Insurance Billing Best Practices

The following are essential elements for insurance billing. Please note that these are general guidelines and you should read your insurance contracts to ensure you are in compliance.

Prior to services

  1. Ensure a picture of the front and back of the insurance card is uploaded to the client’s file.

    1. Make sure to obtain all health insurance plans. They may have secondary insurance, which we must have in order to bill.

  2. Ensure there is a credit card on file to process copayments, coinsurance, and deductibles.

  3. Ensure all demographic information is completed. For clients who are not the primary insured, we must also have the demographics for the primary insured. A sex must be indicated and match what is on file with the insurance provider.

  4. You may also request the client contact their insurance provider to further confirm their benefits prior to initiating services.

  5. Enter the copay information (if given by billing) into the insurance tab in the client file.

  6. Plan your first session to be an intake assessment. You should always bill your first session as a 90791, which is the procedure code used for diagnostic evaluation of new behavioral health concerns and/or illnesses.

Following sessions

  1. Progress notes must be complete, signed, and locked prior to submission of billing. The session is not considered complete until the note is signed and locked.

  2. Charge co-pays, coinsurance, and private pay at the time of session. Make sure to select the credit card on file to process the payment. If a payment is declined, inform your client. You may need to request a new credit card for their file.

  3. If clients accrue large balances, make sure to document outreach that you have attempted to collect payments from them. Insurance payers assume you've been collecting since these amounts go towards deductibles/out-of-pocket maximums.

Insurance payment terminology

  1. Copay: A copay is a fixed amount of money that a policyholder (patient) is required to pay for specific healthcare services

  2. Coinsurance: Coinsurance is a cost-sharing arrangement between the policyholder and the insurance company after the deductible has been met. It represents the percentage of healthcare costs that the policyholder is responsible for paying, with the insurance company covering the remaining percentage. For instance, if a policy has an 80/20 coinsurance arrangement, the insurance company pays 80% of covered expenses, and the policyholder pays the remaining 20%.

  3. Deductible: A deductible is the initial amount of money that a policyholder must pay out of their own pocket for covered healthcare services before their insurance plan starts to cover the costs. Once the deductible is met, the insurance company typically begins to share the cost of covered services through coinsurance or copays.

  4. Out-of-pocket max: The out-of-pocket maximum is the maximum amount of money that a policyholder is required to pay for covered healthcare expenses during a specific time period (usually a calendar year). Once this limit is reached, the insurance company covers all eligible healthcare costs, and the policyholder is no longer responsible for any additional payments for covered services. This maximum includes deductibles, copays, and coinsurance payments.

Diagnosing following the intake assessment

When it comes to mental health services and insurance reimbursement, using appropriate diagnostic codes, including F-codes from the International Classification of Diseases, 10th Edition (ICD-10), is typically necessary for insurance to pay for these services. For insurance payers, you must have an F-code diagnosis (Z-codes as primary will be denied). You may update your diagnoses, but one must be assigned following your initial assessment. Here are some reasons why insurance requires an F-code diagnosis:

  1. Documentation of Medical Necessity: Insurance companies require a clear and documented diagnosis to establish the medical necessity of mental health services. Using specific diagnostic codes (such as F-codes) helps demonstrate that the services provided are based on a recognized and clinically appropriate diagnosis.

  2. Treatment Authorization: Insurance providers often require prior authorization for certain mental health treatments. The use of diagnostic codes, along with supporting clinical documentation, helps justify the need for treatment and obtain authorization from the insurance company.

  3. Claim Submission: When mental health services are provided, claims must be submitted to the insurance company for reimbursement. These claims must include the appropriate diagnostic codes to describe the condition being treated. The diagnostic codes on the claim form help the insurance company determine coverage and reimbursement levels.

  4. Reimbursement: Insurance companies use diagnostic codes to determine how much they will reimburse for specific mental health services. Different codes may result in different reimbursement rates, so accurate coding is essential for fair and appropriate payment.

  5. Treatment Planning: Diagnostic codes also play a crucial role in treatment planning. Mental health professionals use these codes to guide treatment decisions, develop treatment plans, and communicate with other healthcare providers about a patient's condition.

  6. It's important to note that the specific diagnostic code used should accurately reflect the patient's condition and be supported by clinical evidence and assessment. Inaccurate or inappropriate coding can lead to claim denials or delays in payment.

