Frequently Asked Questions

Opioid Treatment Programs (OTPs) provide medication-assisted treatment for people diagnosed with an OUD. OTPs must be certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and accredited by an independent, SAMHSA-approved accrediting body. For SAMHSA certification, OTPs must comply with all pertinent state laws and regulations and all regulations enforced by the Drug Enforcement Administration.

What services are covered under the Opioid Treatment Program (OTP) benefit??

Under the OTP benefit, Medicare covers:

U.S. Food and Drug Administration (FDA)-approved opioid agonist and antagonist medication-assisted treatment (MAT) medications
Dispensing and administration of MAT medications (if applicable)
Substance use counseling
Individual and group therapy
Toxicology testing
Intake activities
Periodic assessments

New for Calendar Year 2021

New covered services include FDA-approved opioid antagonist medications, specifically naloxone, for emergency treatment of opioid overdose, as well as overdose education provided in conjunction with opioid antagonist medication

Where can I find more information about Medicare Administrative Contractors (MACs) and their role with CMS?

As a newly eligible Medicare provider, you should get to know your MAC. CMS contracts with MACs to process enrollment applications and Medicare Fee-For-Service (FFS) claims (also known as Medicare Part A and Part B claims). Each MAC processes FFS claims (including claims for OTP services) for certain areas of the country called jurisdictions. If you deliver OTP services in multiple jurisdictions, you might work with more than one Medicare A/B MAC. MACs also communicate information about the Medicare FFS Program to health care providers enrolled in the Medicare program. Learn more about MACs

Billing & Payment

What Place of Service (POS) codes are allowed on claims for OTP services?

Only the new POS code 58 for nonresidential opioid treatment facilities can be used on OTP claims.

Can more than one OTP bill for the same patient in the same week?

There are limited clinical scenarios when a patient may appropriately receive OUD treatment services at more than one OTP within a 7 contiguous day period, such as for guest dosing or when a patient transfers care between OTPs. In these limited circumstances, each of the involved OTPs may bill the appropriate HCPCS codes that reflect the services furnished to the patient. We expect that both OTPs involved would provide sufficient documentation in the patient’s medical record to reflect the clinical situation and services provided. We will monitor the claims data to ensure that this flexibility is not abused.

Can a physician’s office bill for the bundled OTP services?

No. OTPs can only bill Medicare using the specific codes for OTP services. No other provider or supplier type except for an OTP can bill for OTP services (billed using HCPCS codes G2067-G2080). However, the CY2020 Physician Fee Schedule includes bundled payment codes (billed using HCPCS codes G2086-G2088) and payment rates for an episode of opioid use disorder (OUD) treatment furnished by physicians and other practitioners in the office setting.

How are the add-on codes for take-home supplies of medication billed?

There are two codes that describe take-home dosages of medication:

HCPCS code G2078 - take-home supplies of methadone - describes up to 7 additional days of medication and is billed along with the respective weekly bundled payment in units of up to 3 (for a total of up to a one month supply). This add-on code is only used with the methadone weekly episode of care code (HCPCS code G2067).

HCPCS code G2079 - take-home supplies of oral buprenorphine- describes up to 7 additional days of medication and is billed along with the base bundle in units of up to 3 (for a total of up to a 1 month supply). This add-on code is only used with the oral buprenorphine weekly episode of care code (HCPCS code G2068).

SAMHSA allows a maximum take-home supply of one month of medication; therefore, we do not expect you to bill the add-on codes describing take-home doses of methadone and oral buprenorphine any more than 3 times in one month (in addition to the weekly bundled payment).

What is the threshold for billing the weekly bundled payment codes?

The threshold to bill a full episode is that at least one service is furnished (from either the drug or non-drug component) to the patient during the week that corresponds to the episode of care. If no drug was provided to the patient during that episode, the OTP must bill the G-code describing a weekly bundle not including the drug (HCPCS code G2074) and the threshold to bill would be at least one service in the non-drug component. If a drug was provided with or without additional non-drug component services, the appropriate G-code describing the weekly bundle that includes the drug furnished may be billed.

Can HCPCS code G2068 be billed for treatment with buprenorphine combination products that combine buprenorphine and naloxone?

