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

Date Issued: 2/3/2017

I. 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 Carelon Behavioral Health (formerly Beacon Health Options) website for more tips before sending your paper or electronic claims.²

II. Montefiore CMO Providers (until March 31, 2023)

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.*

III. 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 Carelon Behavioral Health (formerly Beacon Health Options)2 on your behalf.

¹Emblem Behavioral Health Services Program and Behavioral Management Program are administered by Carelon Behavioral Health (formerly Beacon Health Options).²ValueOptions Inc. and Beacon Health Strategies, LLC completed a merger on December 23, 2014 to become Beacon Health Options, Inc.