisee's licensing board.

Procedure:

Horizon shall consider for reimbursement behavioral health services rendered by practitioners (LSW and LAC) who are provisionally licensed by the NJ Board of Social Work Examiners and the Professional Counselor Examiners Committee of the NJ Board of Marriage and Family Therapists when these claims are submitted with Modifier HO and performed by a qualified, independently licensed practitioner who is engaged in a NJ Licensure Board-approved Plan of Supervised Clinical/Counseling Experience with the provisionally licensed practitioner.

Eligible services provided by a provisionally licensed LSW/LAC will be considered for reimbursement at the applicable Horizon BCBSNJ fee schedule rates of the participating supervising LCSW/LPC.

Services submitted by supervisors of a higher licensure level (i.e, masters level provisional license supervised by a psychologist) shall be denied.

Services rendered by an out of network provisionally licensed practitioner (LSW, LAC) shall be denied.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

Group or Individual benefit;
Practitioner Participation Agreement;
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity;
Mandated or legislative required criteria will always supersede.

History:

9/26/2022: Policy approved

Policy 155_v1.0_09262022