Yes, G2068 should be used in instances in which a patient is receiving treatment with buprenorphine combination products as well as in instances in which a patient is receiving treatment with a buprenorphine-only product.

What is the threshold for billing the counseling add-on code?

The counseling add-on code (HCPCS code G2080) may be billed when counseling or therapy services are furnished that substantially exceed the amount specified in the patient’s individualized treatment plan. OTPs will be required to document the medical necessity for these services in the patient’s medical record.

How should hospital-based OTPs identify the costs associated with these services in their cost reports?

Currently, hospitals can report opioid treatment program (OTP) costs on Worksheet A, line 194 (Other Nonreimbursable Cost Center), by identifying the line description as “Opioid Treatment Program” and entering the applicable costs. In the future, we will revise the cost report by adding a dedicated line for OTP costs. To accommodate the costs of OTPs, the cost report (CMS Pub. 15-2, chapter 40, Form CMS-2552-10) will be revised to facilitate the reporting of OTP service costs. A new dedicated standard cost center (cost center line 115.25, Opioid Treatment Programs) will be added to Worksheet A, and all applicable corresponding worksheets, to accommodate reporting costs associated with OTPs. In addition, CMS Pub. 15-2, chapter 40, §4095, Table 5, of the cost report electronic reporting specifications will be revised to add a unique dedicated standard cost center code 11525 (Table 5 - Standard Cost Center Descriptions and Codes) to accommodate the identification of OTP service costs reported on Worksheet A.

We’re currently enrolled as an OTP via the Form CMS-855B. We’d like to switch to a Form CMS-855A enrollment, but we’re concerned that OTP institutional claims we’ve been holding pending the ability to enroll via the Form CMS-855A won’t be paid because of the 30-day limit on retroactive billing in 42 CFR §§ 424.520(d) and 424.521(d). Will we be able to bill for these past OTP services?

Yes. Under 42 CFR § 424.67(c)(2), if a Form CMS-855B-enrolled OTP changes to a Form CMS-855A enrollment (or vice versa), the effective date of billing established for the OTP’s prior enrollment is applied to the OTP’s new enrollment.T his will allow an OTP to retroactively bill to the effective date of its prior enrollment if it chooses to delay submission of these claims. To illustrate, suppose an OTP initially enrolled via the Form CMS-855B in 2020. The effective date of billing was April 1, 2020. Wishing to submit an 837I institutional claim form for the services it has provided since April 1, 2020, the OTP elects to end its Form CMS-855B enrollment and enroll via the Form CMS-855A. It successfully enrolls under the Form CMS-855A in March 2021. The billing effective date of the Form CMS-855A enrollment would thus be retroactive to April 1, 2020. Please note, however, that the time limits for filing claims found in § 424.44 continue to apply; specifically, all Medicare Part A and Part B claims must be filed within 1 calendar year after the date of service unless one of a very limited number of exceptions applies. As we stated in the CY 2021 Physician Fee Schedule final rule, switching from a Form CMS-855B enrollment to a Form CMS-855A enrollment (or vice versa) is not grounds for an exception.

Enrollment

When can Opioid Treatment Programs (OTPs) start enrolling in Medicare?

OTP providers should enroll in Medicare now to be able to bill Medicare for OTP services beginning January 1, 2020.

My Opioid Treatment Program (OTP) has provisional certification from the Substance Abuse and Mental Health Administration (SAMHSA), can we enroll in Medicare now?

No. To enroll in Medicare, OTPs must be fully certified by the SAMHSA and accredited by a SAMHSA-approved accrediting body. Medicare will not accept provisional SAMHSA certifications during the Medicare enrollment process. For more information on the accreditation process, visit SAMHSA’s Certification of Opioid Treatment Programs (OTPs) webpage.

Can hospitals enroll and bill for outpatient OTP services? NEW

Yes. Beginning January 1, 2021, Medicare Part B covers hospital outpatient Opioid Treatment Program services. Health care organizations may now apply on the Medicare Enrollment Application for Institutional Providers (CMS-855A (PDF)) 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.

