Common questions about primary and secondary CCBHC claims

Most clinics bill Medicaid for each service. In many states, Medicaid pays Certified Community Behavioral Health Clinics (CCBHCs) a fixed rate for each day or month.

If the patient also has Medicare or a commercial plan, you bill that payer first. If it doesn't pay or adjust the daily or monthly charge, your secondary claim to Medicaid won't balance.

This guide answers questions we commonly hear from CCBHC billing teams that use Stedi.

What is a CCBHC?

A CCBHC is a behavioral health clinic that meets federal certification criteria. It provides 9 core mental health and substance use services, including 24/7 mobile crisis response.

A clinic can become a CCBHC in three ways. How Medicaid pays the clinic depends on which one:

• Demonstration. The clinic is part of its state's Section 223 CCBHC Demonstration. Medicaid pays the clinic under payment rules from the Centers for Medicare & Medicaid Services (CMS).
• State program. The state pays for CCBHC services through its Medicaid state plan or a waiver instead of the demonstration. The state sets its own payment method.
• Grant only. The clinic gets a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). The grant doesn't change how Medicaid pays the clinic.

This guide covers the demonstration. Some state programs use the same billing codes.

How does Medicaid pay CCBHCs?

In the demonstration, Medicaid pays each CCBHC a prospective payment system (PPS) rate. It's a fixed amount the state sets in advance from the clinic's costs.

Each state picks whether Medicaid pays the rate daily or monthly. Medicaid pays for each day or month that the patient gets at least one CCBHC service.

Some states also pay a separate rate for crisis services. CMS defines four PPS methods based on these choices: CC PPS-1 through CC PPS-4. Your state billing guide can use these names.

If the patient has a Medicaid managed care plan, the state decides who pays the PPS rate:

• The plan. The plan pays the CCBHC the full PPS rate.
• The plan and the state. The plan pays its usual rate. The state pays the CCBHC the difference.

What billing codes did CMS create for CCBHCs?

CMS created HCPCS billing codes that states can use for CCBHC Demonstration claims.

CCBHC billing codes

This guide calls T1040 and T1041 the CCBHC codes.

CMS also says CCBHC claims should list each service the patient got. These lines are for data reporting. Some state billing guides call them shadow lines. States can use the Q2 modifier to flag them.

Which payer do I bill first?

Medicaid is the payer of last resort, so you usually bill the patient's other coverage first. Common primary payers include Medicare and commercial payers, like employer plans. A patient with both Medicare and Medicaid is a dual eligible.

Some states let you bill Medicaid first for the CCBHC codes. Check your state billing guide, and recheck it each year.

To find other coverage, ask the patient. You can also run a COB check. A COB check shows overlapping coverage and, when it can, which payer is primary. COB checks support many Medicare Advantage plans, but not traditional Medicare.

For traditional Medicare, send an eligibility check to CMS. Use payer ID CMS. If the patient has a Medicare Advantage plan, the response includes it.

CMS checks require the patient's Medicare Beneficiary Identifier (MBI). Medicaid eligibility responses for dual eligibles can include it. If you don't have the MBI, run an MBI lookup.

How much does Medicaid pay after another payer?

It depends on the primary payer and the patient's Medicaid coverage.

For a patient with Medicare and full Medicaid, Medicaid pays up to the PPS rate after Medicare's payment. For example, Medicare pays $80 for a visit. The clinic's daily PPS rate is $250. Medicaid pays up to $170.

For commercial primary payers, check your state billing guide. The CMS PPS guidance doesn't cover them.

Why don't secondary CCBHC claims balance?

A common cause is a CCBHC code line with a charge that the primary payer didn't pay.

Medicare doesn't pay HCPCS T codes. Every secondary claim must balance:

Total charges = All payments + All adjustments

Include every payment and adjustment from the primary payer's Electronic Remittance Advice (ERA) in the secondary claim. Each line on the primary payer's ERA must balance too. If an ERA doesn't balance, contact us. We'll work with the payer to fix it. If the ERA doesn't adjust the CCBHC code line's charge, the claim is out of balance.

What should I check in my state billing guide?

