Back to Insights and Updates for ProvidersMarch 2024

Coverage update for mental health wellness examinations

Harvard Pilgrim Health Care Commercial  |  Tufts Health Direct  |  Tufts Health Plan Commercial

We’re pleased to share that effective for dates of service beginning March 31, 2024, mental health wellness exams performed by a primary care provider or licensed mental health professional will be covered annually—at no cost—to eligible members of Massachusetts Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, and Tufts Health Direct plans.

A mental health wellness examination, as defined by the Mass Department of Mental Health, is a screening or assessment that seeks to identify any behavioral or mental health needs and appropriate resources for treatment. The examination may include:

  • Observation; a behavioral health screening; education and consultation on healthy lifestyle changes; referrals to ongoing treatment; mental health services and other necessary supports; and discussion of potential options for medication
  • Age-appropriate screenings or observations to understand a covered person’s mental health history, personal history, and mental or cognitive state, and when appropriate, relevant adult input through screenings, interviews, and questions

Providers are encouraged to refer to the Mental Health Examination Overview and Requirements (Appendix A) of DOI Bulletin 2024-02 for detailed information on exam components and guidance for communicating with patients.

Prior authorization for mental health wellness examinations is not required. When submitting claims for these exams, providers must use the following codes:

  • Procedure Code: 90791 (an integrated biopsychosocial assessment—including history, mental status, and recommendations)
  • Diagnosis Code: Z13.30 (encounter for screening examination for mental health and behavioral disorders—unspecified)
  • Modifier: 33 (to indicate that evaluation is for preventive purposes, not for a particular presenting issue/illness and that evaluation is not subject to cost sharing)

For more information and additional billing details, please refer to Point32Health’s updated Behavioral Health and Substance Use Disorder and Outpatient Behavioral Health & Substance Use Disorder payment policies.

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