Category: Health Insurance

More insurance billing information and guides visit axisirg.com.

Here’s a cheat sheet for insurance billing related to substance abuse and mental health:

Verify insurance coverage: Before beginning treatment, it’s important to verify the patient’s insurance coverage for substance abuse and mental health services. This includes checking if the insurance plan covers the specific services being provided, such as individual therapy, group therapy, or medication management.
Obtain pre-authorization: For certain types of treatment, such as inpatient hospitalization or intensive outpatient programs, pre-authorization from the insurance company may be required. Make sure to obtain this authorization before beginning treatment to avoid any billing issues.
Check for co-pays and deductibles: Determine the patient’s co-pay and deductible amounts for substance abuse and mental health services. These amounts may be different from those for general medical services, so it’s important to double-check.
Code accurately: Use the correct billing codes for the services provided. This includes the diagnosis codes for the patient’s mental health or substance abuse condition, as well as the procedural codes for the specific services rendered.
Submit claims promptly: Submit claims to the insurance company promptly after the services are provided. This will help ensure timely payment and prevent any delays or denials.
Follow up on unpaid claims: If a claim is not paid within a reasonable amount of time, follow up with the insurance company to determine the reason for the delay. This may require resubmitting the claim or providing additional documentation.
Document thoroughly: Document all services provided and any communication with the insurance company related to billing or reimbursement. This will help ensure accurate billing and prevent any potential audit issues.

By following these guidelines, you can help ensure accurate and timely insurance billing for substance abuse and mental health services.

CPT Cheatsheet

The most common CPT Codes used by professional clinicians and therapists

Diagnostics:

• 90791 – Psychiatric Diagnostic Evaluation (usually just one/client is covered)

• 90792 – Psychiatric Diagnostic Evaluation with medical services (usually just one day per client is covered)

Therapy:

• 90832 – Psychotherapy, 30 minutes (16-37 minutes).

• 90834 – Psychotherapy, 45 minutes (38-52 minutes).

• 90837 – Psychotherapy, 60 minutes (53 minutes and over).

• 90846 – Family or couples psychotherapy, without patient present.

• 90847 – Family or couples psychotherapy, with patient present.

• 90853 – Group Psychotherapy (not family).

Crisis:

• 90839 – Psychotherapy for crisis, 60 minutes (30-74 minutes).

• +90840 – Add-on code for an additional 30 minutes (75 minutes and over). Used in

conjunction with 90839.

Other:

• +90785 – Interactive Complexity add-on code. Covered below.

There are also E/M (evaluation & management) in conjunction with psychotherapy, used by

authorized prescribers. Coding E/M is trickier, harder to document and more vulnerable to

audit but usually results in greater reimbursement. There’s also a series of E/M codes that are

used without the psychotherapy component. For more in-depth coverage on E/M coding for

psychotherapy there are some good free webinars released by AACAP on E/M CPT Codes.

• +90833 – E/M code for 30 minutes of psychiatry (used with 90832).

• +90836 – E/M code for 45 minutes of psychiatry (used with 90834).

• +90838 – E/M code for 60 minutes of psychotherapy (used with 90837).

For Facilities and Offices/Clinics

Residential Treatment:

H0018: Behavioral health; residential, per diem
H0019: Substance abuse treatment; per diem

Partial Hospitalization:

H0035: Mental health; partial hospitalization, treatment, per diem
H0015: Substance abuse treatment; partial hospitalization, per diem

Intensive Outpatient:

H0016: Behavioral health; intensive outpatient program, per session
H0017: Substance abuse treatment; intensive outpatient program, per session

Outpatient:

90832: Psychotherapy, 30 minutes with patient and/or family member
90834: Psychotherapy, 45 minutes with patient and/or family member
90837: Psychotherapy, 60 minutes with patient and/or family member
H0004: Behavioral health; counseling and therapy, per 15 minutes
H2035: Substance abuse treatment; group counseling, per 15 minutes

Other Services:

96150: Health and behavior assessment
96151: Health and behavior reassessment
96152: Health and behavior intervention, individual
96153: Health and behavior intervention, group (2 or more patients)
96154: Health and behavior intervention, family (with patient present)

It’s important to verify the correct codes with the insurance company and ensure accurate billing to prevent any potential issues with reimbursement.

These codes are just a starting point, and the specific codes used may vary depending on the patient’s insurance plan and the services provided. It’s important to verify the correct codes with the insurance company and ensure accurate billing to prevent any potential issues with reimbursement.

Before creating your template for referring to PHP or other levels of care for behavioral health, it is good to remember some basic medical necessity criteria from insurance.

Medical necessity criteria for Partial Hospitalization Programs (PHP) in behavioral health may vary depending on the specific treatment facility, insurance provider, and the individual patient’s needs. However, there are some common medical necessity criteria often used to determine if a patient qualifies for PHP care in behavioral health settings. Here are some typical criteria:

Diagnosis: The patient must have a diagnosable mental health condition that requires intensive treatment. This could include conditions such as severe depression, bipolar disorder, schizophrenia, substance use disorders, eating disorders, or other severe mental illnesses.
Risk of Harm: The patient should present a risk of harm to themselves or others. This could manifest as suicidal ideation, self-harm, severe impairment in daily functioning, or violent tendencies.
Symptom Severity: The severity of the patient’s symptoms should be such that they require more than outpatient care but do not require 24-hour inpatient hospitalization. PHP is typically considered when the patient needs structured and intensive treatment during the day but can return home or to a safe living environment in the evenings.
Functional Impairment: The patient’s mental health condition should significantly impair their ability to function in daily life, including but not limited to work, school, relationships, and self-care.
Lack of Progress in Outpatient Care: The patient should have demonstrated a lack of progress or inadequate response to outpatient treatment or less intensive levels of care, such as individual therapy or outpatient group therapy.
Medical Stability: The patient should be medically stable enough to participate in a day program without requiring constant medical supervision. Any medical conditions that need attention should not be so severe that they overshadow the need for mental health treatment.
Support System: Ideally, the patient should have a support system or a safe and stable living environment to return to in the evenings when they are not in the PHP. This helps ensure that they can continue their recovery outside of the program.
Treatment Plan: There should be a clear and comprehensive treatment plan in place that outlines the patient’s specific goals and objectives in the PHP, as well as a plan for transitioning to lower levels of care when appropriate.

It’s important to note that the specific criteria can vary by state, insurance provider, and the policies of the treatment facility.

Sample referral letter to help with authorization approval:

[Your Name]

[Your Title]

[Your Clinic/Hospital Name]

[Address]

[City, State, ZIP Code]

[Phone Number]

[Email Address]

[Date: MM/DD/YYYY]

To Whom It May Concern,

I am writing this letter to provide a strong recommendation for [Patient’s Full Name], a valued patient under my care, to receive treatment at the Partial Hospitalization Program (PHP) level of care for mental health. I have had the privilege of overseeing [Patient’s Name]’s medical care for [duration of treatment relationship], and I believe that the PHP level of care is an appropriate and necessary step in their journey towards improved mental health and well-being.

[Patient’s Name] is a [age]-year-old [gender] who has been struggling with [brief description of the patient’s mental health condition or concerns, including any relevant diagnoses, such as depression, anxiety, bipolar disorder, etc.]. Despite our best efforts, [he/she/they] have experienced significant challenges in managing their symptoms, which have begun to impact [his/her/their] daily functioning, relationships, and overall quality of life.

