Rates and Out-of-Network Information
Provider Rate-Setting
The HealthChoices behavioral health program has two different rates depending on the type of service offered: Standard and Non-Standard.
Standard Rates
Certain levels of care have a standard rate, meaning the rate is the same across all providers of that level of care (LOC). Standard rate reviews are conducted routinely and collectively. Providers with standard rates are encouraged to notify CBH of their financial challenges. That information will inform standard rate rebasing; however, individual increases are not considered.
Standard LOCs include:
- Intensive Behavioral Health Services (IBHS)
- Outpatient Substance Use Disorder (SUD)
- Intensive Outpatient SUD (IOP)
- Outpatient Mental Health
- Inpatient SUD Services (ASAM 4.0, 4.0WM)
- Non-Hospital SUD (ASAM 3.1, 3.7, 3.7WM)
- Mobile Psychiatric Rehabilitation Services (MPRS)
- Laboratory Services
The following is taken into consideration during standard rate rebasing:
- Timing of the last increase
- Funding availability
- Increased costs associated with providing the service
- Current PA Medical Assistance (MA) rates
Please Note: New and out-of-network providers receive the current standard rate.
Non-Standard Rates
Certain levels of care have non-standard rates, meaning the rate may differ among providers of the same LOC. Non-standard rates are reviewed routinely; however, increases are considered if providers submit adequate proof of significant financial challenges.
Requests for rate increases should only be submitted in extenuating circumstances. Requests are reviewed biannually and are due by March 15th and September 15th, with decisions made by June 1st and December 1st, respectively. Providers may submit only one request per calendar year for an LOC at a specific service location.
Providers must submit all requests using CBH’s Rate Increase Request Submission Form and rate request documentation package located below. All sections of the form must be completed, and all necessary documents must be attached.
Once all information is received, it will be reviewed by CBH’s Rate Request Committee, as well as CBH’s Provider Strategy and Financial Stability team or the CBH/DBHIDS Finance Committee.
Non-Standard LOCs include:
- Inpatient Psychiatry
- Non-Hospital SUD (ASAM 3.5)
- All residential programs with per diem rates (including RTF)
- Intensive Case Management (ICM)
- Resource Coordination (RC)
- Partial Hospitalization Services (ASAM 2.5)
The following is taken into consideration during rate request reviews:
- Timing of the last increase
- Funding availability
- Rate equity with similar services
- Current PA Medical Assistance (MA) rates
- Budget and/or actual financial data
- City of Philadelphia’s living wage increases
- Quality, clinical, program integrity, and network adequacy considerations
Rate Request Submission Form and Documentation Package
CBH Rate Increase Request Submission Form
All sections of the form must be completed, including a completed rate request documentation package:
- CBH Cover Sheet
- Corresponding letter justifying the need
- Appendix A: Certification Statement
- CBH-formatted Excel Spreadsheet containing the following:
- Appendix B: Expenditure Summary
- Appendix C: Personnel Invoice Schedule
- Appendix D: Miscellaneous Item Detail
- Most recent audited financial statement
- Appendix E: Expected Clinical Outcomes and Monitoring Methods
Requests for rate increases should only be submitted in extenuating circumstances. Requests are reviewed biannually and are due by March 15th and September 15th, with decisions made by June 1st and December 1st, respectively. Providers may submit only one request per calendar year for a level of care at a specific service location.
For questions or concerns, please email us at CBH.RateRequest@phila.gov.
Rate-Setting Resources
Non-Par/Out-of-Network Provider Information
CBH works to maintain a robust provider network. If an in-network provider cannot meet the clinical needs of a member, an Out-of-Network (OON) provider may be considered. CBH will approve and reimburse OON medically necessary behavioral health services provided to members when there is a demonstrated need for the service. Please review and complete the OON Provider Application which includes an attestation that all information submitted is accurate and the organization agrees to comply with all stipulations outlined in the attestation.
Out-of-Network Application Tutorial Webinar
Any questions regarding the CBH OON/Non-Participating Provider Application process can be directed to the CBH OON Provider Hotline at 215-413-7660 (select option 2) or via e-mail at CBHOON@phila.gov. Please provide the facility name, contact person, phone number, and email address when contacting CBH.
