Billing Instructions for Long Acting Injectable Antipsychotics, Vivitrol and Injectable Naloxone

Date Issued: 2/3/2017

  1. Behavioral Health Providers
    1. If any evaluation and management services were performed with the medication administration, fill out the Health Insurance Claim Form (CMS-1500) developed by the Centers for Medicare & Medicaid Services (CMS). When completing the form, be sure to use the correct Current Procedural Technology (CPT) codes for the drug and its administration. Also add the National Drug Code (NDC) number and drug name on the claim. Mail paper claim forms to:

      Emblem Behavioral Health Claims Services1
      PO Box 803
      Latham, NY 12110
    2. If evaluation and management services were not performed with the medication administration, fill out a CMS-1500 form with the correct CPT codes for the drug and its administration. Also add the NDC number and drug name on the claim. Mail paper claim forms to:

      EmblemHealth
      PO Box 2845
      New York, NY 10116
    3. Please visit the provider section of the Beacon Health Options website for more tips before sending your paper or electronic claims.2

  2. Montefiore CMO Providers
    1. After administration of the drug, fill out a CMS-1500 form. When completing the form, be sure to use the correct CPT codes for the drug and its administration. Also add the NDC number and drug name on the claim, as well as any evaluation and management services. Mail paper claim forms to:

      CMO, the Care Management Company
      200 Corporate Dr.
      Yonkers, NY 10701
    2. Please visit the Claims section of the EmblemHealth Provider Manual for more tips before sending your paper or electronic claims.*

  3. All Other Providers
    1. After administration of the drug, fill out a CMS-1500 form. When completing the form, be sure to use the correct CPT codes for the drug and its administration. Also add the NDC number and drug name on the claim. Hospital claims should use the revenue code 636. Mail paper claim forms to:

      emblemhealth*
      PO Box 2845
      New York, NY 10116
    2. Please visit the Claims section of the EmblemHealth Provider Manual for more tips before sending your paper or electronic claims.

 

*You may get an Explanation of Change (EOC) telling you to “Resubmit to ValueOptions, PO BOX 803 Latham NY 12110,” but EmblemHealth will send those claims to Beacon Health Options2 on your behalf.