What You Need to Know for PHP Insurance Billing in 2023

A partial Hospitalization Program (day hospitalization) is a structured day program providing several hours of therapy and necessary skill-building groups daily. Participants in a daily PHP routine go back home each night. The program can last for a week or up to six months.

PHP treatment programs closely resemble a highly structured but short-term hospital inpatient program. It’s more intense than psychosocial rehabilitation or outpatient day treatment. We have prepared this article to provide general guidelines for insurance billing for PHP.

Behavioral Health Levels of Care

Behavioral health facilities provide four types of services needed by patients that insurance companies may reimburse. These include:

1. Hospital-based inpatient programs where patients need medical monitoring, nursing care, or other behavioral health services requiring 24/7 treatment.
2. Residential treatment programs (RTC) are a form of sub-acute facility-based monitoring that offers other behavioral health services.
3. Partial hospital programs (PHP) provide services in an ambulatory setting and often require 20 hours per week.
4. Intensive outpatient programs (IOP) where patients get behavioral health services for nine to 19 hours per week (adults) and at least six hours for children and adolescents.

Insurance Billing for PHP in a Nutshell

PHP services receive insurance reimbursement for an all-inclusive per diem payment, including services used in the program or the lesser charges. It includes all disciplines and services such as therapies, social workers, psychiatric nurses, dieticians, occupational therapists, and licensed addiction counsellors.

Psychologists, psychiatrists, psychiatrist physician assistants, and psychiatric nurse practitioners may bill separately on a CMS-1500 Claim Form if they provide services outside of a treatment program, for example, individual therapy, E&M services, or psychological testing. Additionally, appropriately licensed providers can bill separately for labs or psychiatric diagnostic evaluations.

Providers cannot bill Family or group counseling in addition to PHP.

Instructions for Insurance Billing for PHP

Facilities provide different substance use and psychiatric service levels with various licensure types. Each care level requires specific coding and billing information to determine appropriate reimbursement. Below is the insurance billing for PHP guide on the UB-04 Claim Form.

Psychiatric Services

Facility or Service Type	Bill Type	Revenue Code	Level	HCPCS
PHP	131	0912	Full day	H0035
PHP	131	0912	Eating Disorder Program	S9485

Substance Use Services

Facility or Service Type	Bill Type	Revenue Code	HCPCS
PHP	131	0912	S9475

Billing Limitations and Exclusions

When insurers consider reimbursement, payment determination is subject to the following:

• Individual or group benefit
• Provider Participation Agreement
• Mandated or legislative-required criteria always supersede
• Routine claim editing logic that includes but not limited to mutually exclusive or incidental logic and medical necessity

If the insurance provider participates based on member benefits, then coinsurance, co-payment and deductible apply.

Does Medicare Cover PHP?

Medicare could cover PHP programs if a Medicare-certified CMHC or a hospital outpatient department provides them. Medicare does not cover psychosocial programs that provide only socialization, vocational rehabilitation, or a structured environment. A program comprised primarily of social, recreational, or diversionary activity does not constitute a PHP.

Patients that meet benefit category requirements for PHP Medicare coverage comprise of two groups:

• Those discharged from inpatient hospital treatment programs where PHP is in place of a continued inpatient treatment
• Those who would be at risk of needing inpatient hospitalization in the absence of PHP

Over to You

Reimbursement policies for insurance billing for PHP are intended to establish general guidelines under the specific insurance providers’ plans. Therefore, providers retain the right to review and update reimbursement policy guidelines at their discretion.

We hope this short but informative article was helpful. If you have any queries about insurance billing for PHP and how to maximize your reimbursement, please contact us via email or our contact us website page.