Billing Procedures and Rates for Mental Health Services
Providers should submit mental health bills on CMS 1500 or 1450 forms and when possible, include at least four dates of service on the form.
Along with the first CMS 1500 form submitted for each claimant, a CalVCB Mental Health Billing Intake Form must be completed in its entirety and signed by the treating provider. Submission of this form is required before payment can be made. If the claimant has insurance, the insurance Explanation of Benefit (EOB) is also required. There are certain exemptions to the EOB submission requirements listed on the Mental Health Billing Form that the applicant will need to certify if the EOB cannot be obtained.
Bills must be submitted within 90 days of each date of service provided. If multiple dates of service are included in one CMS 1500 form, then it must be submitted within 90 days from the first service date on the bill. If bills are not submitted within 90 days of each date of service, reimbursement will be denied.
Providers must complete all required sections. Failure to correctly complete the form may lead to the bill being returned and a delayed payment.
| 1A* & 23* | CalVCB Application Number/Claimant’s ID Number |
| 2 | Claimant’s Name |
| 3 | Claimant’s Date of Birth |
| 5 | Claimant’s Address/Phone Number |
| 11 | Claimant’s Insurance Policy Information |
| 11A | Insured’s Date of Birth (if different than the claimant) |
| 11B | Claimant’s Employer or School, if known |
| 11C | Insurance Plan Name or Program Name |
| 11D | Additional Health Plans |
| 17 | Treating Mental Health Provider and Licensure |
| 19 | Supervising Mental Health Provider Licensure, if applicable |
| 21 & 24E | ICD-10 Diagnosis Codes from Current Diagnostic Statistical Manual |
| 24A | Dates of Services (List a minimum of four dates of service per form) |
| 24B | Identify place of treatment – Office (11 or O) or Home (12 or H) indicate “GT” for Audio and Video Telecommunications as the technology used to facilitate the telehealth session in box 24 D “Modifier.” |
| 24D | Procedure Codes CPT codes authorized by CalVCB (link needed) |
| 24F | Customary rate for the service provided |
| 24G | Units (please use hourly increments) for 1/2 hours please use .5 and for 60 minutes use 1 (**) |
| 24J | Intern’s Registration Number, if applicable; treating therapist’s name and clinical license number |
| 25 | Tax ID/SSN/FEIN Number of payee as registered with the IRS |
| 28 | Total Charges/Billed Amount |
| 29 | Amount paid by claimant, or another reimbursement source |
| 30 | Balance due |
| 31 | Printed name of Treating/Supervising Therapist, License Number, and Signature (Signature Stamps acceptable) |
| 32 | Name & address where services rendered (if different than box 33) |
| 33 | Provider/Payee’s name as registered with IRS, address, & phone number |
Billing Mental Health Sessions
Providers should bill mental health sessions in units (box 24G):
- “1” is equal to one standard hour of mental health treatment.
- “.5” is equal to a half hour of mental health treatment.
| 1/2 Session | Less than 45 minutes |
| 1 Session | 45-75 minutes |
| 1 1/2 Session | 75-104 minutes |
| 2 Sessions | 105-120 minutes |
| 1/2 Session | 60 minutes |
| 1 Session | 120 minutes |
| 1 1/2 Session | 180 minutes |
| 2 Sessions | 240 minutes |
Submit Completed Forms
Mail:
CalVCB
P.O. Box 3036
Sacramento, CA 95812-3036