Category: Revenue Cycle Management

Client Kelly Doe went to treatment. Medical necessity was met but it had to go to review to get approved. Claims magically got lost. After 4 follow up calls and 2 months later, claims finally paid. Although paying at an embarrassingly low rate, 2 of the 4 RTC claims paid correctly. The other 2? Mysteriously short on $.12. A measly dime and two pennies.  

So how can you ensure you’re staying on top of that $.12? Limiting your Denial Gap and being precise when addressing any correspondence from the insurance company. 

Creating and maintaining a solid process from the Date of Admission until Discharge is only half the battle when dealing with insurance claims. Depending on each individual insurance policy, most treatment programs do not align with the benefits allowed for behavioral health. When this happens, most programs will bill as an Out of Network provider, meaning more hoops and hurdles to get through, and of course ultimately affecting the allowed amounts paid to members.

Typically a facility will start billing at the RTC or PHP Levels of Care, then based on the Treatment Plans involved with the patient and Treatment Team, will step down to lower levels of care like IOP and Routine Outpatient Services. What most don’t realize is the hard work and attention to detail that goes into making each claim from RTC all the way down to ROP get processed smoothly, but it’s not so smooth sometimes. 

The time it takes for things to be updated and processed can take a huge toll of members if they have to come out of pocket to pay for treatment, so every cent is needed to help cover any losses financially members and their families go through. 

A scenario could be something like this. Receiving correspondence on pending claims requesting a correction on the billing or needing updated clinical, then once re-submitting with everything they requested, it finally gets paid, but at a lower allowed amount then you’re used to. Frustrating, right? It was the same level of care for the same amounts billed, but why do they not pay the same?

There are many factors why this could be. It can be a simple processing error, in which case needs to be sent back for review, or it can be a billing error and 1 or 2 days did not get billed, however, usually the difference in the paid amounts has to do with the members policy and how in and out of network providers are looked at. In our experience, we have approached it in a way of never giving up and being prompt on requested information needed to complete processing. 

We’ve also found out that having the therapists and nurses assistance when treatment is not deemed medically necessary, and utilizing detailed medical records that cater to the insurance company verbiage and jargon, can definitely help with improving daily rates for the higher levels of care like RTC and PHP.

Of course it is not worth the program to fight for that $.12 amount– however, if an insurance company is doing this to millions of members on millions of claims. We’re talking fractions of a penny, but over time, this adds up to be a lot. Just ask the guys from “Office Space”.

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.

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:

  1. Acute Intoxication and/or Withdrawal Potential
  2. Biomedical Conditions/Complications
  3. Emotional, Behavioral, or Cognitive Conditions/Complications
  4. Readiness to Change
  5. Relapse, Continued Use or Continued Problem Potential
  6. 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.

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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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:

  1. 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).
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.

More insurance billing information and guides visit axisirg.com.

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

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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
  1. 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.

Is it possible to submit claims for 90837, 90847, or 90853 along with IOP services?

Normally 90853 is not separated out from IOP per diem claims. Some of the below codes are what Medicare has suggested previously for IOP.

$20 per claim is the Medicare average on occasion because there are normally multiple patients being able to receive benefits in the group for that same service. So theoretically, as medicare and other carriers see this, the provider is being reimbursed for 8-20 patients for the same group 90853 service.

The Centers for Medicare & Medicaid Services (CMS) publish the Medicare Physician Fee Schedule (MPFS) every year, which includes the current procedural terminology (CPT) codes and reimbursement rates for various medical services, including intensive outpatient programs (IOP) for substance abuse.

However, the reimbursement rates may vary based on factors such as geographic location, individual patient characteristics, and other circumstances. It is recommended that you contact Medicare or consult with a healthcare billing professional for more specific information.

That being said, here are some CPT codes commonly used for IOP for substance abuse treatment that Medicare may accept:

H0015: Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education

H0016: Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 6 hours/day and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education

H0017: Alcohol and/or drug services; intensive outpatient (treatment program that operates less than 3 hours/day and less than 5 days/week), including assessment, counseling; crisis intervention, and activity therapies or education

Please let us know any questions!

One common code for non-intensive outpatient groups for Mental Health or insurance billing for Substance Abuse diagnoses is CPT code 90853.

This code is used to bill for group psychotherapy services, which involve treating two or more patients in a group setting.

To use this code for insurance billing for substance abuse, the mental health provider must conduct a group therapy session that is typically around 60 minutes in length. During the session, the provider works with the group members to address mental health concerns, such as depression, anxiety, or substance use disorders.

It’s important to note that the use of this code is typically limited to certain mental health diagnoses, such as those listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Additionally, insurance companies may have specific requirements or limitations on the use of this code, so it’s always best to check with the patient’s insurance provider before submitting a claim.

Here is the common mistake, not adding the correct modifier. Often times it could possibly be done to use modifier 59 to do 2 groups on the same day, however most carriers don’t allow for the same code on the same day.

