Third Party Payers

Effective January 1, 2012, clinical social workers and other health care providers, health care clearinghouses, covered entities, and business associates who use electronic transactions mandated by the Health Insurance Portability and Accountability Act (HIPAA), will be required to replace the current software, Version 4010/4010A standards, with Version 5010 standards. Version 5010 updates standards including claims submission and status, remittance advice, eligibility, and referral authorizations. Electronic transactions that do not use Version 5010 beginning January 2012, will be rejected for non-compliance with HIPAA electronic transactions. Rejections include denial of reimbursement.

NASW members are seeking reimbursement clarifications when performing psychotherapy services to Medicare Part B beneficiaries who do not wish to use their Medicare benefits. In such situations, a clinical social worker may opt-out of Medicare. Opting out means that the clinical social worker cannot bill Medicare for any services they provide for a two year period. Instead, reimbursement is received from the Medicare beneficiary under the terms of a private contract.

Effective January 1, 2011, the Centers for Medicare and Medicaid Services (CMS) announced the following Medicare policy changes that affect clinical social workers who are Medicare providers.

Under The Omnibus Budget Reconciliation Act of 1989, clinical social workers became eligible as Medicare providers to seek reimbursement under Medicare Part B for the diagnosis and treatment of mental illnesses performed in an outpatient setting.

Effective January 1, 2010, the Centers for Medicare and Medicaid Services (CMS) announced the following Medicare policy changes that affect clinical social workers who are Medicare providers.