Pennsylvania Billing Guide for Mental Health Therapists and Psychiatrists
Who pays, where to enroll and which rules change your claims in Pennsylvania, for psychotherapists and psychiatric prescribers.
Last checked October 25, 2026. Reviewed against the official sources listed at the bottom of this page.
This Pennsylvania billing guide covers Medicaid, Medicare, Blue Cross, other private payers and state law for therapists and psychiatrists, with sources and a last-checked date.
Pennsylvania billing guide: how Pennsylvania pays for outpatient care
Pennsylvania delivers Medicaid (Medical Assistance) behavioral health through Behavioral HealthChoices. Each county contracts with a behavioral health managed care organization (BH-MCO), and you must be in the network of the BH-MCO for the member's county. Physical health is handled by separate HealthChoices plans.
Fee-for-service Medical Assistance also exists and is billed through the Department of Human Services (DHS) PROMISe system. Work requirements for adults 19 to 64 begin January 1, 2027.
Who to bill, at a glance
| Payer type | Who you bill | Where to enroll or check rules |
|---|---|---|
| Medicaid | Department of Human Services; county BH-MCOs; PROMISe for fee-for-service | DHS Behavioral HealthChoices |
| Medicare Part B | Novitas Solutions, Jurisdiction L | CMS MAC page |
| Blue Cross Blue Shield | Highmark Blue Cross Blue Shield, Highmark Blue Shield and Independence Blue Cross | See the Blue Cross section below |
Pennsylvania Medicaid: Medical Assistance and Behavioral HealthChoices
This Pennsylvania billing guide starts with Medicaid, because it decides who pays and how you file.
Behavioral HealthChoices is mandatory managed care by county. It is carved out from physical HealthChoices. Providers serving HealthChoices behavioral health members submit claims under each BH-MCO's procedures, according to OMHSAS bulletin 25-05.
The Office of Mental Health and Substance Abuse Services (OMHSAS) oversees behavioral health within DHS.
| Item | What to know |
|---|---|
| Agency | Pennsylvania Department of Human Services |
| Provider information | DHS behavioral health providers page |
| Clinic services outside the clinic | OMHSAS-25-05 says psychiatric outpatient clinics (provider type and specialty 08/110), outpatient drug and alcohol clinics (08/184) and methadone providers (08/084) can be paid for clinically appropriate services delivered outside the clinic by mobile or telehealth, after Act 46 of 2025. Source |
| Psychiatric rehabilitation | OMHSAS-26-01 added Psychiatric Rehabilitation Services to the MA Fee Schedule effective 1/1/2026. Claims without the required modifier are denied. Source |
| Work requirement | DHS says work requirements begin January 1, 2027 for adults 19 to 64 without a dependent child under 14: 80 hours a month of work, volunteering, training or half-time school, or at least $580 a month in income. Exemptions include people in alcohol or substance use treatment and the medically frail. Source |
Managed-care plans and carve-outs
| Plan or entity | Role in behavioral health |
|---|---|
| Community Behavioral Health | BH-MCO for Philadelphia. |
| Community Care Behavioral Health Organization | BH-MCO for many counties, including Allegheny, Berks, Chester, Delaware, Erie, Luzerne and York. See the DHS county list. |
| Magellan Behavioral Health of Pennsylvania | Bedford, Bucks, Cambria, Lehigh, Montgomery, Northampton and Somerset counties. |
| PerformCare | Cumberland, Dauphin, Franklin, Fulton, Lancaster, Lebanon and Perry counties. |
| Carelon Health of PA | Armstrong, Beaver, Butler, Crawford, Fayette, Indiana, Lawrence, Mercer, Washington, Westmoreland and Venango counties. |
The county assignments above follow the DHS page. Check the DHS BH-MCO list for the current assignment before you contract.
Medicare Part B in Pennsylvania
For Medicare, this Pennsylvania billing guide names your contractor and the current telehealth rules.