Again, The billing code for non-intensive outpatient group therapy for mental health diagnoses is known as CPT code 90853. This code is used to bill for group therapy sessions that are conducted in an outpatient setting, and the therapy is provided by a licensed mental health professional, such as a psychologist, social worker, or counselor.

CPT code 90853 is used for group therapy sessions that typically last for about an hour and are attended by several patients with similar mental health issues. These therapy sessions may focus on a specific mental health diagnosis or issue, such as depression, anxiety, or addiction.

When billing for non-intensive outpatient group therapy using CPT code 90853, the mental health professional must provide documentation that includes the date and duration of the session, the number of patients in attendance, the diagnosis or issue addressed during the session, and a description of the therapy provided.

It’s important to note that insurance coverage for mental health services varies by plan, so it’s important to verify coverage and reimbursement rates before billing for services. Additionally, mental health professionals should be familiar with the specific requirements and guidelines for billing and documentation set forth by insurance companies and regulatory agencies.



Prepare for the call and make SURE to input all necessary information at the step in the system. Remember, do all work at the steps.

Confirmatory Questions

1. Patient Birthdate?

2. Phone Number?

3. Confirms the NPI?

4. Confirm tax ID?

Medical Information Questions

5. How many hours a week for how many hours a day?

6. Asks to confirm the diagnosis codes

7. Any medical conditions?

8. Pregnant or Postpartum?

9. What brought member into this facility?

10. “Any support at home?”

11. Does member go to school or work?

12. Legal issues?

13. Trauma History?

–Potential follow-up questions about whether or not incidents were reported—

14. Substance Abuse notes?

15. Any family mental illness and psychiatric history?

16. Asks about previous treatment history.

17. MSE upon admission?

18. ADL’s?

19. What medications did member come in with/current/changes and what are the dosages?

20. Member compliant with the meds that we know of?

21. What are the goals while member is there with you?

22. Safety precautions for member at this time?

23. What is the discharge plan?

24. Is the facility communicating with outpatient providers? Who are they?

25. Has member agreed to the current treatment plan?

26. Has member named an outpatient provider?”

– Then they issue the approval

To obtain authorization for behavioral health services, follow these steps:

Check your insurance plan: Before seeking behavioral health services, check your insurance plan to determine if prior authorization is required. Some insurance plans require pre-authorization for certain types of services or for services provided by specific providers.

Choose a provider: Choose a behavioral health provider who is in-network with your insurance plan. If you choose a provider who is out-of-network, your insurance may not cover the cost of the services or may require you to pay a higher out-of-pocket cost.

Contact your insurance company: Contact your insurance company to initiate the authorization process. You may need to provide some basic information, such as your name, insurance plan details, and the type of service you are seeking. The insurance company may also require additional information, such as the provider’s name, the reason for the service, and the expected length of treatment.

Obtain authorization: Once your insurance company has reviewed the request, they will either approve or deny the authorization. If approved, the insurance company will provide you and your provider with an authorization number, which you will need to give to the provider before receiving services. If denied, you may need to appeal the decision or seek alternative services.

It is important to note that the authorization process can take some time, so it is best to start the process as soon as possible to avoid delays in receiving treatment. Also, be sure to follow up with your insurance company and provider to ensure that the authorization has been obtained before scheduling appointments.




Substance abuse treatment is an important aspect of healthcare that helps individuals overcome addiction and lead healthier, more fulfilling lives. However, the cost of treatment can be a barrier for many people, which is where insurance comes in. Insurance can help cover the cost of treatment, making it more accessible to those in need.


Further, the process of billing insurance for substance abuse treatment can be complex and confusing.

Here is an overview of substance abuse insurance billing and what you need to know:

  1. Check your coverage: The first step in substance abuse insurance billing is to check your insurance policy to see what is covered. Most insurance plans will cover some or all of the cost of substance abuse treatment, but it’s important to understand the specifics of your coverage. This includes the type of treatment covered, the amount of coverage, and any exclusions or limitations.
  2. Choose an in-network provider: To get the most out of your insurance coverage, it’s best to choose an in-network provider. These providers have agreed to accept the insurance company’s payment rates, which can help lower your out-of-pocket costs.
  3. Gather documentation: In order to bill your insurance for substance abuse treatment, you will need to provide documentation of your treatment. This may include receipts, treatment plans, and progress reports. It’s important to keep thorough records of your treatment to ensure that your insurance claim is processed correctly.
  4. Submit a claim: Once you have all of the necessary documentation, you can submit a claim to your insurance company. This can typically be done online or by mailing in a paper form. Be sure to include all relevant documentation with your claim.
  5. Follow up on your claim: It’s important to follow up on your insurance claim to ensure that it has been processed and that you are receiving the coverage you are entitled to. If you have any issues with your claim, you can contact your insurance company or provider for assistance.

Once an individual has chosen a treatment facility, the facility will typically handle the billing process on their behalf. This may include verifying insurance coverage, submitting claims, and negotiating with the insurance provider on behalf of the individual. It is important for individuals to stay informed about the status of their billing and to address any issues or discrepancies that may arise.