After careful consideration and a thorough assessment, I firmly believe that the PHP level of care offers the intensive and comprehensive treatment that [Patient’s Name] requires at this stage. The structured environment, consistent therapeutic support, and access to a multidisciplinary team of mental health professionals provided by the PHP program will be instrumental in addressing [Patient’s Name]’s complex needs.

Specifically, I anticipate that the PHP program will provide the following benefits for

[Patient’s Name]:

Structured Therapy: [Patient’s Name] will have the opportunity to engage in structured group and individual therapy sessions designed to address [his/her/their] specific mental health challenges.

Medication Management: The PHP program’s medical staff will closely monitor [Patient’s Name]’s medication regimen, ensuring that [he/she/they] receive the appropriate adjustments and support.

Psychoeducation: [Patient’s Name] will gain valuable insights and coping strategies through psychoeducational sessions, empowering [him/her/them] to better manage [his/her/their] symptoms outside of the program.

Peer Support: Interacting with peers who are navigating similar struggles can foster a sense of camaraderie, reducing feelings of isolation and promoting a supportive environment.

Holistic Approach: The PHP program’s holistic approach to treatment will address various aspects of [Patient’s Name]’s well-being, including physical, emotional, and psychological health.

In conclusion, I wholeheartedly recommend [Patient’s Full Name] for admission to Partial Hospitalization for mental health. I am confident that the program’s expert team and comprehensive resources will provide the necessary support to help [him/her/them] achieve meaningful progress in [his/her/their] mental health journey.

Please feel free to contact me at [phone number] or [email address] should you require any additional information or insights regarding [Patient’s Name]’s medical history and current condition. I am dedicated to collaborating closely with the PHP program to ensure the best possible outcomes for [Patient’s Name].

Thank you for your attention to this matter and for the invaluable service you provide to individuals seeking to improve their mental health and well-being.

Sincerely,

[Your Signature]

[Your Printed Name]

[Your Title]

[Your License Number]

[Your Clinic/Hospital Name]

Insurance carriers all look at eating disorder treatment differently. Submitting claims or billing for eating disorders can be complicated.

Navigating an insurance billing for eating disorders can be a nuisance if you do not know what to do or where to “touch.” One of the main obstacles to treatment for facilities and outpatient programs helping individuals with eating abnormalities is the cost of the treatment. Some residential treatment centers can cost up to $30,000 a month. Clearly with everything that has happened in 2020-2021, a crucial driver in where someone chooses to get treatment is the ability to accept insurance as payment.

This makes holding insurance companies accountable to their policies and contracts in terms of reimbursement for those needing help with eating disorders very critical.

Now, while studies show that early diagnosis and evidence-based medical care approach are both critical for recovery, insurance regulations and guidelines in most cases make it almost impossible to receive the appropriate care needed.

So, if you or your loved one is faced with this type of condition, where do you start? Sadly, these challenges sometimes include determining how to analyze your insurance plans to understand the treatment coverage that is ideal for you. Here are some aspects that you should know about insurance billing for disorders:

What type of eating disorders are covered by your insurance? Billing for eating disorders varies by insurance carrier.

Many insurance policies have these disorders covered by benefits that technically are dictated by the DSM-5 eating disorder list these eating disorder diagnoses:

Binge eating disorder
Anorexia nervosa
Bulimia Nervosa
Avoidant/ restrictive intake disorder
EDNOS Splits Up
ARFID

What will be deducted and what will be go to the out of pocket max for my insurance, and how much is it?

In most cases, once we make a phone call to the insurance company that we know will make billing for eating disorders as about as tough as any art possible, the admission department or the respective department will check the benefits. After the confirmation, we will be informed of any deductible that is supposed to pay out of pocket. This is usually the amount that is supposed to pay before an insurance company covers a claim. The specific amount sometimes varies depending on the insurance company as well as the plan.

For instance, if a deductible is $ 500 and treatment is billed at $ 250 daily, the patient would be responsible for covering the initial two days on their own. After payments are made or the patient meets their deductible, the insurance firm will cover the expenses 100%. Some insurances or actual treatment programs require policyholders to pay co-insurance. This is where the patient is responsible for paying a certain percentage of the entire insurance billing for eating disorders. This can range from 10 to 50%.

What level of care is paid for?

In most cases, the level of care that insurance companies approve for is individual outpatient therapy. The most common process for insurance in terms of level of care, however, of behavioral healthcare is inpatient, then residential care, PHP (Partial Hospital program (PHP), and finally the IOP (intensive outpatient program). Note that, for anyone to access any of the above treatments, they must:

Have benefits under their plan for these levels of healthcare and have out of network coverage is the program is not credentialed as an in-network provider.
Meet the necessity, which is evaluated by the severity of symptoms, current weight, vital signs, and blood work results.

How long will the coverage last?

This will depend on various factors. Has the condition improved? Is it deteriorating? Most insurances state in their “insurance billing for eating disorders” policy that according to the ACA almost all have unlimited days, depending on medical necessity. Once medical necessity stops meeting the level of care required for a certain program, insurance will most certainly require a step down for a less intensive level of care.

For instance, a patient can be admitted into a residential program once stabilized and no longer in need of critical care or is not meeting the clinical or medical criteria. Similarly, if you do not improve in that care, and your condition is worsening, you will be admitted to a better level of care, such as inpatient.

What if insurance does not cover eating disorders?

There are a few things you can do depending on the personal and financial circumstances:

Switch plans; This should be pretty straightforward for anybody whose current plan does not cover eating disorders. Not all insurance companies offer this, but some reliable ones do it as a reprieve for members from a high-cost treatment.
Some non-profit organizations now partner with various treatment centers to provide financial help to those who cannot afford life-saving treatments. Look for one and ask for help.

It is important to understand these factors so that you can advocate to receive the right treatment. You are capable and strong enough to mastermind your future.

Please text us at 804-424-BILL with any questions!

Getting clients for an Partial Hospitalization Program/Intensive Outpatient Program (PHP/IOP) treatment facility in any location, involves a combination of marketing, networking, and providing high-quality services. Here are some steps to help you attract clients to your PHP/IOP treatment facility:

1. **Understand the Market**:

– Research the local market to understand the demand for PHP/IOP treatment services, including addiction or mental health treatment.

– Identify your target audience, such as individuals struggling with substance abuse, mental health issues, or other behavioral health concerns.

2. **Regulatory Compliance**:

– Ensure your facility complies with all relevant state and federal regulations, including licensing requirements.

3. **Develop a Strong Program**:

– Create a comprehensive and effective PHP/IOP treatment program that addresses the needs of your target population.

– Hire experienced and qualified staff, including therapists, counselors, and medical professionals.

4. **Build an Online Presence**:

– Create a professional website with information about your facility, treatment programs, staff credentials, and contact details.

– Optimize your website for search engines (SEO) to improve its visibility in local search results.

5. **Social Media Marketing**:

– Use social media platforms to share educational content, success stories, and updates about your facility.

– Engage with the online community by responding to comments and messages promptly.

6. **Content Marketing**:

– Develop and share informative and engaging content related to addiction treatment, mental health, and recovery on your website and social media.

