CalVCB is the payor of last resort and can only pay for treatment not covered by any other reimbursement source, including health insurance, civil suits, vehicle insurance, business insurance, home insurance, state disability insurance, and Worker’s Compensation.
The provider must bill the applicant’s insurance prior to submitting expenses to CalVCB. If an expense is not covered, or is only partially covered, a provider should submit a bill with a copy of the explanation of benefits (EOB). Failure to do so will result in delays in payment or rejection of the bill. (CCR 649.31). 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.
Examples
1: Provider is an LCSW with a customary rate of $150 per hour. The provider is contracted with the insurance carrier of the claimant. Provider provides one hour of treatment and receives their contracted rate of $60 from insurance. The claimant has a $20 responsibility for the co-pay. CalVCB will pay the $20 copay to either the provider or claimant.
2: Provider is an LCSW with a customary rate of $150 per hour. The provider is not contracted with the insurance carrier of the claimant. Provider provides one hour of treatment and bills the insurance and is denied because they are not an in-network provider. The claimant is responsible for the bill. CalVCB will pay $105 to either the provider or claimant.
CalVCB cannot pay for:
- Treatment that is unrelated to the crime
- missed appointments
- interest or similar administrative charges
- expenses incurred while accompanying the claimant to court hearings
- travel time and expenses
- treatment related to child custody issues
CalVCB can only pay for the percentage of treatment that is necessary as a direct result of the qualifying crime for which the application was approved. CalVCB will contact providers if crime-relatedness needs to be verified.
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 a service provider determines the treatment is not 100% related to the qualifying crime:
- The provider must inform CalVCB.
- The provider must inform the claimant of the percentage of treatment related to the qualifying crime.
CalVCB payments will reflect the percentage that is indicated by a provider as related to the crime.
CalVCB has the authority to collect or offset overpayments for any treatment that is not directly related to the qualifying crime.
For treatment prior to January 1, 2023, only mental health providers licensed in California are eligible to provide services to CalVCB claimants pursuant to Cal. Code of Regs., tit. 2, § 649.29. Out-of-state mental health providers must submit a copy of their California license.
For treatment that began on or after January 1, 2023, Senate Bill 877 authorizes CalVCB to reimburse the costs of mental health counseling services performed by providers who are licensed in the state where the victim is residing or supervised by a person licensed in that state.
| CPT CODE | DESCRIPTION | DURATION |
| 90791 | Intake – Psychiatric diagnostic interview examination | 1 to 2 units/hours |
| 90792 | Intake – Psychiatric diagnostic interview examination with med management | 1 to 2 units/hours |
| 90832 | Individual psychotherapy | 30 minutes (.5 unit/hour) |
| 90834 | Individual psychotherapy | 45 minutes (1 unit/hour) |
| 90837 | Individual psychotherapy | 60 minutes (1 unit/hour) or longer based on units billed |
| 90846 | Family psychotherapy, without the patient present | 1 to 2 units/hours |
| 90847 | Family psychotherapy (including conjoint), with the patient present | 1 to 2 units/hours |
| 90853 | Group psychotherapy | 1 to 2 units/hours |
| 90863 | Pharmacological Management – for pharmacological management with counseling this code must be used in conjunction with 90832 or 90837 (whichever is appropriate) as a separate line item on the CMS 1500 form | 30 minutes (.5 unit/hour) to 1 unit/hour |
| 90875, 90876, 90901, 90911 | Biofeedback Therapy – Provided by a licensed mental health clinician or supervised intern | 45 to 60 minutes (1 unit/hour) |
| 90880 | Hypnotherapy – Provided by a licensed mental health clinician or supervised intern | 45 to 60 minutes (1 unit/hour) |
| 97110, 97112, 97116, 97150, 97530, 97535 | Music Therapy – Provided by a licensed mental health clinician or supervised intern (Additional CPT Codes: 97537, 97139, 97532, 97533, 92507, 97799) | 45 to 60 minutes (1 unit/hour) |
| 90887 | Case Management – limit 5 units/hours per application Does NOT count towards session limits | 45 to 60 minutes (1 unit/hour) |
| 96101, 96102 | Testing, psychological – submission of test results and evaluation of results are required | up to 8 units/hours |
| 96118, 96119, 96120 | Testing, neuropsychological – submission of test results and evaluation of results are required | up to 8 units/hours |
| 98968 | Telehealth, non-psychiatrist – limit 5 units/hours per application | 30 minutes (.5 unit/hour) to 1 unit/hour |
| 99443 | Telehealth, psychiatrist – limit 5 units/hours per application | 30 minutes (.5 unit/hour) to 1 unit/hour |
Unit Calculations (Individual/Family Therapy)
| Unit(s) on CMS 1500 | Applied to Session Count | Time |
| .5 | 1/2 Session | Up to 44 min. |
| 1 | 1 Session | 45-74 min. |
| 1.5 | 1 1/2 Sessions | 75-104 min. |
| 2 | 2 Sessions | 105-120 mins. |
Unit Calculations (Individual/Family Therapy)
| Unit(s) on CMS 1500 | Applied to Session Count | Time |
| 1 | 1/2 Session | 60 min. |
| 2 | 1 Session | 120 min. |
| 3 | 1 1/2 Sessions | 180 min. |
| 4 | 2 Sessions | 240 min. |