Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
October 24, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group. You say that you have been enrolled in 
the Medicare program to provide Opioid Treatment Program (OTP) services since January 01, 2020. The Plan 
denied your request. The Plan says that an individual provider cannot bill for OTP services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The rules state that Medicare Part B coverage is available for outpatient Opioid Treatment Program services 
provided by hospitals, CAHs, and Free-Standing Opioid Treatment Program facilities. You can find this rule at 
the Medicare Claims Processing Manual, Chapter 39, section 50- Institutional Opioid Treatment Program 
(OTP) Services  A/B MAC (A). 
 
The rules state that beginning January 1, 2020, claims for OTP services are submitted using the 837P 
transaction to transmit health care claims electronically, or using the CMS-1500 (the paper version of the 
837P). Beginning January 1, 2021, OTPs may apply on the Medicare Enrollment Application for Institutional 
Providers (CMS-855A) or through the Internet-based Provider Enrollment, Chain and Ownership System 
(PECOS) (837I) when they enroll in the Medicare Program. These providers will submit claims using the 
CMS-1450. You can find this rule at the Medicare Claims Processing Manual, Chapter 39, section 40- 
Practitioner Claims submission  A/B MAC (B). 
 
The rules state that OTPs should list the prescribing or medication ordering physicians or other eligible 
professionals National Provider Identifier in Field 17 (the ordering/referring/other field) of the Form CMS
1500 (Health Insurance Claim Form; 09381197) or the digital equivalent thereof. You can find this rule at the 
Medicare Claims Processing Manual, Chapter 39, section 40.3 - Prescribing Individuals. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on October 24, 2022.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.