There are several factors that can impact an individual’s substance abuse insurance billing, including the type and length of treatment received, the specific services provided, and the individual’s insurance coverage. It is important for individuals seeking treatment to be proactive in understanding their insurance coverage and working with their treatment facility to ensure that they receive the coverage they are entitled to.

Overall, substance abuse insurance billing can be a complex and confusing process, but it is an important aspect of seeking treatment for substance abuse. By understanding their insurance coverage and working closely with their treatment facility, individuals can help ensure that they receive the coverage they need to support their recovery journey.

Insurance is an important step in getting treatment for those in need. By understanding your coverage, choosing an in-network provider, and submitting a complete and accurate claim, you can help ensure that you get the coverage you are entitled to.

Get Quicker Access to Payments from UHC/OPTUM… Is this true?

Is this true from UHC?

To speed up payments to your practice, UnitedHealthcare is phasing out paper checks and moving to digital transactions, where not prohibited by law.

You’ll need to choose between two options for receiving payment from UnitedHealthcare – ACH/direct deposit or virtual card payments. Both of these are facilitated by Optum Pay on behalf of UnitedHealthcare.

If your practice/health care organization is already enrolled and receiving claim payments through ACH/direct deposit, there is no action you need to take.

https://www.cmadocs.org/newsroom/news/view/ArticleId/48988/UnitedHealthcare-moving-exclusively-to-electronic-payments

The California Medical Association (CMA) has learned that UnitedHealthcare (UHC direct pay issue) is in the process of discontinuing physician payments via paper checks and will instead require both contracted and non-contracted physicians to receive payment via automated clearinghouse (ACH)/direct deposit or through virtual credit card payments.

The change, first communicated in UHC’s March 2020 Network Bulletin, was originally planned to be rolled out in phases beginning in mid-2020. Due to the COVID-19 pandemic, the rollout of the program was delayed.

UHC has since announced in its August 2020 Network Bulletin that the program will move forward with a phased rollout beginning with its commercial line of business starting in August 2020.  UHC Medicare Advantage and Community and State (Medicaid) Plans will follow with rollouts slated for fall 2020 and early 2021.  

UHC will be publicizing the change to both contracted and noncontracted physicians, who will be directed to sign up for ACH/direct deposit through Optum Pay or via the UHCprovider.com/payment website. Physicians who do not elect to sign up for ACH/direct deposit will automatically be signed up to receive virtual credit card payments in place of paper checks. 

Physicians with questions or concerns, or that need to request a hardship exemption from this policy, should contact their UHC Provider Service Advocate or UHC at (877) 842-3210 for more information.

What is a virtual credit card?

With the virtual credit card (VCC) payment method, payors send credit card payment information and instructions to physicians, who process the payments using standard credit card technology.

This method is beneficial to payors, but costly for physicians. Health plans often receive cash-back incentives from credit card companies for VCC transactions. Meanwhile, VCC payments are subject to transaction and interchange fees, which are borne by the physician practice and can run as high as 5%per transaction for physician practices. Physicians can avoid these interchange fees by enrolling in ACH/direct deposit.

What to do on the UHC direct pay issue?

This all depends on the business set up and values of your institution. This can cause major problems for some programs and be slightly beneficial to others. Below is an exert from the specialty benefits form for UHC:

“I authorize UnitedHealthcare Specialty Benefits to direct the net amount of my benefit payment to be deposited directly by electronic funds transfer and credited to my account as indicated at the financial institution designated below. If any payments made are dated after the date of my death, I hereby authorize and direct the said financial institution on my behalf and on behalf of my executors or administrators to refund any such payments to UnitedHealthcare Specialty Benefits and to charge the same to my account.”

The form does not have all the disclaimers that could possibly affect your group/facility or your providers.

Direct-Deposit-Form-STD-LTD-DIDownload
Claims Department
Direct Deposit Agreement
For Payment of Benefit to Financial Institution

Here is what UHC says the benefits are for ACH

Automated Clearing House (ACH) /direct deposit

  • We recommend ACH because it’s the quickest form of payment available and there are no fees for the service. 
  • Payments can be routed by both the tax ID number (TIN) and National Provider Identifier (NPI) number level.
  • Enrollment generally takes less than 10 minutes. You will need to provide your current bank account information.
  • Funds are deposited directly in to your bank account – there are no paper checks or remittance information to lose or misplace.

Here is what UHC says the benefits are for Virtual Card Payment (VCP)

  • If you don’t enroll in ACH, in most instances you’ll receive a virtual card payment from Optum Pay. VCPs are electronic payments that use credit card technology to process claim payments. There is no requirement to share bank account information.
  • A 16‐digit, single-use virtual card will be issuedopen_in_new for payment (single or multiple claims). You’ll receive a VCP in the mail; for quicker access, you can view the VCP statement in Document Library.
  • Each VCP is issued for the full amount of the claim payment. However, VCPs are subject to additional terms and conditions, including fees, between you and your card service processor.
  • You can enroll in ACH even after receiving a VCP. However, ACH will only apply to future payments and can’t be applied to previous payments.

We can help navigate if this is something that would benefit any behavioral health institution