Provider Notice issued 10/18/2024

This notice provides an update to the August 9, 2024, provider notice prompted by Public Act 103-0102 announcing coverage for behavioral health services provided by sub-clinical behavioral health professionals. A sub-clinical behavioral health professional is defined as an individual possessing a master’s or doctoral degree in counseling and guidance, rehabilitation counseling, social work, psychology, pastoral counseling, marriage and family therapy, or related field. The services will be covered under both the Medicaid fee-for-service (FFS) program and the HealthChoice Illinois (HCI) managed care organizations (MCOs).

• The previous provider notice specified the sub-clinical behavioral health professional be under the “direct” supervision of a psychiatrist, nurse practitioner with a psychiatric specialty, licensed clinical social worker (LCSW), licensed clinical psychologist (LCP), licensed clinical professional counselor (LCPC), or licensed marriage and family therapist (LMFT). The Department of Healthcare and Family Services (HFS) has reassessed that requirement and will only require general supervision of the sub-clinical behavioral health professional. Licensed, clinical behavioral health professionals such as LCSWs, LCPs, LCPCs,  and LMFTs are eligible supervisors under "other practitioners" as provided for in the definition of "General Supervision" at 42 CFR 410.26.

     · Rural health clinics were inadvertently omitted from the previous provider notice. RHCs as well as FQHCs that deliver behavioral health services may be reimbursed for services delivered by a sub-clinical behavioral health professional operating under the general supervision of a psychiatrist, nurse practitioner with a psychiatric specialty, LCP, LCSW, LCPC, or LMFT.

      · For billing clarification, claims for services delivered by a sub-clinical behavioral health professional, regardless of the supervising clinician, are to be submitted as behavioral health encounters. Procedure code T1040 identifying a behavioral health encounter must be used along with one of the following modifiers corresponding to the licensure of the supervising clinician. No modifier is needed to denote a supervising physician or nurse practitioner with a psychiatric specialty.

·         Modifier AJ = LCSW
·         Modifier AH = LCP
·         Modifier HO = LCPC or LMFT

Reimbursement for services delivered by sub-clinical behavioral health professionals will be at the clinic’s existing behavioral health encounter rate.

As stated in the previous provider notice, claims may now be submitted for the services of these sub-clinical behavioral health professionals. HFS will provide systematic timely filing overrides for claims dating back to January 1, 2024, for 180 days from the date of this correction notice.

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565, or the applicable HCI MCO.

Kelly Cunningham, Administrator
Division of Medical Programs