– Consider starting a blog or producing videos that provide valuable information to potential clients.

7. **Local SEO**:

– Claim and optimize your Google My Business listing to ensure your facility appears in local searches.

– Encourage satisfied clients to leave reviews on Google and other review platforms.

8. **Networking**:

– Establish relationships with local healthcare professionals, therapists, psychiatrists, and other professionals who may refer clients to your facility.

– Attend industry events, conferences, and meetings to network and build partnerships.

9. **Community Outreach**:

– Engage with the local community by participating in health fairs, workshops, and events.

– Offer free or low-cost educational sessions on addiction, mental health, or related topics.

10. **Advertising**:

– Consider running targeted online ads on platforms like Google Ads and Facebook to reach potential clients.

– Use online advertising to promote specific treatment programs or special offers.

11. **Insurance and Payment Options**:

– Accept a variety of insurance plans to make your services more accessible.

– Clearly communicate your payment options and any financial assistance programs you offer.

12. **Track and Analyze**:

– Use tools like Google Analytics and social media insights to track the effectiveness of your marketing efforts.

– Adjust your strategies based on what works best for your facility.

13. **Client Testimonials**:

– Encourage satisfied clients to share their success stories and testimonials on your website and social media.

14. **Continuous Improvement**:

– Continuously evaluate and improve your treatment programs based on client feedback and outcomes.

Truth be Told

The number one way to increase your inquiries to your program is to get credentialed as in-network for most major insurance carriers. This is not always a simple process, but works out in the long run.

Remember that building a strong reputation for your PHP/IOP treatment facility may take time. Focus on delivering high-quality care, maintaining ethical standards, and demonstrating empathy and compassion to help clients on their journey to recovery. Over time, positive word-of-mouth referrals and reviews can be one of your most valuable assets in attracting clients.

How does Insurance determine Medical Necessity?

Many insurance carriers determine RTC/PHP/IOP authorization for care by utilizing medical necessity criteria to make determinations. The medical necessity criteria applied varies according to the behavioral health service being requested. To determine which criteria set will be used, general examples use the list below:

Level of Care Utilization System (LOCUS) will be used to evaluate behavioral health treatment requests for adults age 19+ years.
Child and Adolescent Level of Care Utilization System (CALOCUS) will be used to evaluate mental health treatment requests for children and adolescents ages 6-18 years.
Early Childhood Service Intensity Instrument (ECSII) will be used to evaluate mental health treatment requests for infants, toddlers and children ages birth through 5 years.
ASAM Criteria will be used to evaluate substance use disorder service and treatment requests
New Directions medical policies apply to the following treatments and services, as applicable:
- Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder (ABA for ASD)
- Applied Behavior Analysis for the Treatment of Down Syndrome (ABA for DS)
- Transcranial Magnetic Stimulation (TMS)
- Electroconvulsive Therapy (ECT)
- Psychological/Neuropsychological Testing (PNT)
- 23-Hour Observation

LOCUS was developed by the American Association of Community Psychiatrists (AACP). CALOCUS was developed by AACP in collaboration with the American Academy of Child and Adolescent Psychiatry (AACAP). Both are maintained by Deerfield Solutions, LLC. ECSII was developed by AACAP. The ASAM Criteria was developed by the American Society of Addiction Medicine. New Directions administers each benefit as designed by the health plan and set out in the member’s benefit agreement. The presence of a specific level of care criteria within a criteria set does not constitute the existence of a specific benefit. Providers and facilities should verify the member’s available benefits online when available, or by contacting the applicable Customer Service department.

Access to LOCUS can be found by clicking here.

Access to CALOCUS can be found by clicking here.

Access to ECSII can be found by clicking on the following links:
ECSII Domains (Handout)
ECSII SI Definitions (Handout)
ESCII Manual 1.1 (Rev 4.2019) – QUICK REFERENCE ANCHOR POINT SHEETS INCLUDED

Access to the ASAM Criteria can be found by clicking here.

Specific policies or criteria set by insurance carriers in 2023. Insurance coverage and criteria can vary significantly depending on the insurance company, the specific plan, and the jurisdiction in which you reside. Insurance carriers often update their policies and criteria regularly.

However, we look can at some general information about the levels of care commonly seen in mental health treatment. These RTC/PHP/IOP levels of care may require varying criteria for insurance coverage:

Outpatient Care: This typically includes individual therapy, group therapy, counseling, and medication management provided on an outpatient basis. Patients may need a mental health diagnosis and recommendation from a healthcare professional to access this level of care.
Intensive Outpatient Program (IOP): IOP offers more structured and intensive treatment than traditional outpatient care. It may involve several hours of therapy and support services each day, usually for several days a week. Insurance carriers may require a mental health diagnosis and a treatment plan from a healthcare professional for coverage.
Partial Hospitalization Program (PHP): PHP provides a higher level of care than IOP. It involves full-day or nearly full-day treatment programs, usually provided in a hospital or specialized facility. PHP may be recommended for individuals who need more support but do not require 24-hour inpatient care. Insurance coverage may require medical necessity criteria and a treatment plan.
Inpatient Hospitalization: This level of care involves round-the-clock treatment in a hospital setting. It is typically reserved for individuals who are in crisis or at risk of harm to themselves or others. Insurance carriers often require a medical necessity determination and authorization for coverage.

The specific criteria for insurance coverage may include other factors for medical necessity, including severity of symptoms, risk of harm, and the recommendations of healthcare professionals.

What is the criteria for medical necessity using LOCUS assessment for RTC/PHP/IOP mental health?

The Level of Care Utilization System (LOCUS) is a tool used to assess the level of care needed for individuals with mental health and substance use disorders. It provides a framework for evaluating the severity of a person’s condition and determining the appropriate level of care, including Residential Treatment Centers (RTC), Partial Hospitalization Programs (PHP), and Intensive Outpatient Programs (IOP). While I can provide a general overview of the LOCUS assessment criteria, please note that the specific criteria and scoring may vary depending on the version and guidelines implemented by different organizations or jurisdictions. It’s always best to refer to the official documentation or guidelines provided by your healthcare provider or insurance carrier.

A look in detail of the LOCUS assessment of six different dimensions

Certainly! The Level of Care Utilization System (LOCUS) assessment evaluates individuals with mental health and substance use disorders across six different dimensions to determine the appropriate level of care. Here’s a detailed explanation of each dimension:

Risk of Harm: This dimension assesses the individual’s risk of harm to themselves or others due to their mental health condition. It considers factors such as the severity of suicidal ideation, presence of self-harm behaviors, risk of aggression, or violence. The assessment may include evaluating the frequency, intensity, and duration of these behaviors. A higher score in this dimension indicates a greater risk of harm and may indicate a need for a more intensive level of care.
Functional Status: This dimension focuses on the individual’s functional abilities and limitations. It evaluates their ability to perform activities of daily living, including self-care, work or school functioning, social functioning, and relationships. Impairments in these areas may indicate the need for a higher level of care. The assessment may consider factors such as the individual’s ability to maintain personal hygiene, manage finances, sustain employment or education, and engage in social interactions.
Medical, Addictive, and Psychiatric Co-Morbidity: This dimension assesses the presence of additional medical conditions, substance use disorders, or co-occurring psychiatric disorders that may impact the individual’s overall functioning and treatment needs. The assessment considers the severity and complexity of these co-morbid conditions, including their impact on physical health, mental health, and substance use. A higher score in this dimension indicates a greater need for comprehensive care that addresses these co-occurring conditions.
Recovery Environment: This dimension evaluates the individual’s living situation, support system, and access to resources that promote recovery. It considers factors such as stable housing, family support, availability of outpatient services, and involvement in the criminal justice system. The assessment examines the quality and stability of the individual’s recovery environment, including the level of support and resources available to them. A higher score in this dimension indicates a more supportive recovery environment and may influence the level of care recommended.
Treatment and Support History: This dimension examines the individual’s history of mental health and substance use treatment. It considers the effectiveness of past interventions, engagement in treatment, and adherence to medication regimens. The assessment may also evaluate the individual’s experience with different treatment modalities, such as therapy, medication management, or residential programs. A comprehensive understanding of the individual’s treatment history helps determine the most appropriate level of care and treatment interventions.
Engagement/Relapse Potential: This dimension assesses the individual’s motivation and ability to engage in treatment and their potential for relapse or non-compliance with recommended treatment. It considers factors such as the individual’s readiness for change, level of motivation, willingness to participate in treatment, and history of relapse or treatment non-compliance. A higher score in this dimension may indicate a need for a more structured and intensive level of care to support engagement and prevent relapse.

Each dimension is scored on a scale ranging from 0 to 4 or 0 to 5, with higher scores indicating a greater level of severity or need for care. The total scores across these dimensions are used to determine the appropriate level of care, such as Residential Treatment Centers (RTC), Partial Hospitalization Programs (PHP), or Intensive Outpatient Programs (IOP).

Specific guidelines and scoring criteria may vary depending on the version and guidelines implemented by different organizations or payers. There are other official LOCUS guidelines available online, or seeking guidance from a healthcare professional familiar with the assessment can help provide the most accurate and up-to-date information regarding the six dimensions of the LOCUS assessment.

A more specific model of what questions the LOCUS assessment requires to complete criteria

While I can provide a general overview of the dimensions assessed in the Level of Care Utilization System (LOCUS) assessment, I don’t have access to the exact questions or specific questionnaires used in the assessment. The LOCUS assessment is typically administered by trained professionals, such as mental health clinicians or care managers, who follow specific guidelines provided by the organization or jurisdiction implementing the assessment.

However, I can outline the general areas of inquiry that are typically covered in each dimension of the LOCUS assessment:

Risk of Harm:

Inquire about suicidal ideation, intent, and plans.
Assess for self-harm behaviors or risk of harm to others.
Explore recent history of aggression or violence.

Functional Status:

Evaluate the individual’s ability to perform activities of daily living, such as personal hygiene, dressing, and eating.
Assess their work or school functioning, including attendance, productivity, and ability to carry out tasks.
Examine social functioning, including relationships, social support, and engagement in social activities.

Medical, Addictive, and Psychiatric Co-Morbidity:

Gather information about any medical conditions or physical health concerns.
Assess the severity and impact of substance use disorders, including patterns of use, dependence, or withdrawal symptoms.
Evaluate the presence and impact of co-occurring psychiatric disorders, such as anxiety, depression, or personality disorders.

Recovery Environment:

Inquire about the individual’s living situation, stability of housing, and availability of a safe and supportive environment.
Assess the presence and quality of social supports, including family, friends, or support groups.
Evaluate the availability of outpatient services and resources that promote recovery, such as transportation or financial assistance.

Treatment and Support History:

Gather information about previous mental health and substance use treatment experiences.
Assess the effectiveness of past interventions and treatments.
Evaluate the individual’s level of engagement and adherence to treatment plans, including medication management.

Engagement/Relapse Potential:

Assess the individual’s motivation and readiness for change.
Evaluate their willingness to participate in treatment and engage in therapeutic activities.
Inquire about the individual’s history of relapse, treatment non-compliance, or difficulty sustaining recovery.

The questions and scoring criteria may vary based on the version and guidelines implemented by different insurance carriers.

Just because a person is fully covered with a great health insurance plan does not mean they “medically” qualify for the proper addiction treatment or mental health care.

Problem: not all benefits, levels of care, or the interpretation of “medical necessity” are created equal.

In our experience, we have seen most approvals or denials of treatment based on the principal of medical necessity. Half of the information needed by insurance companies to make an educated decision comes from the patient themselves.

Because of this, you can understand the importance for the patient to tell the truth about their actual level of current and past drug use – as well as other concerning behavioral or mental health issues.

Most families are unaware of how addiction works and aren’t able to fully advocate the right way for their loved one. Remember, addiction is a chronic illness – and though the exact definition of a chronic disease varies, but these ailments are usually identified as long lasting, noncontagious, and resistant to cure.

This brings up another extremely valid point when dealing with addiction and substance abuse and how the insurance system is set up: these conditions that work in so many ways against the patient. Quality care is very expensive and a long term solution is generally not covered out-of-the box by insurance companies. You have to fight for coverage – that is why getting every level of care deemed necessary is so important.

Every patient must show that they have medical need for substance abuse treatment on any level – detox, residential coverage, partial hospitalization, or intensive/general outpatient care.

David Goldhill of The Atlantic has a great take to create a logical foundation for medical necessity:

We have a vague definition of medical necessity in the back of our minds: if the mastectomy was necessary, doesn’t that mean the reconstruction is, too? Should we pay for prosthetic limbs only if they are functional, or are cosmetic attributes alone worthy of reimbursement? If cosmetic surgery helps a woman develop greater self-esteem or avoid postpartum blues, wouldn’t it serve the same purpose as an antidepressant? And following that logic, shouldn’t it be reimbursed just like a prescription?

Lets start with who defines medical necessity by most insurance companies?

This is a great question that has many, many players involved. This can only be defined by a personal therapist, the medical history of the patient, and the customer service rep at any given insurance company. The “who” is an ongoing, evolving, not-always-straight-forward enigma.

The same problem happens with what defines medical necessity by most insurance companies.

Here is one of many definitions given by payors:

Definition and Application of Medical Necessity. Medical necessity is defined as accepted health care services and supplies provided by health care entities, appropriate to the evaluation and treatment of a disease, condition, illness or injury and consistent with the applicable standard of care.

What all this should really come down to for us as a nation and for insurance law is not, Is it worth the money? But, Is it good for us?

Ok, you have a potential patient with health coverage – what now?

All health coverage plans vary by company and by benefit package. Now its time to determine what is covered and what isn’t. They very well could have the medical portion of care covered, but housing and other ancillary aspects are not.

A patient’s need for the different levels and settings of care is not per-determined, it is established upon arrival at a drug treatment facility through discussions with professionals and the insurance company. A few things that go into this decision include:

Acute Intoxication and/or Withdrawal Potential
Biomedical Conditions/Complications
Emotional, Behavioral, or Cognitive Conditions/Complications
Readiness to Change
Relapse, Continued Use or Continued Problem Potential
Recovery/Living Environment

Do they qualify for all levels of care?