Medicare Part B pays for outpatient psychotherapy and psychiatric visits billed to the Medicare Administrative Contractor (MAC) for your state. CMS's July 14, 2026 fact sheet on the CY2027 Physician Fee Schedule proposed rule says the Consolidated Appropriations Act, 2026 extended telehealth payment authority through December 31, 2027, and proposes that in-person visit requirements for mental health visits not apply to services furnished through that date.
| Item | What to know |
|---|---|
| Contractor | Novitas Solutions, Inc. |
| Jurisdiction | Jurisdiction L: Pennsylvania, Maryland, Delaware, New Jersey and the District of Columbia |
| Source | CMS.gov MAC page |
Blue Cross Blue Shield in Pennsylvania
This part of the Pennsylvania billing guide names the exact Blue Cross licensee, because Blue plans never share rules.
Blue Cross Blue Shield is a federation of independent companies, so one licensee's rules never apply to another. Pennsylvania has several independent Blue licensees. Highmark covers western, north central and northeastern Pennsylvania as Highmark Blue Cross Blue Shield, and covers central Pennsylvania, the Lehigh Valley and part of southeastern Pennsylvania as Highmark Blue Shield. Independence Blue Cross covers southeastern Pennsylvania. Highmark's own provider overview says a claim for an Independence member must go to Independence, not Highmark. Do not apply one licensee's rules to another.
| Licensee | Parent or affiliation | Where it applies | Provider resources |
|---|---|---|---|
| Highmark Blue Cross Blue Shield | Highmark Inc. | Western, north central and northeastern Pennsylvania (42 counties) | Highmark: our businesses |
| Highmark Blue Shield | Highmark Inc. | 21 counties in central Pennsylvania, the Lehigh Valley and 5 counties in southeastern Pennsylvania | Highmark: our businesses |
| Independence Blue Cross | Separate Blue licensee | Southeastern Pennsylvania | Highmark SEPA overview |
Other private payers and EAPs in Pennsylvania
The Pennsylvania billing guide also covers commercial plans and employee assistance programs.
These commercial payers and plan families most often matter for behavioral health billing in Pennsylvania. Check each payer's current provider manual before you submit.
| Payer | Behavioral health note | Provider resources |
|---|---|---|
| Highmark and Independence Blue Cross | Highmark says a claim cannot be sent to both Highmark and Independence Blue Cross. Submit the claim to the plan that holds the member's coverage. | Official page |
| Highmark Wholecare (Gateway Health Plan) | Highmark-affiliated Medicaid plan. Confirm how it connects to the member's county BH-MCO. | Official page |
Pennsylvania billing guide: state law that changes billing
Use this section of the Pennsylvania billing guide to separate state law from payer policy.
State law sets the floor for commercial plans in Pennsylvania. Medicare and Medicaid rules are covered in their own sections above.
Medicaid clinic services outside the clinic
Act 46 of 2025 abrogated 55 Pa. Code 1223.14(11) and 1153.14(6), the rules that limited payment for clinic services delivered outside the clinic. OMHSAS-25-05 explains the change for psychiatric outpatient, outpatient drug and alcohol, and methadone providers. Bulletin
Not legal advice. Confirm statute details with counsel.
Pennsylvania billing guide: codes and rates
This Pennsylvania billing guide lists only codes and rates confirmed on official pages.
These are the Pennsylvania-specific codes, modifiers and rate items confirmed on official pages. Medicare's own CY2027 conversion factor proposal is listed under What changed.
| Code or item | What to know |
|---|---|
| Psychiatric Rehabilitation Services | Added to the MA Fee Schedule effective 1/1/2026. Per 15-minute unit: H0036 U7 $23.50, H0036 U8 HQ $4.70, H0036 U9 $27.07, H0036 UB HQ $6.77, H2030 U7 $23.50 and H2030 U8 HQ $4.70. Source |
| Clinic provider types | Provider type and specialty 08/110 (psychiatric outpatient clinic), 08/184 (outpatient drug and alcohol) and 08/084 (methadone) may bill clinic services outside the clinic. Source |
| ASAM level-of-care rates | 2026 rates are posted on the DHS behavioral health providers page. Source |
Pennsylvania billing guide: what changed, newest first
Check this Pennsylvania billing guide update log before you rely on an older rule.
