Payers and Codes Survey

Payers List and Payer ID*

List what payers you are credentialed with. If you submit claims electronically please include Payer ID.

Payer Name	Clearinghouse Payer ID

Mental Health - Employee Assistance Program
Select ONLY the codes that you will use for this type of service
Mental Health - Employee Assistance Program*
Select the codes you use.
- 90832 HJ - Individual Therapy: 16-37 Min
- 90834 HJ - Individual Therapy: 38-52 Min
- 90837 HJ - Individual Therapy: 53+ Min
- 90846 HJ - Family Therapy without Patient
- 90847 HJ - Family Therapy with Patient
- 99404 - Cigna EAP
- Other
Please enter the rates you would like to charge per unit for the codes above*
(Example: 90791 - $2.00; 90791 TS - $1.00; etc.) If you selected other above please enter the codes you would like us to add and the rate for the code along with the name.

Housing Stabilization
Select ONLY the codes that you will use for this type of service
EIDBI Codes*
Select the codes you use.
- H0043 U5 - Supplemental Services
- H2015 U8 - Housing Transition
- H2015 U8 TS - Housing Sustaining
- T2024 U8 - Housing Consultation
- Other
Please enter the rates you would like to charge per unit for the codes above*
(Example: 90791 - $2.00; 90791 TS - $1.00; etc.) If you selected other above please enter the codes you would like us to add and the rate for the code along with the name.

Code 1
Code*
Code Number Modifier (if applicable) Revenue Code Code Name
Allow override of time/units ratio?*
- No - use fixed time/unit ratio above
- Yes - allow staff to change time and units
- Always 1 Unit
If you answered no above please list the Hours/Minutes per unit here:
Hours Minutes
Inpatient*
- Yes
- No
Is this code used for Group Services?*
- Yes
- No
Is there a Default Place of Service for this code? If no put N/A.*
Rate per Unit*
Do you have more codes to enter?*
- Yes
- No

Code 2
Code*
Code Number Modifier (if applicable) Revenue Code Code Name
Allow override of time/units ratio?*
- No - use fixed time/unit ratio above
- Yes - allow staff to change time and units
- Always 1 Unit
If you answered no above please list the Hours/Minutes per unit here:
Hours Minutes
Inpatient*
- Yes
- No
Is this code used for Group Services?*
- Yes
- No
Is there a Default Place of Service for this code? If no put N/A.*
Rate per Unit*
Do you have more codes to enter?*
- Yes
- No

Code 3
Code*
Code Number Modifier (if applicable) Revenue Code Code Name
Allow override of time/units ratio?*
- No - use fixed time/unit ratio above
- Yes - allow staff to change time and units
- Always 1 Unit
If you answered no above please list the Hours/Minutes per unit here:
Hours Minutes
Inpatient*
- Yes
- No
Is this code used for Group Services?*
- Yes
- No
Is there a Default Place of Service for this code? If no put N/A.*
Rate per Unit*
Do you have more codes to enter?*
- Yes
- No

Code 4
Code*
Code Number Modifier (if applicable) Revenue Code Code Name
Allow override of time/units ratio?*
- No - use fixed time/unit ratio above
- Yes - allow staff to change time and units
- Always 1 Unit
If you answered no above please list the Hours/Minutes per unit here:
Hours Minutes
Inpatient*
- Yes
- No
Is this code used for Group Services?*
- Yes
- No
Is there a Default Place of Service for this code? If no put N/A.*
Rate per Unit*
Do you have more codes to enter?*
- Yes
- No

Code 5
Code*
Code Number Modifier (if applicable) Revenue Code Code Name
Allow override of time/units ratio?*
- No - use fixed time/unit ratio above
- Yes - allow staff to change time and units
- Always 1 Unit
If you answered no above please list the Hours/Minutes per unit here:
Hours Minutes
Inpatient*
- Yes
- No
Is this code used for Group Services?*
- Yes
- No
Is there a Default Place of Service for this code? If no put N/A.*
Rate per Unit*

Please List all your Payers and Payer IDs that you bill to