Residential (RTC)

the effects of addition on the individual’s life are so significant and the level of addition-related impairment is so great that outpatient strategies alone would not be feasible or effective. Programming and staffing address more severe medical, emotional, cognitive, and behavioral problems. Case management provides a “wrap-around” service.

Partial Hospitalization (PHP)

Ready access to psychiatric, medical, and lab services make this level of service a step up from the previous. The effects of addition on the individual’s life are so significant and the level of addition-related impairment is so great that outpatient strategies alone would not be feasible or effective. . Typically this level of service is the situation warrants daily monitoring or management but can be appropriately addressed in structured outpatient setting

Intensive Outpatient (IOP)

Psychiatric and medical services are addressed through consultation and referral arrangements. This service is provided in 9 or more hours of structured counseling and education services per week.

General Outpatient (GOP)

Designed to treat the assessed level of illness severity and to achieve permanent changes in substance using behavior. This service is provided in fewer than 9 contact hours per week.

It is Complicated

With all these coverage types, you can see some of the generic language in them and how it can be difficult to determine which is absolutely necessary. There are times when insurance companies require an individual to “fail” out of a lower level of care in order to get approved for the structure actually needed. it can be a very backwards system sometimes.

And of course you will need all the appropriate licensing in order to bill for each level of care. Whether a facility qualifies for each license is determined by the State it is in.

When you think of insurance billing, you probably think of some nice sweet receptionist type person in your doctor’s office taking your insurance card before your appointment and charging your co-pay. Technically, this is a type of insurance billing – just not what I am talking about in this blog. There are huge differences when you think medical billing vs. behavioral health billing.

Behavioral health billing compared to medical billing is very different in the fact that medical professionals (like your primary care physician) bill for specific treatments such as:

Office visit
lab test
X-rays
MRI

This billing is pretty simplified and streamlined. However, with mental health/substance abuse facilities, they may bill for therapy, psychological testing along with medical management for the patient – most of the time in “bundled” services and codes for levels of care such as RTC, PHP, and IOP.

What does that include and mean for the patient and mental health professionals? I’ll tell you.

The insurers may have certain regulations and guidelines like:

limiting how long therapy sessions will be,
how many days they’ll pay for,
and may even have a maximum on treatments they’ll even pay for in all.

This, in turn, makes it difficult for mental health professionals to come up with a master plan to treat the patient and also make sure they get reimbursed for services rendered.

Another thing is, It is important for behavioral health providers to know that many insurance carriers and state Medicaid programs will outsource their mental health claims to a third party. This means they use a contracted company to process, manage, and pay claims.

It is important for an inpatient mental health or addiction program to be aware of this when submitting claims. If this is missed, your claims can be sent to the wrong place — and will just be denied and then obviously not paid in a timely manner.

All you have to do is ask who processes the claims when you call provider services. You can do this when you are actually checking benefits for a patient or anytime before you actually submit claims.

This process of billing for behavioral health can get very complicated. One reason is that even when you are calling into the insurance companies (instead of using a web portal), either the customer service representative is not fully trained, or they are unable to give you the correct information and you wind up being transferred to several different departments and representatives. Furthermore, a lot of these call centers are overseas and the connection is not always the best – making the conversation very difficult to understand. Often times there is this weird volume issue where it sounds like the rep is whispering. One way to overcome these issues is to ask for an “onshore representative” or even request speaking with a supervisor to get an honest and helpful customer service experience.

I’ve found many times, some representatives will try and distract from giving you the right information to move forward in the claims process, and keep you in limbo or going in circles. It is almost like perhaps they are trained to do so in order to slow the payment for the claim.

I really don’t know exactly what the issue is when these situations arise, but I do have some ways to get through those walls of confusion. It gets frustrating and always is a good idea to have someone on your side that knows how and what to do in those situations.

As simple as it sounds, always and I repeat..ALWAYS getting a reference number and name of the representatives you speak with, is one of the smartest pieces of information you can get for each and every interaction when calling on claims. Documentation..rules the nation is what I say!

Imagine being on the phone for over hours just for one difficult claim, and you finally speak to someone who makes sense, and you hang up thinking everything ok, just to find out a couple days later that nothing was done, and they have no record of what was discussed. Talk about heartbreaking. So do yourself and everyone else a favor, and just make sure to get that all so important reference number. Trust me, you’ll thank yourself later.

Heaven forbid you’ll have to go through the “Claims Chamber Torture”, and all goes well, it should only take at least 30 days from the when they first receive the claim. In some cases, they can move faster with a quicker turnaround time if everything goes smoothly. But as a general rule, you can expect it to be around 30 days.

For most in-network mental health facilities, they are contracted with insurance companies and cannot bill their patients for any balance after reimbursement is done. This is what is called “balance billing”. They have to accept that rate given and write off the remaining balance. As far as out of network facilities, you can accept the reimbursement and bill the patient whatever balance may be outstanding.

There are so many factors that must be accounted for when billing for mental health services. If you are running into issue after issue when attempting to get reimbursement, you aren’t alone.

There are a number of third-party insurance billing companies who are experts at this and don’t cost you all that much. If you haven’t considered outsourcing your insurance billing processes, maybe it’s time to do so now. With the many options of outsourcing for mental health billing, it is very important to team up with a company that knows what and how things are done when billing.

Reaching out to an outsourcing company and getting an assessment is the first step in building a strong relationship with your practice. In the long run, you’ll find yourself giving all of your focus on your patients where it really matters.

What are the Alcohol and Drug Abuse Treatment HCPCS Code range H0001-H0043

The HCPCS (Healthcare Common Procedure Coding System) code range for Alcohol and Drug Abuse Treatment is as follows:

H0001 – Alcohol and/or drug assessment

H0002 – Behavioral health counseling and therapy, per 15 minutes

H0003 – Alcohol and/or drug screening

H0004 – Behavioral health counseling and therapy, per hour

H0005 – Alcohol and/or drug education

H0006 – Alcohol and/or drug prevention, per 15 minutes

H0007 – Individual counseling and therapy, per 15 minutes

H0008 – Group counseling and therapy, per 15 minutes

H0009 – Alcohol and/or drug services; not otherwise specified

H0010 – Alcohol and/or drug screening, brief intervention, and referral to treatment (SBIRT)

H0011 – Alcohol and/or drug program administration and coordination

H0012 – Alcohol and/or drug prevention, per hour

H0013 – Alcohol and/or drug services; group counseling by a clinician

H0014 – Alcohol and/or drug services; group counseling by a peer

H0015 – Alcohol and/or drug services; group counseling by a non-physician

H0016 – Alcohol and/or drug services; group counseling by a physician

H0017 – Alcohol and/or drug services; individual counseling by a clinician

H0018 – Alcohol and/or drug services; individual counseling by a peer

H0019 – Alcohol and/or drug services; individual counseling by a non-physician

H0020 – Alcohol and/or drug services; individual counseling by a physician

H0021 – Alcohol and/or drug services; ambulatory detoxification

H0022 – Alcohol and/or drug services; partial hospitalization (6 or more hours)

H0023 – Alcohol and/or drug services; partial hospitalization (less than 6 hours)