Rules vary by state. In your state's billing guide, look for:

• Where the CCBHC code goes. Some states put it on both claims, and others put it only on the Medicaid claim.
• Line charges. This includes the CCBHC code line and each shadow line. The guide also says which lines get the primary payer's payments and adjustments.
• Claim type. Medicaid can require a professional or institutional claim. The claim type decides which Stedi endpoint you use.
• Crossover claims. If Medicare is primary, it can forward the claim to Medicaid for you. Some states still require a new claim.

If you're unsure, ask your state Medicaid program. If you have questions about how to structure your claims, contact us.

Where can I find CCBHC billing guidance for my state?

The following table links to each state's official CCBHC source, as of November 12, 2026. If a state hasn't published guidance yet, the table links to its official announcement.

Program types come from SAMHSA. U.S. territories and Washington, D.C., don't have a CCBHC demonstration or state program. States added to the demonstration in 2026 start between July 1, 2026, and July 1, 2027.

If your state isn't listed, ask your state Medicaid program.

Can I submit CCBHC claims through Stedi?

Yes. CCBHC claims are standard professional or institutional claims. You can submit them using Stedi's APIs, SFTP, or X12 upload in the Stedi portal.

To find the payer ID for a state Medicaid program or Medicaid managed care plan, search the Payer Network.

To get ERAs, you need an ERA enrollment with each payer, including the primary payer.

How do I submit a secondary CCBHC claim with Stedi?

If you billed another payer first, wait for its ERA.

If Medicare is primary, check the ERA for a crossover. A claim status code of 19 means Medicare forwarded the claim to the secondary payer. Check your state billing guide for what to do next.

If there's no crossover, or your state needs a new claim, send the secondary claim to Medicaid. Mark the prior payer as primary, and include its payments and adjustments from the ERA. Stedi rejects claims that don't include information for the primary payer.

The Create Professional Claim (CMS-1500) JSON endpoint doesn't support secondary claims. For institutional claims, see Submit institutional claims. For professional claims, use one of these endpoints:

{
  "subscriber": {
    "paymentResponsibilityLevelCode": "S", // Claim for the secondary payer
    ...
  },
  "claimInformation": {
    "otherSubscriberInformation": [
      {
        "paymentResponsibilityLevelCode": "P", // Prior payer is primary
        "payerPaidAmount": "100.00", // Primary payer's total payment
        "otherPayerName": {
          "otherPayerIdentifier": "12345", // Primary payer's ID
          ...
        },
        ...
      }
    ],
    "serviceLines": [
      {
        "professionalService": {
          "lineItemChargeAmount": "150.00", // Line charge
          ...
        },
        "lineAdjudicationInformation": [
          {
            "otherPayerPrimaryIdentifier": "12345", // Matches otherPayerIdentifier
            "serviceLinePaidAmount": "100.00", // Primary payer's line payment
            "claimAdjustmentInformation": [
              {
                "adjustmentGroupCode": "CO",
                "adjustmentDetails": [
                  {
                    "adjustmentReasonCode": "45",
                    "adjustmentAmount": "50.00" // $150 = $100 paid + $50 adjusted
                  }
                ]
              }
            ],
            ...
          }
        ],
        ...
      },
      ... // Other service lines
    ],
    ...
  },
  ...
}

SBR*S*18*******MC~        // Loop 2000B: claim for the secondary payer
...
SBR*P*18*******CI~        // Loop 2320: prior payer is primary
AMT*D*100~                // Primary payer's total payment
...
SV1*HC:...*150*UN*1***1~  // Line charge
...
SVD*12345*100*HC:...**1~  // Loop 2430: primary payer's line payment
CAS*CO*45*50~             // $150 = $100 paid + $50 adjusted
...                       // Other service lines

The examples show where the primary payer's details go, not which line gets the CCBHC code. Some states put the CCBHC code on the same line as the primary payer's payment and adjustments.

For the full field list, see Submit to a secondary or tertiary payer.

Stedi checks claim-level and service line-level COB balancing before it sends the claim to the payer. If a claim doesn't balance, Stedi rejects it. API submissions get an error in real time. For example, a line that doesn't balance returns:

{
  "errors": [
    {
      "code": "33",
      "description": "Coordination of Benefits (COB) balancing failed. For line 1, the total charged amount of $150.00 does not equal the sum of the paid amount of $0.00 and all adjustment amounts of $200.00 for payer STEDITEST. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

SFTP submissions get the same error in a 277CA claim acknowledgment.

To test a claim before you send it to a payer, use test mode. Submit a test claim to the Stedi Test Payer.

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