The denial pattern
Behavioral health care runs over many sessions, and payers ration it: an authorization covers a set number of visits or a date range, and concurrent review decides whether more are approved. When nobody is counting, session twelve is delivered on an authorization that covered ten, and the claim comes back CO-197.
How we prevent it
- Authorized units and date ranges tracked against the schedule
- Renewal requests filed before the current authorization runs out
- Concurrent review documentation requested from the clinician in time
- Eligibility re-checked on recurring appointments
- Denials for authorization appealed with the paper trail already in hand
Systems we work in
Behavioral health practices commonly run SimplePractice or TherapyNotes; we work inside whichever you use. Credentialing for therapists, counsellors and psychologists — CAQH, Medicaid, managed care and commercial panels — runs alongside billing so new clinicians can bill from their effective date.
Psychotherapy codes and what they need
Outpatient therapy is billed mostly on a small set of CPT codes, and each has its own documentation test:
- 90791 — psychiatric diagnostic evaluation, usually the first visit
- 90832, 90834, 90837 — individual psychotherapy, chosen by documented face-to-face time (roughly 30, 45 and 60 minutes)
- 90846 and 90847 — family psychotherapy without and with the patient present
- 90853 — group psychotherapy
- 90839 and 90840 — psychotherapy for crisis, with time thresholds of their own
Behavioral health carve-outs
Many medical plans hand mental health benefits to a separate behavioral health administrator. The patient's card names the medical plan, but the claim, the authorization and often the credentialing belong to the carve-out. Billing the medical plan produces a wrong-payer denial weeks later. We identify the carve-out during eligibility verification, so the claim goes to the right payer the first time.
Telehealth therapy
Telehealth is routine in behavioral health, but the billing rules aren't uniform. Payers differ on the place-of-service code (02 or 10), the modifier (95, GT or none) and whether audio-only sessions are covered. We apply each payer's current rule per claim rather than one setting for everyone, and re-check when payers update their telehealth policies.