H0024 – Alcohol and/or drug services; detoxification

H0025 – Alcohol and/or drug services; day treatment/partial hospitalization

H0026 – Alcohol and/or drug services; short-term residential

H0027 – Alcohol and/or drug services; intermediate residential

H0028 – Alcohol and/or drug services; long-term residential

H0029 – Alcohol and/or drug services; crisis intervention

H0030 – Alcohol and/or drug services; environmental intervention

H0031 – Alcohol and/or drug services; peer support services

H0032 – Alcohol and/or drug services; acupuncture

H0033 – Alcohol and/or drug services; residential (non-hospital)

H0034 – Alcohol and/or drug services; day treatment

H0035 – Alcohol and/or drug services; partial hospitalization (treatment program of at least 20 hours per week)

H0036 – Alcohol and/or drug services; halfway house

H0037 – Alcohol and/or drug services; family/couples counseling

H0038 – Alcohol and/or drug services; intensive outpatient (treatment program of at least 9 hours per week)

H0039 – Alcohol and/or drug services; medicated assisted treatment (MAT) with extended-release injectable naltrexone (XR-NTX)

H0040 – Alcohol and/or drug services; medicated assisted treatment (MAT) with buprenorphine

H0041 – Alcohol and/or drug services; medicated assisted treatment (MAT) with methadone

H0042 – Alcohol and/or drug services; therapeutic leave

H0043 – Alcohol and/or drug services; not otherwise classified

The most recent version of the HCPCS codebook can change and sometimes getting denials and resubmitting claims is the only way to find the right code for each service, or check with your biller for appropriate coding for the most accurate and up to date information.

So, what else is needed besides the right codes to bill insurance for Alcohol and Drug Abuse Treatment HCPCS Code range H0001-H2043?

Billing insurance requires more than just the correct HCPCS codes. Here are some additional elements that may be needed:

Accurate and complete documentation: Proper documentation is essential for billing insurance. It should include relevant patient information, assessment results, treatment plans, progress notes, and any other supporting documentation required by the insurance company.
Verification of insurance coverage: Before providing services, it’s important to verify the patient’s insurance coverage and benefits. This helps determine if the services are covered, any limitations or pre-authorization requirements, and the patient’s financial responsibility.
Prior authorization: Some insurance plans may require prior authorization for certain services. The provider must submit a request to the insurance company, providing clinical documentation to support the need for treatment. The insurance company will review the request and either approve or deny the authorization.
Credentialing: Providers must be properly credentialed and contracted with the insurance company to bill for services. This involves submitting necessary paperwork and meeting the insurance company’s requirements for network participation.
Correct coding and modifiers: Ensure that the appropriate HCPCS codes from the designated range (H0001-H2043) are used for the specific services provided. Additionally, if any specific modifiers are required by the insurance company, they should be applied correctly to indicate additional information about the services rendered.
Timely submission of claims: Claims should be submitted to the insurance company in a timely manner, following their specific guidelines and deadlines. Late submission may result in claim denials or delays in reimbursement.
Compliance with insurance policies and guidelines: Familiarize yourself with the insurance company’s policies, guidelines, and reimbursement rules for Alcohol and Drug Abuse Treatment services. This helps ensure that services are provided in accordance with their requirements and that claims are submitted correctly.

HCPCS codes in the range H0001-H2043, modifier codes may be required in certain situations:

U1 – Modifier U1 is used to indicate that services are provided by a licensed clinical psychologist.
U2 – Modifier U2 is used to indicate that services are provided by a licensed master’s level clinician.
U3 – Modifier U3 is used to indicate that services are provided by a licensed bachelor’s level clinician.
U4 – Modifier U4 is used to indicate that services are provided by a peer specialist.
U5 – Modifier U5 is used to indicate that services are provided by a non-physician.
U6 – Modifier U6 is used to indicate that services are provided by a physician.
U7 – Modifier U7 is used to indicate that services are provided by a certified physician assistant.
U8 – Modifier U8 is used to indicate that services are provided by a certified nurse practitioner.
U9 – Modifier U9 is used to indicate that services are provided by a certified clinical nurse specialist.
U1U9 – Modifier U1U9 is used to indicate services provided by a licensed clinical social worker or a licensed marriage and family therapist.

Modifiers vary depending on the requirements of each insurance company, if any are necessary, they will be needed for accurate billing.

Tips to get care authorized treatment HCPCS Code range H0001-H2043

What else is needed besides the right codes to bill insurance for Alcohol and Drug Abuse Treatment HCPCS Code range H0001-H0043?

The medical necessity guidelines for Alcohol and Drug Abuse Treatment can vary depending on the insurance company and plan:

Diagnosis of Substance Use Disorder (SUD): Generally, a patient must have a documented diagnosis of Substance Use Disorder, which may include alcohol or drug dependence or abuse. The diagnosis should be based on established diagnostic criteria such as those outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Functional Impairment: The patient’s substance abuse or addiction should be causing significant functional impairment in their daily life. This can include impairments in occupational functioning, social relationships, physical health, psychological well-being, or other areas of life functioning.
Severity of the Condition: The severity of the patient’s Substance Use Disorder is often considered. This may include the frequency and intensity of substance use, presence of withdrawal symptoms, risk of harm to self or others, or the level of impairment caused by the substance use.
Failed Attempts at Less Intensive Treatment: In some cases, insurance companies may require documentation of failed attempts at less intensive levels of treatment, such as outpatient counseling or support groups, before authorizing more intensive levels of care, such as residential treatment or partial hospitalization.
Treatment Goals: The requested services should align with specific treatment goals and objectives. The treatment plan should be designed to address the patient’s substance abuse or addiction, promote recovery, and improve overall functioning and well-being.
Evidence-Based Practices: Insurance companies often look for evidence that the requested services align with established evidence-based practices for Alcohol and Drug Abuse Treatment. These may include recognized treatment modalities, therapies, or approaches that have been shown to be effective in addressing Substance Use Disorders.

Medical necessity for behavioral health insurance authorization refers to the criteria that must be met in order for insurance companies to approve coverage for behavioral health services. It involves demonstrating that the requested treatment is medically necessary and appropriate for the patient’s condition.

To summarize medical necessity for behavioral health as far as most insurance is concerned:

To establish medical necessity, certain factors are typically considered. These include the presence of a diagnosable mental health or substance use disorder, functional impairment caused by the condition, the severity and impact of symptoms on daily life, failed attempts at less intensive treatments, and the alignment of the treatment plan with evidence-based practices. Documentation should clearly articulate the treatment goals, the expected outcomes, and how the proposed services will address the patient’s specific needs. Collaborating with other healthcare professionals and following the insurance company’s guidelines and documentation requirements can improve the chances of obtaining authorization for behavioral health services.

To obtain accurate and up-to-date information regarding ChampVA billing codes, condition codes, occurrence codes, and value codes for behavioral health RTC, PHP, and IOP claims. It can be best to consult the official resources provided by ChampVA.

Every plan is different, and they can provide you with the most current and accurate information related to their billing and coding requirements.