If I have a National Provider Identifier (NPI), does that mean I’m eligible to enroll as a Medicare provider?

Having an NPI does not constitute Medicare enrollment eligibility. You must go through the application process in Internet-based PECOS or submit a paper CMS 855 Medicare provider enrollment form to a Medicare contractor to enroll in Medicare.

How do I change my PECOS password?

You may change your PECOS password by selecting the "Forgot Password" link on the PECOS Welcome and Login page and following the instructions on the screens.
Note: CMS recommends PECOS users change their PECOS passwords at least once a year. User IDs cannot be changed.

Who do I contact if I cannot remember my password for PECOS?

You may change your PECOS password by selecting the "Forgot Password" link on the PECOS Welcome and Login page and following the instructions on the screens. For additional information, visit Forgot Password FAQ.
If you need additional assistance, contact the External User Services (EUS) Help Desk:
Hours of Operation: Monday - Friday, 7am-7pm EST
Website: https://eus.custhelp.com
By Chat: Live Chat Launch Page
By Email: EUSSupport@cgi.com
By Phone: Toll-Free : (866) 484-8049
TTY/TDD : (866) 523-4759

Can I change my PECOS User ID?

For security reasons, you cannot change your PECOS User ID.

When and why did CMS implement fingerprint-based background checks for certain Medicare providers and suppliers?

CMS began phasing in the fingerprint-based background check in 2014 as part of the enhanced enrollment screening provisions mandated by Section 6401 of the Affordable Care Act. CMS also published a final rule with comment period on February 2, 2011.

If you have a 5 percent or greater direct/indirect ownership interest in a Medicare-enrolled provider or supplier, CMS puts you in the high-risk screening category, which requires you to complete the fingerprint-based background check.

Do the fingerprinting-based background checks apply to Outpatient Treatment Program (OTP) providers?

Your MAC may ask you to submit fingerprints for individuals who have a 5% or greater direct/indirect ownership, even as a partner of an OTP provider when:

Initially enrolling
Substance Abuse and Mental Health Services Administration (SAMHSA) certified after October 23, 2018.

The CY 2020 Medicare Physician Fee Schedule final rule designates OTP providers as “high” categorical risk.

When must organizational providers applying to be OTP providers submit fingerprints?

After you submit your enrollment application, your MAC may ask you to submit fingerprints for individuals who have a 5% or greater direct/indirect ownership, even as a partner of an OTP provider when:

Initially enrolling

Substance Abuse and Mental Health Services Administration (SAMHSA) certified after October 23, 2018.

How does CMS define an “owner”?

According to 42 Code of Federal Regulations (C.F.R.) 424.502, an owner means any individual or entity that has any partnership interest in or that has 5 percent or more direct or indirect ownership of the provider or supplier as defined in the Social Security Act (SSA) § 1124 and § 1124A(A).

The Act defines the term “person with an ownership or control interest”, with respect to an entity, as a person who meets one or more criteria:

Has directly or indirectly an ownership interest of 5 per centum or more in the entity
Is the owner of a whole or part interest in any mortgage, deed of trust, note, or other obligation secured (in whole or in part) by the entity or any of the property or assets thereof, which whole or part interest is equal to or exceeds 5 per centum of the total property and assets of the entity
Is an officer or director of the entity if the entity is organized as a corporation
Is a partner in the entity if the entity is organized as a partnership

For more information on owners and ownership interest, refer to the Medicare Program Integrity Manual, Chapter 15, Sections 15.5.5 and 15.5.6 (PDF).

Do publicly traded company shareholders need to submit fingerprints?

Publicly traded company shareholders only submit fingerprints if they own 5 percent company shares or more.

Will every organization have an individual that meets the definition of “ownership or investment interest?”

No. Depending on your ownership structure, you may not have anyone who meets this definition. For example, non-profit organizations generally do not have owners and typically only have individuals with managing control.

Who evaluates whether an applicant is an individual who meets the definition of “ownership or investment interest?”

Your MAC will determine if you meet the definition of ownership or investment interest based on your OTP provider enrollment application and supporting documentation. For example, if you are a non-profit organization you must submit a copy of your 501(c)(3) forms to verify non-profit status.

