CHPW would like to remind providers that Medicare is the primary payer for dually eligible beneficiaries who receive Opioid Treatment Programs (OTP) services.
- “Dual-eligible beneficiaries” means people enrolled in both Medicare and Medicaid.
- Medicare pays for OTP through bundled payments for opioid use disorder (OUD) treatment services.
- OUD services include toxicology testing, medication-assisted treatment (MAT), and counseling.
Providers must be enrolled as an OTP provider under Medicare. Medicare allows providers to retroactively (retro) enroll back to 30 days prior to the date of the decision that the provider is qualified. The provider can then bill for dates of service (DOS) effective back to the 30 days.
HCPCS G codes are used for reimbursement by Medicare.
Please refer to the Centers for Medicare & Medicaid Services (CMS) Opioid Use Disorder Billing and Payment webpage for more information.
The Washington State Health Care Authority (HCA) has identified that code H0020 should not be billed to Medicaid if the provider is enrolled as an OTP provider with Medicare; those providers must bill Medicare as the primary payer. If the provider is enrolled as an OTP provider, claims submitted to CHPW will be denied for Medicare Explanation Of Benefits (EOB). Please see the HCA Substance Use Disorder Billing Guide, “Opioid Treatment Programs (Opiate Substitution Therapy)” section.
Medicare-enrolled providers should notify the HCA upon approval of Medicare enrollment.
If providers have the capacity to do so, they may complete a self-audit, review their own claims, and submit adjustments or voids after Medicare has made payment. Providers who self-audit and send a check as an adjustment should include supporting documentation indicating the claim(s) to which the check is applicable.
Providers will submit claims to CHPW (or the applicable Managed Care Organization) along with the Medicare EOB per the standard Coordination of Benefits (COB) process. This includes claims that are within the 30-day retro enrollment timeframe.
If you have questions about payment of OTP/OUD services, please contact our Customer Service Department at:
- CHPW Washington Apple Health Integrated Managed Care (IMC) Customer Service: 1 (800) 440-1561 (Toll Free) Monday through Friday, 8am to 5pm
- CHPW Medicare Advantage Customer Service: 1 (800) 942-0247 (Toll Free) 7 days/week, 8am to 8pm