For any DOS effective 10/1/25 and thereafter Healthfirst will reimburse psychiatric evaluation services that is with the accordance to the CMS LCD #L35101 and the Local Coverage Article (LCA) A57130 for Jurisdictions H & L.

To access the Local LCD please click here.

To access the Local LCA- for codes info, please click here.

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The following plans are affected:

• Child Health Plus (CHP)
  •Medicaid Managed Care (MMC)
  •Medicare Advantage
  •Personal Wellness Plan (PWP)/Health & Recovery (HARP)
  •Medicaid Managed Care (MMC)
  •Essential Plan (EP)
  •Medicaid Advantage Plus/MAP (CompleteCare)
  •Medicare PPO
  •Qualified Health Plan (QHP)

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Coding:

90791: Psychiatric diagnostic evaluation (without medical services)
90792: Psychiatric diagnostic evaluation with medical services

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Billing:

Limitations– providers are only allowed to bill a frequency of 3 units per calendar year by the same provider for the same member. Anything billed over 3 units will be denied.

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Coverage: for any plan that is not mentioned above does not cover, or reimburse these services.

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