HOW DO I GET BCBS TO PAY FOR METHADONE GIVEN AT A TREATMENT CENTER??

Hi, I work for a major health insurance company in CA in their behavioral health department. I do not work for BCBS so it may be a little different. We do not generally cover methadone clinics because they are not licensed as outpatient programs and often times the patient doesn't see a therapist or psychiatrist when they are seen at the clinic. Is your husband seeing a licensed clinician such as a LCSW, MFT, PHD, MD... etc. If he is then you may be able to file for reimbursement of the visit its self (I can give you the revenue codes).

Insurance coverage is very confusing and there are sometimes good reasons to not cover certain things. Believe me that I am not defending the insurance company when it comes to not covering things. I am insured by the same company I work for and I myself have experienced the frustration of having things denied that are medically necessary.

The reason methadone clinics are not usually covered is because the patient usually just shows up and gets their medication. They are not generally assessed by a licensed clinician. Allot of times the counselors at a clinic are just that (trained counselors). They have not received extensive education in the field and may actually be psych interns who have not yet completed their education. Methadone can be very dangerous when it is not taken as directed or if the patient doesn't follow the instructions after taking it. It can be important to be under the supervision of a licensed health professional to make sure that there are no serious side effects... etc. That being said if you cannot find a way to get it covered you may be able to find an outpatient chemical dependency program that administers methadone and that could be reimbursed by your insurance or you may be able to find a psychiatrist that is willing to work with your husband on an outpatient basis and would perscribe the methadone.

I really wish you luck on getting some of the cost reimbursed to you. If your husband is seeing a licensed therapist or psychiatrist at the clinic let me know the counselors name and I will look them up in our database to see how they are licensed. Also if you could let me know how long they are seeing your husband during each visit. If it sounds like something that could meet our standards I will send you the revenue codes and you can try to get some of the cost reimbursed. I know how much of a burdon the cost of treatment can be and how beneficial it is to your lives.

Ugh, first of all....Kelly, methadone clinics are licensed by the DEA to distribute medication and clients have access to a prescribing Medical Doctor, pharmacist, or psychiatrist at all times. In North Carolina clinics are licensed by several accredidation agencies. No one just shows up and gets medicine...and that is insulting. Methadone can be dangerous if not taken as prescribed but so is Tylenol and any other medication. All the health professionals employeed by a methadone clinic are licensed and trained specifically on side effects, administration of medication, overdose warnings, lethal combinations, and daily client assessments. By the way, if a psychiatrist or MD prescribes Methadone for opiate dependance outside of an OTP (methadone clinic) they may lose his or her license as this is a violation of DEA policy. I will be glad to supply for you more education if you are interested.

That being said...Gemini, I think I can help you if you would like to post your e-mail. I can contact you and give you more information.

Maybe you missed the part where I said "If your husband is seeing a licensed therapist or psychiatrist at the clinic let me know the counselors name and I will look them up in our database to see how they are licensed. Also if you could let me know how long they are seeing your husband during each visit. If it sounds like something that could meet our standards I will send you the revenue codes and you can try to get some of the cost reimbursed." I didn't say that he wasn't seeing a licensed professional while there. But I happen to know that the reason the particular insurance company I work for doesn't reimburse methadone clinics is because the patient doesn't see a licensed psychiatrist every visit or sees them only briefly. (I am only speaking in generalities as this will vary based on different state and different insurance companies) There are different revenue codes that can be billed based on how long the visit is. For example a revenue code of 90807 is the universal code to bill for outpatient individual psychotherapy with medication management lasting 45-50 minutes. There are different codes depending on how long the visit is and some of those codes are not payable through an insurance company. The clinics are licensed by the DEA but that doesn't mean that they meet the medical necessity criteria for reimbursement from a health insurance company. There are two sets of criteria that we work off of. One is “intensity of service” and the other is “severity of illness”. Intensity of service is a list of criteria that a facility or provider has to meet to be payable through an insurance company. Before an insurance company will look at the intensity of service for the program they will check the licensure and accreditation. If the program is licensed and accredited appropriately we then speak to a clinical director or business manager at the program. I do not have a list of the “intensity of service” for a methadone clinic but I do have it for a psychiatric outpatient program. This is just an example and obviously the intensity of service criteria is different for a methadone clinic. So yes the methadone clinic is licensed by the DEA and may even be accredited by such agencies as JCAHO or CARF but that is not the only requirements for insurance payment.
1. Facility will provide multidisciplinary program of at least 3 treatment hours per day at least three times per week; the frequency may be decreased as clinically indicated.
2. Multidisciplinary assessment with an individualized treatment plan which addresses psychological, social, medical, cognitive, and substance abuse needs.
3. To be seen by a psychiatrist by the third day of attendance.
4. Monitoring of psychotropic medications
5. Family assessment and therapy by a licensed behavioral health provider.
6. Discharge planning is initiated on the day of admission and includes appropriate continuing care plan.

