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April 2026 Top of Mind
Adherence to billing guidelines can lead to smoother processing of MassHealth wellness claims
MassHealth updated its billing requirements and guidance for MassHealth ACO (Medicaid) member annual behavioral health wellness exams effective Sept. 23, 2025. The behavioral health wellness exam includes screening or assessment to identify member behavioral or mental health needs and identification of appropriate treatment resources.
The billing codes are determined by where the wellness exam is conducted and rendering service provider specialty. Please make any necessary adjustments to your billing processes to prevent claim denials or payment delays.
Key Changes
- MassHealth will pay for one annual behavioral health wellness examination per member, per year.
- No pre-existing clinical criteria or behavioral health diagnosis is required before completing the wellness exam.
- Providers must not use modifier 33 for claims billed for any MassHealth ACO member. This modifier is not recognized by the U.S. Centers for Medicare & Medicaid Services.
Billing Guidelines
- The table below provides billing guidelines by service code and provider specialty. Unlicensed mental health professionals are not qualified to render annual behavioral health wellness examinations.
- The diagnosis code Z13.30 may be used in any diagnostic code position. It is not required to be listed as the primary diagnosis code.
- The rendering provider should add any additional applicable diagnosis codes if a condition is discovered during the screening.
- Providers who bill using this code combination do not need to conduct a Child and Adolescent Needs and Strengths (CANS) assessment for members younger than 21 years of age.
| Provider Type | Visit Type | Service Code | Diagnosis Code |
|---|---|---|---|
| BH Provider non-CHC* | Standalone BH Wellness Visit | 90791 – Psychiatric diagnostic evaluation (an integrated biopsychosocial assessment, including history, mental status and recommendations) |
Z13.3 – Encounter for screening examination for mental health and behavioral disorders |
| BH Clinician CHC | Standalone BH Wellness Visit | T1040 Medicaid certified community behavioral health clinic services, per diem.
|
Z13.3 Encounter for screening examination for mental health and behavioral disorders |
*CHC: Community Health Center
Benefits and eligibility
For assistance with member benefits, please call the phone number on the back of the member’s insurance card.
For clinical questions
Our dedicated Massachusetts provider services team is available for assistance by phone at 1-866-860-7308, Monday–Friday, 8 a.m.–8 p.m. ET.
