Temporary Clinical Policy Modifications: Payment for Healthy Opportunities Screening and Referral

Effective Jan. 1, 2021, NC Medicaid and NC Health Choice are temporarily covering Healthy Opportunities screenings to encourage providers to gain capacity for screening Medicaid beneficiaries for unmet health-related resource needs and referring them to appropriate community-based resources prior to the launch of Medicaid Managed Care.  

• Reimbursement is limited to Carolina Access II providers and is a time limited opportunity through June 30, 2021.  
• Coverage of this code after Medicaid Managed Care launch will be at the discretion of the health plans. 

This bulletin temporarily enables Carolina Access II providers to receive reimbursement for positive Healthy Opportunities screenings conducted using the North Carolina Department of Health and Human Services (DHHS) standard screening questions or an equivalent instrument with similar questions covering beneficiary needs related to DHHS’s 4 priority domains (food, housing/utilities, transportation and interpersonal safety). For providers who have not already adopted a tool, we strongly encourage the use of the DHHS standard questions. 

• Recipients of screenings are not required to be beneficiaries assigned to the Carolina Access II practice.  
• Upon completing a positive screen, providers should refer enrollees to community-based resources to address the identified needs.  
• While reimbursement will not be contingent upon such referrals, providers are strongly encouraged to refer beneficiaries who screen positive for unmet social needs to appropriate resources. 

Many providers in North Carolina use NCCARE360 to electronically connect those with identified needs with community resources and allow for a feedback loop on the outcome of that connection. Providers are encouraged to use NCCARE360 to support screenings and referrals for patients with unmet health-related resource needs; however, providers are not required to do so to obtain reimbursement for Healthy Opportunities screenings under this temporary policy modification.   

Providers must keep records of all screenings conducted. DHHS may audit activities conducted under this temporary policy modification at any time. 

Definitions 

• Healthy Opportunities are unmet resource needs related to food, housing, transportation and interpersonal violence that have an impact on a person’s health, safety and well-being, as well as healthcare utilization and costs. 
• Positive Screening means a screening that identifies the individual as having an unmet need in at least one of DHHS’s 4 priority domains (food, housing/utilities, transportation and interpersonal safety).  

Billing Guidance for Carolina Access II Providers: HCPCS code G9919 

A. Claim Type 

Professional (CMS-1500/837P transaction) 

B. International Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS) 

Providers are encouraged, but not required, to include Z codes indicating a patient’s identified resource needs when submitting claims for Healthy Opportunities screenings. See table below for Z codes providers should use to indicate patients’ resource needs. 

C. Code(s) 

Providers should bill the following code for new and established patients, when provided by an eligible provider in person or during a telehealth visit (audio and video). This code may not be billed during telephonic visits. Physicians, nurse practitioners, physician assistants, nurse midwives, or designated staff may bill the code. Additionally, any eligible federally qualified health centers (FQHCs), FQHC lookalikes and rural health centers (RHCs) may bill under fee-for-service reimbursement. 

Coding Guidance 

• Eligible providers bill for and receive reimbursement from positive Healthy Opportunities screens which is indicated by the accompanying z-code. 
• Each eligible provider may bill this code up to once per 30-day period per patient receiving a positive Healthy Opportunities screening.  

D. Modifiers 

N/A- providers will not need to append modifiers to claims for Healthy Opportunities screenings. 

E. Billing Unit 

Provider(s) shall report the appropriate code(s) used which determines the billing unit(s). 

F. Place of Service 

Providers may bill code G9919 in the following places of services: 

Providers may bill code G9919 as part of in-person or telehealth visits using real time audio and visual technology. This is not billable for telephonic only or portal communication care. Telehealth claims should be filed with the provider’s usual place of service code per the appropriate clinical coverage policy and not place of service (POS) 02 (telehealth).  

G. Copayments 

• For Medicaid, refer to Medicaid State Plan, Attachment 4.18-A, page 1, located at https://medicaid.ncdhhs.gov/. 
• For NC Health Choice, refer to G.S. 108A-70.21(d), located at http://www.ncleg.net/EnactedLegislation/Statutes/HTML/BySection/Chapter_108A/GS_108A-70.21.html. 

H. Reimbursement 

NC Medicaid and Health Choice shall reimburse eligible providers in accordance with the published fee schedule for each positive Healthy Opportunities screening billed to code G9919.  

Additional Resources 

NC Healthy Opportunities Overview at https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities   

NC Medicaid Contact Center, 888-245-0179