What are the ChampVA Billing Codes for Behavioral Health

ChampVA follows the standard coding systems for billing behavioral health services. The most commonly used coding systems for behavioral health services are the Current Procedural Terminology (CPT) codes and the Healthcare Common Procedure Coding System (HCPCS) codes. Here are some common CPT and HCPCS codes that may be used for billing behavioral health services with ChampVA:

CPT Codes:

90791: Psychiatric diagnostic evaluation
90832: Individual psychotherapy, 30 minutes
90834: Individual psychotherapy, 45 minutes
90837: Individual psychotherapy, 60 minutes
90846: Family psychotherapy without the patient present
90847: Family psychotherapy with the patient present
90853: Group psychotherapy
96101: Psychological testing evaluation services
96118: Neuropsychological testing
99213: Evaluation and management (E/M) service for an established patient, 15 minutes

HCPCS Codes:

H0031: Mental health assessment, by a non-physician
H0035: Partial hospitalization (PHP) services, per diem
H0036: Community-based psychiatric rehabilitation and support, per 15 minutes
H2011: Crisis intervention, per hour
H2035: Alcohol and/or drug services, group counseling
H0004: Behavioral health counseling and therapy, per 15 minutes
S9484: Behavioral health, counseling and/or therapy provided via synchronous telecommunication
T1015: Mental health case management

The specific codes used for billing behavioral health services may vary depending on the nature of the service provided, the duration, the level of care, and other factors. Consult the most recent version of the ChampVA provider manual or contact ChampVA directly for the most accurate and up-to-date information on billing codes specific to their program.

How to become credentialed with ChampVA as a healthcare provider?

Providers need to go through a credentialing process. Here are the general steps involved:

Determine eligibility: First, ensure that you meet the eligibility criteria to participate as a provider in the ChampVA program. This typically involves having the necessary licenses, certifications, and qualifications to provide the specific healthcare services covered by ChampVA.
Complete the application: Obtain the provider application form from ChampVA. You can typically find the application form on their official website or by contacting their provider enrollment department. Fill out the application form accurately and completely, providing all the required information.
Gather required documentation: Along with the application form, you will need to submit various supporting documents. These may include proof of your professional qualifications, such as copies of licenses, certifications, and educational degrees. You may also need to provide documentation related to your professional liability insurance, practice locations, and other relevant details.
Submit the application: Once you have completed the application and gathered the necessary documentation, submit the application and supporting documents to ChampVA according to their specified instructions. This is typically done either electronically or by mail, depending on their preferred method.
Follow up and respond to inquiries: After submitting your application, be prepared to respond to any additional requests for information or clarifications from ChampVA. They may contact you if they require any further documentation or have questions regarding your application.
Await review and decision: The ChampVA provider enrollment department will review your application, verifying your credentials and evaluating your eligibility to participate in the program. The review process can take some time, so it’s important to be patient.
Notification of credentialing decision: Once the review process is complete, you will receive a notification from ChampVA regarding the status of your credentialing application. If approved, you will be provided with further instructions on the next steps to become an enrolled provider with ChampVA.

Specific requirements and processes for credentialing with ChampVA can be dependent on each provider. Providers can also contact the enrollment department directly to obtain the most accurate and up-to-date information on their credentialing process and any specific requirements they may have.

Health insurance carriers have rarely provided coverage for families that chose a wilderness program to help their child.

With higher levels of therapeutic intervention, processes, safety, and now accreditation, the debate about whether insurance should cover outdoor behavioral programming is heating up.

Struggling with either addiction or mental health issues is no matter to be taken lightly for anyone, especially those still in developmental stages. It is widely agreed upon that it takes multiple models and multiple “tries” in order to have a successful outcome after treatment – and this includes wilderness programs.

Wilderness therapy programs can act as a huge resource for those that need it, however they can also use up 30 to 45 days of benefits – even without being billed to the insurance carrier.

Why is 30 to 45 days a big deal?

Because a lot of families have behavioral health benefits with a set number of days allowable for treatment purposes. This means that although these benefits are not being used – the child can be viewed as still “in treatment” or receiving care towards an overall expected recovery time.

Authorization for additional days receiving residential or partial hospitalization treatment will not be approved in such cases.

Wilderness programs and insurance carriers have never really been on the same page – this is just one of many examples showcasing this disconnect.

Does insurance cover wilderness therapy programs?

This seems like a no-brainer right? Any behavioral health or therapeutic program should be covered under the Affordable Care Act’s ten essential health benefits.

Well, it’s not that black and white.

When it comes right down to it, it can be difficult to get insurance carriers to reimburse RTC, PHP, or IOP for wilderness type programs. At the very least, with the help from billing professionals or a seasoned in-house biller, it is possible to get reimbursement for individual, group, and family therapy given by licensed clinical professionals up to about $300 or so per week.

There is progress being made though, things are changing with wilderness care – the Outdoor Behavioral Health Council and variety of national institutions are now accrediting these programs.

Much like residential and outpatient drug rehabs and mental health programs, a set of operations and processes can now be followed in order to standardize treatment. More and more regulation is coming to the once “troubled” outdoor behavioral therapy world. And that is a good thing for the kids attending, the staff, payors, and the programs themselves.

So much progress has been made that a code specific to wilderness therapy has been developed for billing.

It has already been put in place and gives all programs and third party billers a new tool to advocate for proper reimbursement (as with everything in behavioral health – there are no guarantees).

Maybe it is time for insurance companies to start listening to their members – to the needs of their members.

Many families have teens and young adults who need an option a bit less scary than inpatient drug rehab or therapeutic boarding school. A wilderness program can provide a life experience as well as a solution at a potential fraction of the cost of traditional models.

The fight for insurances to cover wilderness.

A new trend is happening – families are starting to sue insurers in order to get wilderness therapy to cover RTC and other higher levels of care. This has only started to happen in 2017 because of how much more safe and effective wilderness programs have become.

Since January, 2016, there have been class actions filed against Cigna, Oxford, Empire Health, and BCBS. Anthem Health out of Kentucky just recently settled a similar suit.

These lawsuits to get insurance to cover wilderness have been filed in Florida, Kentucky, New York, and Utah – mostly stemming from the expansion of the 10 essential benefits to include mental health.

Because insurance carriers determine level of care needed more by the structure of the program and the professional level of the staff than by the physical nature of the buildings, wilderness programs can be set up in a way that they qualify for Partial Hospitalization (PHP), if not Residential Treatment (RTC).

For instance, it is not uncommon for a week in the life of wilderness to include:

4-5 days hiking/learning outdoors skills
Daily academics/reading assignments
Daily group therapy
Weekly family therapy
Weekly visits with a individual psychologist or social worker
On-call medical assistance from a registered nurse or medical doctor (admits get evaluated prior to enrollment in the programs)

The above structure meets all the requirements for many of the major health insurance carriers out there.

Privately paying $500 per day is steep for any sort of treatment.

It is almost unmanageable for any family without the help from your already expensive health insurance. However, this daily rate helps teens and young adults struggling with:

Addiction
Anxiety
Aspergers
Austism
Depression
Eating disorders
Oppositional Defiance Disorder (ODD)
Post Traumatic Stress Disorder (PTSD)
Self Harm
Suicidal thoughts
Traumatic Brain Injuries (TBI)

Because wilderness programs provide such a unique experience and a unique approach to treatment, they can be expensive.

Without help from insurance these programs can be upwards of $20,000 total per stay.

Is residential or transitional treatment needed after wilderness?

Most licensed mental health and substance abuse professionals will tell you that wilderness programs provide an excellent service to the adolescent and even young adult treatment world. They are a great place for a struggling teen to stabilize and to start the path back to a healthy life.

