We’re pleased to share that mental health wellness exams performed by a primary care provider or licensed mental health professional will now be covered annually — at no cost — to eligible Tufts Health Together members. This coverage will be effective retroactively for dates of service beginning July 1, 2024, and applicable claims will be reprocessed. This aligns with the coverage recently announced and currently in place for Massachusetts Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, and Tufts Health Direct members.
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 (Psychiatric diagnostic evaluation – 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). (Providers are encouraged to include additional diagnosis codes if a condition is determined during the exam. For Tufts Health Together and Harvard Pilgrim Health Care Commercial claims, Z13.30 must be billed in the primary diagnosis field.)
When billing procedure code 90791 with a primary diagnosis of Z13.30, providers do not need to conduct a Child and Adolescent Needs and Strengths assessment for members younger than 21 years of age.
Please keep in mind that Modifier 33 (to indicate that evaluation is for preventive purposes, not for a presenting issue/illness and not subject to cost sharing) is used to bill Commercial claims. It cannot be used for claims billed to Tufts Health Together or any MassHealth plan, as it is not recognized by the Centers for Medicare & Medicaid Services.
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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