Reimbursement

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. Failure to do so will result in delays in payment or rejection of the bill. (CCR 649.31)

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 $81 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.

CalVCB will allow the provider to submit the first three mental health sessions without requiring a treatment plan to be on file. If the claimant already saw another provider for this qualifying crime, the claimant may have already used the initial three sessions.

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.

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.

CPT CODEDESCRIPTIONDURATION
90791Intake – Psychiatric diagnostic interview examination1 to 2 units/hours
90792Intake – Psychiatric diagnostic interview examination
with med management
1 to 2 units/hours
90832Individual psychotherapy30 minutes
(.5 unit/hour)
90834Individual psychotherapy45 minutes
(1 unit/hour)
90837Individual psychotherapy60 minutes
(1 unit/hour) or
longer based on
units billed
90846Family psychotherapy, without the patient present1 to 2 units/hours
90847Family psychotherapy (including conjoint), with the patient present1 to 2 units/hours
90853Group psychotherapy1 to 2 units/hours
90863Pharmacological 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)
90880Hypnotherapy – 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)
90887Case Management – limit 5 units/hours per application
Does NOT count towards session limits
45 to 60 minutes
(1 unit/hour)
96101, 96102Testing, psychologicalsubmission of test results and evaluation
of results are required
up to
8 units/hours
96118, 96119,
96120
Testing, neuropsychologicalsubmission of test results and evaluation
of results are required
up to
8 units/hours
98968Telehealth, non-psychiatrist – limit 5 units/hours per application30 minutes
(.5 unit/hour)
to 1 unit/hour
99443Telehealth, psychiatrist – limit 5 units/hours per application30 minutes
(.5 unit/hour)
to 1 unit/hour

Unit Calculations (Individual/Family Therapy)

Unit(s) on
CMS 1500
Applied to Session CountTime
.51/2 SessionUp to 44 min.
11 Session45-74 min.
1.51 1/2 Sessions75-104 min.
22 Sessions105-120 mins.
Revised 1-27-2017

Unit Calculations (Individual/Family Therapy)

Unit(s) on
CMS 1500
Applied to Session CountTime
11/2 Session60 min.
21 Session120 min.
31 1/2 Sessions180 min.
42 Sessions240 min.
Revised 1-27-2017


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