Behavioral Health Billing Services in Pennsylvania
Last reviewed October 6, 2026 by the Healthcare Logic revenue cycle team.
Pennsylvania is a carve-out state. Medical Assistance members get physical health care from one managed care plan and behavioral health care from a separate, county-based Behavioral Health Managed Care Organization (BH-MCO). A therapy claim sent to the member's physical health plan will deny every time.
Healthcare Logic supports Pennsylvania outpatient clinics, group practices, psychiatry groups, drug and alcohol programs and FQHCs with BH-MCO billing, authorizations, coding, denials and credentialing.
Pennsylvania behavioral health billing at a glance
| Medicaid program | Medical Assistance; managed care program is HealthChoices |
|---|---|
| Behavioral health delivery | Carved out to county-contracted BH-MCOs |
| BH-MCOs | Including Carelon Behavioral Health, Community Care Behavioral Health, Magellan, PerformCare and Community Behavioral Health (Philadelphia) |
| Enrollment system | PROMISe for Medical Assistance provider enrollment and fee-for-service claims |
| Licensing | OMHSAS for mental health programs; Department of Drug and Alcohol Programs (DDAP) for SUD |
| Medicare contractor | Novitas Solutions, Jurisdiction L |
How Pennsylvania Medical Assistance pays for behavioral health
Under HealthChoices, each county (or group of counties) holds the behavioral health contract and works with a BH-MCO to manage mental health and substance use services. The BH-MCO credentials providers, sets authorization rules and pays claims for Medical Assistance members in its counties. Members in Community HealthChoices, the program for older adults and people with physical disabilities, also get behavioral health through the BH-MCOs.
Because contracts are county based, the same service can have different rates, authorization steps and documentation rules depending on where the member lives. Practices serving several counties often work with more than one BH-MCO.
- Providers enroll in Medical Assistance through PROMISe and must have each service location enrolled.
- Outpatient psychiatric clinics are licensed by OMHSAS; drug and alcohol programs are licensed by DDAP.
- Supplemental services and some intensive services need BH-MCO authorization.
- The member's county of residence decides which BH-MCO pays.
Medicare rules for Pennsylvania behavioral health providers
Medicare rules are federal, so they are the same in Pennsylvania as everywhere else. What changes is the contractor: Pennsylvania clinicians enroll and bill Part B through Novitas Solutions (Jurisdiction L).
- Counselors and MFTs can bill Medicare. Since January 1, 2024, marriage and family therapists and mental health counselors (including LPCs) can enroll in Medicare and bill for their services, paid at 75% of the physician fee schedule amount.
- Home telehealth is permanent for mental health. Patients can receive mental and behavioral health telehealth at home, anywhere in the country, and audio-only is allowed when the patient cannot or does not want to use video.
- The in-person visit rule is delayed. The requirement for an in-person visit within six months before starting tele-mental health, and every 12 months after, is waived until January 1, 2028 under the Consolidated Appropriations Act of 2026. Broader Medicare telehealth flexibilities run through December 31, 2027.
- Incident-to under general supervision. Behavioral health services by auxiliary personnel can be billed incident-to a supervising practitioner under general supervision.
- Tele-prescribing of controlled substances. DEA and HHS extended telemedicine prescribing flexibilities through December 31, 2026.
- Medicare Advantage is different. MA plans set their own networks and prior authorization rules, so we verify each MA plan before the first visit.
Pennsylvania commercial plan notes
Pennsylvania has state mental health and substance use parity requirements for state-regulated plans, enforced by the Insurance Department. Major commercial carriers often use a separate behavioral health vendor, so we confirm the correct vendor and payer ID before the first claim.
Common behavioral health denials in Pennsylvania
These are the patterns we see most often with Pennsylvania behavioral health claims, and each one is preventable with front-end checks:
- Behavioral health claims sent to the physical health MCO instead of the BH-MCO.
- Wrong BH-MCO billed after a member moves to a different county.
- Service location not enrolled in PROMISe.
- Missing BH-MCO authorization for supplemental or intensive services.
- Program license type does not match the service billed.
Core behavioral health codes we bill in Pennsylvania
Psychotherapy codes are time based, so documented start and stop times or total minutes must support the code billed. State Medicaid programs and plans may also require HCPCS codes, modifiers or rate codes on top of these.
| 90791 / 90792 | Psychiatric diagnostic evaluation (without / with medical services) |
|---|---|
| 90832 / 90834 / 90837 | Individual psychotherapy, 16 to 37, 38 to 52, and 53+ minutes |
| 90833 / 90836 / 90838 | Psychotherapy add-ons with an E/M visit |
| 90785 | Interactive complexity add-on |
| 90839 / 90840 | Psychotherapy for crisis, first 60 minutes / each extra 30 |
| 90846 / 90847 / 90853 | Family psychotherapy without / with patient; group psychotherapy |
| 96127 | Brief emotional or behavioral assessment (for example PHQ-9, GAD-7) |
Behavioral health billing services for Pennsylvania providers
Healthcare Logic works inside your EHR and clearinghouse as an extension of your team. Use one service or the full revenue cycle:
Learn more about our behavioral health revenue cycle services, how we handle behavioral health coding, and credentialing for new clinicians.
Frequently asked questions
Who pays behavioral health claims for Pennsylvania Medical Assistance members?
The county-contracted Behavioral Health Managed Care Organization (BH-MCO), not the member's physical health plan. The member's county of residence decides which BH-MCO.
What are the Pennsylvania BH-MCOs?
They include Carelon Behavioral Health, Community Care Behavioral Health, Magellan Behavioral Health, PerformCare and Community Behavioral Health in Philadelphia. Assignments are by county.
Do I need PROMISe enrollment to bill a BH-MCO?
Yes. Providers must be enrolled in Medical Assistance through PROMISe, with each service location enrolled, before BH-MCOs can pay them.
Can LPCs and LMFTs in Pennsylvania bill Medicare?
Yes. Since January 1, 2024, licensed professional counselors and marriage and family therapists can enroll in Medicare. In Pennsylvania they enroll through Novitas, Jurisdiction L.
How does Healthcare Logic help Pennsylvania behavioral health providers?
We route each claim to the right BH-MCO, manage county-specific authorizations, keep PROMISe and payer enrollment current, code and bill to each BH-MCO's rules and work denials and appeals.
Talk to a behavioral health billing specialist
Tell us your payer mix and EHR, and we will show you where Pennsylvania claims are getting stuck. Business inquiries only. Reply within 1 business day.
Behavioral health billing in other states
Sources
Payer rules change often. This page reflects official guidance as of October 6, 2026. Confirm current requirements in the state manual and your payer contracts before billing.