Updated reimbursement rates for Commercial plans   

Within the next few weeks, some network (contracted) providers in New York will receive a contract amendment and updated fee schedule. The changes are to align our reimbursement rates for select outpatient services with Part AA of Chapter 57 of the New York Laws of 2024.

Here’s what you need to know

Impacted plans: Fully insured individual and group comprehensive health insurance policies and contracts issued in New York that are renewed, modified, altered or amended on and after Jan. 1, 2025

Reimbursement changes: For dates of service on or after Jan.1, 2025, reimbursement rates for the designated outpatient services must be at or above the Medicaid rate for the services.

What happens next

Watch your mail for updated information: All providers who are affected by this regulatory requirement will receive a mailing with a contract amendment and updated fee schedule that includes revised codes and reimbursement rates

Automatic claim reprocessing: Optum Behavioral Health will automatically reprocess any claims that were reimbursed with an incorrect rate. This applies only to claims who meet the criteria noted above around OMH/OASAS licensing, health plans and date(s) of service. Please do not submit a corrected claim or reconsideration request. 

Use Medicaid rates on claims: To help ensure accurate claim submission and processing, we encourage you to bill using New York’s Medicaid reimbursement amounts. 

If you are an OMH/OASAS licensed provider and bill with a U5 modifier to denote supervision, please exclude it for these claim submissions.

Questions?

Contact your Network Manager or email NYNetworkmanagement@optum.com