Billing Procedures

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
2Claimant’s Name
3Claimant’s Date of Birth
5Claimant’s Address/Phone Number
11Claimant’s Insurance Policy Information
11AInsured’s Date of Birth (if different than the claimant)
11BClaimant’s Employer or School, if known
11CInsurance Plan Name or Program Name
11DAdditional Health Plans
17Treating Mental Health Provider and Licensure
19Supervising Mental Health Provider Licensure, if applicable
21 & 24EICD-10 Diagnosis Codes from Current Diagnostic Statistical Manual
24ADates of Services (List a minimum of four dates of service per form)
24BIdentify 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.”
24DProcedure Codes
CPT codes authorized by CalVCB (link needed)
24FCustomary rate for the service provided
24GUnits (please use hourly increments) for 1/2 hours please use .5 and
for 60 minutes use 1 (**)
24JIntern’s Registration Number, if applicable; treating therapist’s name and
clinical license number
25Tax ID/SSN/FEIN Number of payee as registered with the IRS
28Total Charges/Billed Amount
29Amount paid by claimant, or another reimbursement source
30Balance due
31Printed name of Treating/Supervising Therapist, License Number,
and Signature (Signature Stamps acceptable)
32Name & address where services rendered (if different than box 33)
33Provider/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 SessionLess than 45 minutes
1 Session45-75 minutes
1 1/2 Session75-104 minutes
2 Sessions105-120 minutes
1/2 Session60 minutes
1 Session120 minutes
1 1/2 Session180 minutes
2 Sessions240 minutes

Submit Completed Forms

P.O. Box 3036
Sacramento, CA 95812-3036

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