In many cases wilderness is used as a first step in the continuum of care of the overall treatment process – followed by a brief residential stay, then a longer transitional program, and finally on to outpatient and aftercare.

The bottom line is that medical necessity will determine if residential care is needed. Although each insurance carrier has a different definition, here is the basic criteria:

Has there been a failed attempt at a lower level of care in the recent past? Perhaps outpatient has been tried and there have been failed tests. Or perhaps they left a wilderness program before graduating, or left a residential program against medical advice (AMA).
Plain and simple there are zero wilderness programs that are in-network with any provider. If there are no out-of-network benefits or no chance for a single case agreement, then wilderness won’t be an option.
A potential harm to self or others.
Recorded/documented severe change in any variety of daily active functioning – eating, sleeping, socializing, etc.
Constant cycle of inappropriate behavior and negative actions with zero likelihood of change in the existing environment.

Each one of these criteria can be enough to warrant RTC level of care.

RTC level of care does not mean the entire stay is covered, it just means there is an immediate medical need for residential treatment. An average authorization is only 1-14 days (so utilization reviews become very important in continuing coverage).

After each authorization, a utilization review will need to be done with the case manager in order to approve more coverage or determine if a drop in level of care is warranted.

What are the differences in ongoing treatment options after wilderness?

Long-Term Residential Treatment

This is 24 hour a day treatment for at least 3 months in a stand alone facility. These programs are usually set up to allow participants to drop down to a less structured program while they acclimate back into real life.

Generally long-term RTC facilities take a holistic approach and offer a variety of therapeutic models to cater to a large audience. Treatment is not done in a vacuum. What works for one person may not work for another.

Everyday will be completely planned out in advance with a heavy structure and a set number of rules or guidelines to follow.

Short-Term Residential Treatment

It is common for teens or young adults to transition directly to a short term stay in residential care directly after wilderness. These programs are set-up for a quicker 21-45 day stay where stabilization and transition is more of the priority.

Day Treatment with Sober Living (Transitional Treatment)

Transitional treatment programs are a relatively new concept and were started mostly for the young adult world. Residential programs saw a need to slowly move participants back into the real world – often somewhere away from old acquaintances and old triggers.

These programs start after long or short-term residential treatment and can last up to 18 months

Participants attend individual and group therapy throughout the week while living in a sober house or apartment with their peers.

Outpatient Treatment

The final step down in structured treatment with peers – this is the least intense of the programs. This is also the least expensive and should be done after wilderness at the very least in order to avoid relapse and keep participants engaged in their recovery.

Outpatient programs do not always have a set time frame but 16 weeks is the norm. They include further education on addiction and mental health, drug testing, as well as individual and group therapy up to 12 hours a week.

Insurers Have a Legitimate Defense… With an Asterisk

Health care providers do have cause to deny coverage when it comes to outdoor behavioral therapy. Two main points come to mind when putting yourself in the payors shoes:

Take into consideration the cost and benefits of wilderness therapy. Is this one particular program all that is needed for long term recovery?
- What needs to be proven is that it is more likely that this alternative program is going to be the more cost effective than a traditional model or no treatment at all.
There is not a ton of empirically based evidence to suggest this type of treatment works.
- Cigna flat out suggests that wilderness programs are not evidence-based.
- Aetna considers this form of rehab to be at the very most – experimental and investigational. Here is their policy:

Aetna considers alternative medicine interventions medically necessary if they are supported by adequate evidence of safety and effectiveness in the peer-reviewed published medical literature.

* Here is the asterisk: Medical necessity is tricky. It is the embodiment of personalized care. In many ways behavioral health is trailblazing the way to where our Nation’s healthcare is going – Precision Medicine.

Because every individual’s treatment plan must be tailored to them specifically, to their needs and their issues specifically – it becomes difficult to say that all types of behavioral health programs should be covered for everyone with health insurance.

Insurers require preauthorization be done by before any amount of days of treatment will be covered.

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency.

Preauthorization isn’t a promise your health insurance or plan will cover the cost.

If a kid’s medical history and current physiological issues, personality, or substance use disorders are not going to be significantly helped by spending time in the wilderness (as determined by a mental health professional), then why should a health plan throw blanket coverage over all options?

This is how they work with any condition or disease. Treatments must be vetted – there must be a standard set on how, when, and how often treatment takes place along with other interventions if improvement is not being made.

Just take diabetes as an example. There are a variety of medications and interventions done by both the individual and their treatment team to achieve a successful outcome. This holds true in behavioral health as well.

If you are a family looking at a wilderness program for help – or a program thinking of admitting a family and you are hoping to get some sort of insurance reimbursement, then both sides need to take a close look at medical necessity and if there is an argument for this type of treatment.

There is no inherent negative intent for insurance companies to deny coverage.

They simply must act in the best interests of both their members and their shareholders. Sometimes these lines get blurred – or there is just not enough info out there to make the right decision.

Try to keep an open mind and an adjustable perspective when seeking reimbursement and working with health insurance carriers. The behavioral health world is not a science. It is constantly moving and adapting and we are all trying to catch up as quick as possible.

To Summarize Wilderness Treatment and Insurance Benefits

Wilderness programs, also known as wilderness therapy or outdoor behavioral healthcare programs, are therapeutic interventions that combine outdoor activities and group therapy to address behavioral and emotional challenges in individuals, particularly adolescents and young adults. These programs typically take place in natural settings and involve activities such as hiking, camping, and other outdoor adventures.

When it comes to behavioral health insurance benefits, the coverage and reimbursement for wilderness programs can vary depending on several factors:

Insurance Provider: Different insurance companies have their own policies and guidelines regarding coverage for wilderness programs. Some insurance providers may include wilderness therapy as a covered service, while others may not.

Policy Coverage: The specific insurance policy that an individual has will outline the types of behavioral health services that are covered. It is essential to review the policy documentation or contact the insurance provider directly to determine if wilderness therapy is included.

Medical Necessity: Insurance coverage for wilderness programs often depends on whether the treatment is deemed medically necessary. This determination is typically made by a qualified healthcare professional or mental health provider who evaluates the individual’s condition and recommends the program as part of their treatment plan.

Out-of-Network Coverage: Wilderness programs are almost always considered out-of-network services, meaning they are not directly contracted with the insurance company. In such cases, individuals may have to pay for the program upfront and then seek reimbursement from their insurance provider based on their out-of-network benefits.

Pre-authorization and Documentation: Insurance providers may require pre-authorization for wilderness programs, which means obtaining approval from the insurance company before beginning the treatment. Additionally, proper documentation from healthcare professionals, including diagnoses and treatment plans, may be necessary to support the claim for coverage. This can be done retro-actively as well.

It’s important to note that even if a wilderness program is covered by insurance, there may still be limitations or restrictions, such as a maximum number of days or sessions, co-pays, deductibles, or other out-of-pocket expenses. It’s recommended to thoroughly review the insurance policy and consult with the insurance provider to understand the specific coverage and any associated costs.

Overall, the impact of wilderness programs on behavioral health insurance benefits depends on various factors, including the insurance provider, policy coverage, medical necessity, and the individual’s specific circumstances. It is crucial to gather information directly from the insurance company to determine the extent of coverage and potential reimbursement for wilderness therapy.