Other billing information

Other billing information

Confidentiality of Substance Use Disorder Patient Records 42 CFR Part 2

The federal confidentiality law and regulations protect the privacy of substance use disorder (SUD) patient records by prohibiting unauthorized disclosures of patient records except in limited circumstances. Congress enacted the legislation to encourage individuals with SUDs to enter and remain in treatment. Learn more about the regulations implementing the law commonly referred to as “Part 2”.

Claims and information

If a provider treats or diagnoses a patient for SUD or refers patients for treatment of SUD and is subject to the Confidentiality of Substance Use Disorder Patient Records (42 CFR Part 2) as a Part 2 Program, that provider must comply with the terms of their contact with respect to any claim or other information they submit to a health plan that contains patient identifying information. Payment of these claims is contingent upon compliance with these requirements.

For dates of service on or after April 1, 2020, providers must include a Part 2 disclaimer with any claim (or other record) that contains patient-identifying information when submitting the claim (or other information) to Regence.

When submitting an electronic claim (837 P or I) for Part 2 services on or after April 1, 2020, you must include the information listed below:

  1. On the CLM09 field, indicate an “I” for obtaining informed consent from the patient to release information governed by a federal statute. See below.
    a. Note: This should be familiar with providers, as the field is general – and not specific to Part 2.
  2. Then, under the NTE01 segment, indicate “CER” for a narrative.
    a. Note: Only one CER is permitted per claim.
  3. Under the NTE02 segment, include in the free-form narrative the Part 2 disclaimer language, as required by federal law. See below.
    a. Note: A recent federal rule allowed a short form or long form disclaimer when Part 2 information is shared (e.g. from provider to health insurer).

Here are the two options, though the shorter version is preferable:

  1. Short form (Preferred version)
    a. 42 CFR part 2 prohibits unauthorized disclosure of these records. View a sample form (PDF).
  2. Long form
    a. This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose (see § 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65.

ANSI 837 Field

Value

Description/Notes

CLM09

I

Informed Consent to release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

NTE01

CER

Certification Narrative

NTE02

  1. 42 CFR Part 2 prohibits unauthorized disclosure of these records. OR
  2. This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT enough for this purpose (see § 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65.”

Part 2 disclaimer language, as required by federal law. Regence prefers use of the shorter disclaimer.

Medicare Opioid Treatment Program (OTP) billing

Effective January 1, 2020, Medicare added coverage for OTPs for all beneficiaries. OTPs provide medication‑assisted treatment (MAT) for people diagnosed with an opioid use disorder.

Nonresidential opioid treatment facilities must submit claims for OTP services with a place of service (POS) 58 on an 837P electronic claim. CMS has published the following resources for providers to learn more about the OTP benefit, provider enrollment and coding and billing requirements:

Rendering provider and service facility NPI

Providers are responsible for submitting accurate and complete claims for all medical and surgical services, supplies and items rendered to members using industry standard coding guidelines. Please refer to our Correct Coding Guidelines policy in the Reimbursement Policy Manual.

If you provide services at a facility that are billed separate from the facility claim, the claim for the services you provided must include the service facility NPI where the service was rendered.

When appropriate, the service facility NPI should be included in loop 2310, segment NM109 on an ANSI 837p claim.

Home health and hospice billing guidelines

To ensure accurate reimbursement, claims should include:

  • Contracted per diem codes—one line per date of service (i.e. line level “from” date equals “to” date) with 1 unit of service
  • Hourly codes—one line per date of service (i.e., line level “from” date equals “to” date) with the total units (hours) rendered

Do not use:

  • Date ranges (e.g., 01/01/2020 – 01/03/2020) on a single line
  • Multiple lines with the same date of service for the same code