| Date | What changed | Source |
|---|---|---|
| 2027-01-01 | Work requirements, six-month renewals for some adults and shorter retroactive coverage begin. | Source |
| 2026-10-01 | Medical Assistance for noncitizens ends, per the City of Philadelphia. Rules are unchanged for children under 21 and pregnant and postpartum adults. | Source |
| 2026-07-14 | CMS released the CY2027 Medicare Physician Fee Schedule proposed rule: conversion factor $32.84 for non-qualifying APM participants (down 1.68%) and $33.17 for qualifying participants (down 1.19%). | Source |
| 2026-02-06 | OMHSAS-26-01 issued, adding Psychiatric Rehabilitation Services to the MA Fee Schedule effective 1/1/2026. | Source |
| 2025-12-12 | OMHSAS-25-05 issued on clinic services delivered outside the clinic, effective 11/12/2025. | Source |
How do I bill mental health claims in Pennsylvania?
These answers come from the same sources as the rest of this Pennsylvania billing guide.
Start with the member's county. For Pennsylvania Medicaid behavioral health, bill the BH-MCO assigned to the member's county of residence. Medicare Part B goes to Novitas Solutions in Jurisdiction L. Pennsylvania has several independent Blue licensees, including Highmark and Independence Blue Cross.
Questions about billing in Pennsylvania
Who do I bill for Pennsylvania Medicaid behavioral health claims?
Bill the BH-MCO assigned to the member's county of residence, and make sure you are in that BH-MCO's network.
Who is the Medicare contractor in Pennsylvania?
Novitas Solutions in Jurisdiction L, which also covers Maryland, Delaware, New Jersey and the District of Columbia.
How many Blue plans are there in Pennsylvania?
Several independent licensees, including Highmark and Independence Blue Cross. Submit the claim to the plan that holds the member's coverage.
When does the Pennsylvania Medicaid work requirement start?
DHS says January 1, 2027 for adults 19 to 64 without a dependent child under 14, with exemptions including people in substance use treatment and the medically frail.
Does MCM South bill for practices in Pennsylvania?
MCM South currently serves ten states; request a quote to ask about Pennsylvania.
Sources for the Pennsylvania billing guide
Last checked October 25, 2026. Every source below was opened and read on that date.
- PA DHS Behavioral HealthChoices MCOs, checked October 25, 2026
- PA DHS for providers, checked October 25, 2026
- PA DHS behavioral health providers page, checked October 25, 2026
- PA DHS Medicaid changes, checked October 25, 2026
- OMHSAS-26-01 bulletin, checked October 25, 2026
- OMHSAS-25-05 bulletin, checked October 25, 2026
- CMS: MAC Jurisdiction L, checked October 25, 2026
- Highmark: our businesses, checked October 25, 2026
- Highmark SEPA general overview, checked October 25, 2026
- City of Philadelphia: changes coming to Medicaid, checked October 25, 2026
- CMS: CY2027 Physician Fee Schedule proposed rule fact sheet, checked October 25, 2026
- CMS MAC jurisdiction page, checked October 25, 2026
Related guides
- State & Regional Billing Guides hub
- Pennsylvania insurance companies contact guide
- In-network vs out-of-network credentialing
- Credentialing and network status
- Blue Cross Blue Shield guide for Pennsylvania
- Mental health parity explained
- Medicaid managed care billing
- Medicare behavioral health billing
- Timely filing in the billing glossary
- Who we serve
- New York insurance companies contact guide
- Illinois insurance companies contact guide
Billing in Pennsylvania? Let us handle the payer calls.
MCM South bills only mental and behavioral health, for psychotherapists and psychiatrists, in solo and medium-size practices. We currently serve ten states; request a quote to ask about Pennsylvania.
MCM South currently serves practices in ten states: Georgia, Massachusetts, Connecticut, Texas, Florida, New York, Colorado, Tennessee, North Carolina and Illinois.