Also... I never said a patient "just shows up and gets medicine". I happen to know several people who work at methadone clinics in CA as "drug counselors". They are not licensed as a therapist or psychiatrist. In fact they are often times psych interns or students who have not completed their clinical hours to get their license as a therapist or social worker. Allot of health insurance companies do not pay psych interns or drug counselors. Yes they are educated and trained in the field but they DO NOT hold the required license and therefore cannot be reimbursed. I am not at all saying that they are not qualified to assess patients or that they are not working directly under a licensed provider. I am simply saying that more often than not an insurance company will not reimburse this type of clinician. I am not saying it is right or that I agree with the way that insurance companies handle the situation. Like I said before. I work for an insurance company who has denied my own claims. I am just giving you my perspective. I do not specialize in substance abuse. I have never worked for a methadone clinic and I do not know the specifics of how things work at these clinics. I was giving some suggestions on how to get the claims paid. Because working for an insurance company (in the behavioral health department) I see claims denied and paid all of the time. I happen to know that a claim can be submitted, denied, and then resubmitted with different coding and paid. There are so many details that are important to figure out whether or not this can be reimbursed. It all depends on whether the methadone is being prescribed for pain management or substance abuse. It also depends on what type of policy you have. Every policy is different and allot of policies do not cover substance abuse treatment. So without knowing the specifics it is hard to know how exactly to get this paid. I never said that I was an expert on methadone clinics.

I apologize if anything that was stated in my previous post was offensive to anyone. Obviously I do not know the specifics of methadone clinics other than the insurance company I work for does not normally reimburse payment for treatment there. I just know that there are ways that you can bill things to at least get some of the money reimbursed to you. Depending on what type of provider is being seen a superbill could possibly be submitted to at least request reimbursement of the office visits as long as they took place with a therapist or psychiatrist. Obviously this will not cover all of the costs but since these visits and medications have been paid for out of pocket it may be nice to at least get part of it reimbursed.

My internet has been down for a few days.
Any information is helpful. My husbands cousin has the paperwork and is going to take a look @ it and she used to work for BCBS and knows someone who still works there, but the more info I have, the better off I am! Thanks for the replies!! :D

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The moderator will not allow private emails to be posted. I treid, so if anyone can give more info, I would appreciate it!!

Kelly, you did say in your post that it is not usually covered bc a person shows up and takes their medicine. Maybe you should re-read what you typed. I am not trying to be confrontational, but you did say that.

Anyway, he is seen by an MD and his counselor has a degree. The CPT code they gave me was 90782 and diagnosis code is 304.0. Is that helpful to anyone, that is interested in helping me?

We have filed the claim, I sent it by mail yesterday. So, I guess I will find out soon enough if they are willing to pay, so I will repost as soon as I get notification.

Thanks for reading my post!!

Hello Jollygemini,

Sorry if I mis-spoke. If you have a PPO plan, you can see In-Network and Out of Network Providers, or clinics that do and don't accept BCBS upfront. Out of Network clinics require you to pay with cash upfront, and then go through the steps I listed in the  above post. If you have an HMO, like me, you are limited to IN-Network clinics. Why is that important? Finding a methadone clinic that accepts BCBS upfront (In-Network) is difficult; or is for me in Baltimore, MD. 

I a hoping so much that you can help me. I go once a month to the Methadone Clinic in Georgia for the last 6 years and Im trying to get BCBS to pay. I see a counsler every time and spend atleast an hour at the clinic between getting my medication and talking to the coulnsler. I hope that you can look her up and help me. Her name is Kim King. I know that she has her masters or that she is in the process of getting her masters. She told me to go to the insurance commisioner to find a way to get my medication covered. She had a former client that worked for BCBS and this client got BCBS to reimburse her. Well the insurance commisoner couldnt help me because husbands employer Interface is self insuranced. Please help me if you can.

Do you have an HMO, or a PPO? Is it CareFirst? Sadly, I'm a pro when it comes to methadone maintenance and BC/BS. If you have an HMO, you must find a methadone clinic that is "In-Network". There aren't many of them. If you have an HMO, and your clinic is "Out of Network", they won't reimburse you a dime. If you have a PPO, then it doesn't matter which clinic you attend. Clearly your clinic is not "In-Network", otherwise they would accept your insurance card and you would just pay a co-pay at the clinic.



