Medicaid: Payment for Healthy Opportunities Screening and Referral

Medicaid recently released the Temporary Clinical Policy Modifications: Payment for Health Opportunities Screening and Referral. 

Notice Date: Feb. 1, 2021 

Effective Date: Jan. 1, 2021 (retroactive) 

Effective Through Date: June 30, 2021 (Coverage of this code after Medicaid Managed Care launch will be at the discretion of the health plans.)  

Notice applies to: Carolina Access II providers 

Following is a summary.  For more detailed information click on the Temporary Clinical Policy Modifications: Payment for Healthy Opportunities Screening and Referral 

Overview 

This bulletin temporarily enables Carolina Access II providers to receive reimbursement for positive Healthy Opportunities screenings conducted using the North Carolina Department of Health and Human Services (DHHS) standard screening questions or an equivalent instrument with similar questions covering beneficiary needs related to DHHS’s 4 priority domains (food, housing/utilities, transportation and interpersonal safety). For providers who have not already adopted a tool, we strongly encourage the use of the DHHS standard questions.  

• Recipients of screenings are not required to be beneficiaries assigned to the Carolina Access II practice.   
• Upon completing a positive screen, providers should refer enrollees to community-based resources to address the identified needs.   
• While reimbursement will not be contingent upon such referrals, providers are strongly encouraged to refer beneficiaries who screen positive for unmet social needs to appropriate resources.  

Connecting beneficiaries to resources 

Many providers in North Carolina use NCCARE360 to electronically connect those with identified needs with community resources and allow for a feedback loop on the outcome of that connection. Providers are encouraged to use NCCARE360 to support screenings and referrals for patients with unmet health-related resource needs; however, providers are not required to do so to obtain reimbursement for Healthy Opportunities screenings under this temporary policy modification.    

Record keeping and audit 

Providers must keep records of all screenings conducted. DHHS may audit activities conducted under this temporary policy modification at any time.  

Definitions  

• Healthy Opportunities are unmet resource needs related to food, housing, transportation and interpersonal violence that have an impact on a person’s health, safety and well-being, as well as healthcare utilization and costs.  

• Positive Screening means a screening that identifies the individual as having an unmet need in at least one of DHHS’s 4 priority domains (food, housing/utilities, transportation and interpersonal safety).   

Billing Highlights: 

Billing Guidance for Carolina Access II Providers Professional Claims:  

• Providers should bill the following code for new and established patients, when provided by an eligible provider in person or during a telehealth visit (audio and video).  
• Telehealth claims should be filed with the provider’s usual place of service code per the appropriate clinical coverage policy and not place of service (POS) 02 (telehealth).   

• This is not billable for telephonic only or portal communication care.  
• Physicians, nurse practitioners, physician assistants, nurse midwives, or designated staff may bill the code.  
• Additionally, any eligible federally qualified health centers (FQHCs), FQHC lookalikes and rural health centers (RHCs) may bill under fee-for-service reimbursement.  
• Eligible providers bill for and receive reimbursement from positive Healthy Opportunities screens which is indicated by the accompanying z-code.  
• Each eligible provider may bill this code up to once per 30-day period per patient receiving a positive Healthy Opportunities screening.   

• Providers will not need to append modifiers to claims for Healthy Opportunities screenings 

CPT Code: 

ICD-10 Codes: 

Providers are encouraged, but not required, to include Z codes indicating a patient’s identified resource needs when submitting claims for Healthy Opportunities screenings. See table below for Z codes providers should use to indicate patients’ resource needs.  

Copayments  

• For Medicaid, refer to Medicaid State Plan, Attachment 4.18-A, page 1  
• For NC Health Choice, refer to G.S. 108A-70.21(d), located at http://www.ncleg.net/EnactedLegislation/Statutes/HTML/BySection/Chapter_108A/GS_108A-70.21.html.  

Reimbursement  

NC Medicaid and Health Choice shall reimburse eligible providers in accordance with the published fee schedule for each positive Healthy Opportunities screening billed to code G9919.   

Additional Resources  

NC Healthy Opportunities Overview at https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities

NC Medicaid Contact Center, 888-245-0179