If I think that I or individuals in my organization meet the definition of an owner, when do I submit fingerprints? With my application?

After you submit your application, your MAC may request you to submit fingerprints for individuals who have a 5% or greater direct/indirect ownership, even as a partner of an OTP provider when:

Initially enrolling
Substance Abuse and Mental Health Services Administration (SAMHSA) certified after October 23, 2018.

How much does fingerprinting cost, and who pays for it?

Cost may vary by location. You must pay to get your fingerprints; however, CMS pays for the background check on your fingerprints.

Where can I find step-by-step fingerprinting instructions?

The CMS Fingerprinting Instruction website allows you to:

Download forms and view fingerprinting instructions
Find a fingerprint collection site
Track the status of your submission to CMS

Where can I find additional fingerprinting information?

For more information, refer to MLN Matters® Article SE1417 (PDF) or contact your MAC.

How do I calculate 5% indirect ownership?

Here is an example that explains the term "indirect ownership".
Example 1:
Level 2: Company B (60%)

Level 1: Company A (100%)

Company A owns 100% of the enrolling provider.
Company B owns 60% of Company A.

In this example, Company A is the direct owner of the enrolling provider. Company B, as an owner of Company A, is an indirect owner of the provider. To calculate Company B’s indirect ownership in the provider, multiply 100% (Company A’s ownership in the provider) by 60% (Company B’s ownership in Company A). This comes to 0.6; as such, Company B has a 60% indirect ownership interest in the provider.

Medicaid

Will Medicaid always recoup payments from all Medicare-enrolled OTPs back to January 1, 2020?

No. Medicaid will recoup payment from a Medicare enrolled OTP back to the date the provider can begin billing Medicare (30 days prior to the effective date of the OTP’s Medicare enrollment), and the OTP will then bill Medicare for those services.

Will Medicaid continue to be the primary payer of claims for dually eligible beneficiaries after January 1, 2020?

States must pay claims for OTP services delivered to dually eligible beneficiaries by Medicaid enrolled OTP providers who are not yet enrolled in Medicare, to the extent that the services are covered in the state plan.

To avoid disruption in OTP treatment for dually eligible beneficiaries, states have several options during the interim until Medicare approves the OTP’s provider enrollment:

1) The state may choose to continue to pay OTP claims for dually eligible individuals for a period in early 2020. Once an OTP provider becomes Medicare-enrolled, Medicaid must recoup (“chase”) all Medicaid payments from the OTP provider back to the effective date of the OTP’s Medicare provider enrollment, and advise the provider to bill Medicare to receive payment for these services.

2) A state may advise OTP providers they can hold claims and bill Medicare once the OTP provider becomes Medicare-enrolled. This process will allow Medicare to review the claim and then cross the claim to Medicaid for payment automatically.

We encourage OTPs to reach out to their State Medicaid Agency to learn more about the plans in their state for processing these claims in early 2020.

Medicare Advantage

Are OTPs required to contract with Medicare Advantage Organizations (MAOs) in order to provide OTP services to their enrollees?

OTPs are not required to contract with MAOs. When an OTP chooses to contract with an MAO both parties negotiate the terms and conditions of payment.

If I work for a Medicare-enrolled OTP, do I have to enroll in Medicare separately?

No. Medicare Advantage plans may contract with any Medicare-enrolled OTP. Individual practitioners within an OTP do not need to enroll separately.

What are the basic MA access to services requirements for the OTP benefit?

MA plans may:

Contract directly with a Medicare-enrolled OTP
Arrange for its enrollees to get the OTP benefit from non-contract Medicare enrolled OTPs

An MA plan may require its enrollees to get OTP services only through contracted OTP facilities. In these cases, the MA plan must ensure equitable access to contracted OTPs throughout its service area.

If enrollees use non-contract OTPs, MA plans must contact those OTPs to coordinate plan benefits and timely payment to the OTPs consistent with federal regulations.

Who can an OTP call for help with MA billing questions?

OTPs should contact MA plans and ask for “provider services” to help with questions about payment for OTP services under that MA plan.

Page Last Modified:

11/22/2022 02:26 PM

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