To get reimbursed by filing a claim (if like myself, you have a PPO but your clinic is O.O.N.): download the claim-form online. Fill it out. Then you must get an itemized bill from your clinic. You might have to pay for it ($20). It should look like this:

Date:

To:CareFirst BlueChoice, Inc., Attention: Claims Department.

Patient NAme, DOB, Subscriber ID

Provider Info: Name, Tax ID, Address



This document contains itemized billing for Mr. X, who is an active

client of XX Health Services, Inc. paying weekly a fee of $85.00 in cash. The CPT Code is H0020 and Diagnosis Code is 304.00 for billing purposes. This letter is to inform you that the client bill from MARCH 2010 until MAY 2010 has been paid in full amount ($1105.00) to XX Health Services, Inc. If you have any questions regarding Mr. X's billing, please do not hesitate to contact our office.



Below are the dates of services for billing purposes:

Preview of bill:

W/E 03/ 7/10= 0.00+85.00 = 85.00

W/E 03/14 /10= 85.00+85.00 = 170.00

LIST EACH WEEK LIKE THIS, I JUST SKIPPED THE MIDDLE PORTION!

W/E 05/ 2/10= 935.00+85.00 = 1020.00

W/E 05/ 9 /10= 1020.00+85.00 = 1105.00



Thank You,

XXXX XXXXx



I live in Maryland. I'm sorry if the rules are totally different in N.C. I know methadone in New Jersey is 100% FREE. Public funding has huge benefits over private clinics trying to profit off of addicts. Actually, most counties in MD will provide Medicaid coverage for those who can't afford methadone. Did you check with your County MEntal HEalth and Hygiene (or just HEalth Dept.)? I'm not poor, I have BC/BS from work, but paying for my methadone upfront out-of-pocket has me living paycheck to paycheck.



Please feel free to ask me anything you can think of, really. My friend works in billing for a clinic, and she knows the good, the bad, and the ugly. I'd be happy to run a few questions by her. Good Luck!

This is precisely the question I was going to ask. Has anybody had recent experiences with BCBS  and methadone treatment reimbursement? The methadone clinic I've been attending for a little over a year absolutely refuses to itemize. The clinic director subtley tried to discourage me from even attempting to file a claim(s). They charge $91 a week and i would be fantastic to get even half back.

Clinic director daughter attends discourages filing also. I have been battling this for 6 mos. Daughter is intimated to keep asking so I've left a phone call threatening to call BBB or take it higher up. Director discourages claiming doc in clinic dont want their tax ID given to just anyone...which in turn makes me think....its a shady operation. Clinic is not covered under coverage BUT once out of network out of the pocket co-pay has been met I AM entitled to a percent. Complete

OMG!!!! I'm going threw all of this mess myself... I also go to a clinic in NC. Well what seems to be myproblem is this: My bcbs of Iowa covers the methadone clinic. But I cannot for the life of me get the finance lady at the clinic to file the damn claim! ughh I've tried everything. everytime I call her she will tell me I'm getting ready to file it on so and so day...needless to say it never happens! this has been going on for several months now. I will call atleast once a week to her...she has come up with a new excuse now, she said sometimes it takes the insurance company awhile to get on it, but when I call the company they tell me nothing has been filed at all.. this still going on I wish I new how or to go to that would be over her head, cause this women is impossible, she has also made claims to me that "I'm so sorry it has been so busy, I will file it tomorrow fist thing. not to mention in the very beginning, she claimed to have lost my paper work at fist......please help if you have any info on this.

i also live in Baltimore, Md but I have the Federal Employee Program BlueCross  Blueshield coverage. Does that make a difference at all? I know when I lived in tennessee and did rehab that cost 20,000 dollars, they paid for everything other than 500. And there is a clinic right around where I live that I am interested in getting into. So in short would the Federal Employee Program make a difference? I have noticed a few of you have been saying that the substance abuse part of BCBS is hard to get reimbursed or paid for at all but that hasnt been the case for me at all. Any informationj would be greatly appreciated. I am so sick and tired of the dope habit and spending the money every day to just get well. But it seems it is easier to come up with 40 a day than it would be the 85 a week...Can anyone relate to that at all?

EVERYONE JUST SHOWS UP AND GETS THEIR MEDS. This is after the initial history, physical and counsel phase. I don't know where you are, but in All the clinics I have reviewed, that IS the case. The only exceptions is if the patient is intoxicated by something, or on hold by their counsel person. I don't know why the truth insults you.   This reply is to "guest".