Overview
Effective for dates of service on or after September 20, 2026, DHCS requires DMC and DMC-ODS counties to manually review Narcotic Treatment Program (NTP) counseling claims and apply the GD modifier when a member receives nine (9) or more NTP counseling units on a single date of service, per BHIN 26-022. This change applies only to counseling delivered in an NTP setting. Other NTP services and non-NTP counseling are not affected.
What's Changing
DHCS has established an outlier threshold of nine (9) or more NTP counseling units for a single Medi-Cal member on a single date of service, counted across all claims for that date. When a member meets or exceeds the threshold, the county must manually review the documentation and apply the GD modifier to every NTP counseling service line for that member on that date. DHCS will deny claims that meet or exceed the threshold without the GD modifier.
Why This Change Is Happening
A 2022 audit by the U.S. Department of Health and Human Services Office of Inspector General (OIG) found NTP counseling claims that billed an unreasonable number of units for a single client in one day. BHIN 26-022 responds to the OIG’s recommendations by establishing a statewide threshold and requiring county review before DHCS pays high-volume NTP counseling claims.
Services That Count Toward the Threshold
Code | Service | Applies To |
H0004 | Individual Counseling | DMC and DMC-ODS |
H0005 | Group Counseling | DMC and DMC-ODS |
T1006 | Family Counseling | DMC-ODS only |
Units are billed in 15-minute increments. Other NTP services, such as assessment, medication services, and medical psychotherapy, do not count toward the threshold and are not subject to the manual review or modifier requirement.
Action Required – County Review Before Applying the Modifier
Before the GD modifier is applied, the county must review the documentation for all NTP units claimed for the member on that date of service and confirm that the counseling units were medically necessary. Typically, this review would be conducted by the county’s Quality Assurance (QA) or Utilization Review (UR) staff.
By applying the GD modifier, the county certifies that:
- The NTP has submitted documentation supporting the counseling units;
- The county has reviewed the documentation; and
- The county has determined the units of service are medically necessary to meet the member’s individual needs.
Counties may apply the modifier before or after claim submission:
- Pre-submission: Identify NTP counseling units that meet or exceed the threshold, complete the manual review, and apply the GD modifier before submitting the claim.
- Post-submission: If a claim is denied for meeting the threshold without the GD modifier, complete the manual review. If documentation supports medical necessity, replace the denied claim with the GD modifier applied. If documentation does not support medical necessity, do not replace the claim; the denial remains in effect.
If the review determines that some of the claimed NTP counseling units were not medically necessary, the county may replace the claim to reflect the appropriate number of units.
Counties must also ensure that NTP staff and any subcontracted providers are aware of the threshold and the supporting documentation requirements, that outlier units are manually reviewed before payment, and that all required documentation is completed and retained. DHCS will monitor counties for compliance.
SmartCare Changes
CalMHSA is developing a report to help counties determine which services will need review. This report is still in testing and has not yet been deployed to production systems.