region/plan-specific news
: Pennsylvania HealthChoices
Billing targeted case management
Billing basics, common red flags and outlier awareness
Behavioral health targeted case management (TCM) supports members with complex needs by coordinating services across systems of care. Because TCM is time-based and documentation-driven, accurate billing is essential to reduce the risk of claim reviews and denials and support timely, appropriate reimbursement.
This overview highlights key billing considerations for HCPCS code T1017, including unit reporting, modifier use, and billing patterns that may be considered outliers and result in additional review, including referral to the Special Investigations Unit (SIU).
Understanding behavioral health TCM
TCM focuses on care coordination and linkage — not direct clinical treatment. Common activities include:
- Assessing member needs
- Developing care plans
- Coordinating services and referrals
- Monitoring follow-up and progress
Documentation should clearly show how each activity supports care coordination and the member’s individualized goals.
Key tips for billing T1017 units and modifiers
- Bill T1017 in 15‑minute units, based on actual time spent coordinating care (State‑ or plan‑specific rules may apply.)
- Document both time billed and coordination activities performed.
- Indicate the necessity for contact and service goals and objectives in the progress note.
- Verify that the place of service (POS) code billed matches the documentation.
- Ensure that case manager caseloads remain within regulatory requirements.
- Apply modifiers only when required and supported by documentation.
Red flags to monitor
Magellan’s Special Investigations Unit (SIU) has identified the following frequent billing or documentation patterns that may trigger review:
- Consistently high units billed per day or per member
- Little or no variation in units per encounter
- Billing patterns that significantly exceed peer norms
- Repetitive or near-identical documentation across dates of service
- Service plans that vary minimally from plan to plan
- Limited evidence of individualized coordination efforts
- Documentation focused on scheduling or clerical tasks
- Notes reflecting time spent “waiting with member,” “on hold,” “attempted/missed appointment” or completing paperwork
- Billing for transporting or escorting members, which is not a covered TCM service under 42 CFR §440.169)
Avoiding duplicate services
TCM must remain distinct from therapy, psychiatric services or care coordination included in other programs. Billing overlapping services may lead to denials or recoupment.
Key takeaways
Accurate time tracking, individualized documentation and awareness of billing patterns help support compliant billing—and preserve the value of behavioral health TCM services.
For additional guidance, review applicable program requirements or contact provider relations.
Training resources on targeted case management
- For Pennsylvania HealthChoices, see Compliance Notebooks for May 2024 (PDF) | July 2023 (PDF) | May 2019 (PDF) on the Magellan of Pennsylvania website.
More information
- Review examples of fraud, waste, and abuse and HIPAA standard code sets in Section 4 of Magellan's National Provider Network Handbook (PDF).
- Questions about audits or investigations? Email SIU@MagellanHealth.com or call 1-800-755-0850 (you can remain anonymous).