Procedure codes

  1. 90791 An integrated biopsychosocial assessment, including history, mental status, and recommendations. This procedure code is used for diagnostic evaluation of new behavioral health concerns and or illnesses, or upon treatment of a new client (16 – 90 minutes)

  2. 90832   Psychotherapy, 30 minutes with patient (16-37 minutes)

  3. 90834   Psychotherapy, 45 minutes with patient (38-52 minutes)

  4. 90837   Psychotherapy, 60 minutes with patient (53 or more minutes

  5. 90846   Family psychotherapy (without the patient present), (26 or more minutes)

  6. 90847   Family psychotherapy (conjoint psychotherapy) (with patient present), (26 or more minutes)

  7. CPT codes 90832-90837 may be reported on the same day as codes 90846 or 90847 when the services are separate and distinct.

  8. 90785   Interactive complexity (List separately in addition to the code for primary procedure)

    1. *Can be reported with appropriate psychotherapy code based on length of session = For diagnostic evaluation (90791), psychotherapy (90832, 90834, 90837), and group psychotherapy (90853)

    2. Add-on code 90785 for Interactive complexity refers to factors that complicate the delivery of a mental health procedure, including (Additional information from the American Psychological Association)

      1. The need to manage maladaptive communication (e.g., related to high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicate the delivery of care.

      2. Caregiver emotions or behaviors that interfere with the caregiver’s understanding and ability to assist in the implementation of the treatment plan.

      3. Evidence or disclosure of a sentinel event and mandated reporting to a third party (e.g., abuse or neglect with a report to the state agency) with the initiation of discussion of the sentinel event and/or report with a patient and other visit participants.

      4. Use of play equipment or other physical devices to communicate with the patient to overcome barriers to therapeutic or diagnostic interaction between the physician or other qualified health care professional; and a patient who has not developed, or has lost, either the expressive language communication skills to explain his or her symptoms and respond to treatment; or a patient who lacks the receptive communication skills to understand the physician or other qualified health care professional if he/she were to use typical language for communication.

  9. 90839   Psychotherapy for crisis; first 60 minutes (Additional information from the American Psychological Association)

    1. *Billed for the first 60 mins of psychotherapy for a patient in crisis, and add-on code 90840 billed for each additional 30 mins.

    2. CPT code 90839 is the principal code for a crisis psychotherapy session requiring urgent assessment and history of the crisis state, mental status exam, and disposition. It is billed for the first 60 minutes of psychotherapy for a patient in crisis.

    3. If/when the crisis psychotherapy session lasts longer than 60 minutes, the add-on code, 90840, can be billed for each additional 30 minutes of psychotherapy for crisis.

    4. In order for the new crisis codes to apply, the presenting problem must typically be life-threatening or complex and require immediate attention to a patient in high distress.

  10. 90840   Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code for primary service)

  11. 98966   Telephone evaluation and management service by a qualified non-physician health care professional to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an evaluation and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

  12. 90853 Group psychotherapy

Place of Services (POS) and Modifiers

  1. Place of service (POS) will automatically populate based on the location you select for your session.

  2. For more information about modifiers, please review the “Adding Modifiers to Claims and Superbills” document from Simple Practice.

  3. 02 Telehealth Provided Other than Patient’s Home.

  4. 11 Service Provided In-Office

  5. 10 Telehealth Services Provided in Patient’s Home

  6. Modifier -95 Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System.

    1. Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified healthcare professional and a patient who is located at a distant site from the physician or other qualified healthcare professional.

    2. The totality of the communication of information exchanged between the physician or other qualified healthcare professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.

Secondary Insurance Rules

Claims will likely be denied with an error go indicating the member has another insurance plan, so we need to submit claims to the other insurance payer.

  1. Non-duplication of Benefits: This rule ensures that a policyholder does not receive more benefits than the total cost of the healthcare service. It prevents "double-dipping" where both insurance plans cover the full cost.

  2. Maintenance of Benefits: This rule ensures that a policyholder maintains the same level of benefits when coordinating coverage under multiple plans. It prevents one plan from reducing benefits because another plan is also providing coverage.

  3. Order of Benefit Determination: Insurance plans often have specific guidelines for determining the order in which they pay benefits. For example, one plan may consider itself primary for dependent children, while another plan considers the plan of the parent with custody as primary.

  4. Medicare Coordination of Benefits: When an individual has both Medicare and other health insurance (such as employer-sponsored coverage), there are rules to determine the order in which the plans pay. Typically, Medicare is primary for those aged 65 and older, and the other plan is secondary.

  5. Medicaid Coordination of Benefits: If an individual is eligible for both Medicaid and another insurance plan, Medicaid may be secondary and cover costs not paid by the primary plan.

  6. Actively employed insurance plans will always be primary, even with Medicare.

    1. For additional information on Medicare, read here.

  7. The Birthday Rule: This rule is used to determine the primary insurance plan when both spouses have coverage and their children are listed as dependents. Under the Birthday Rule, the primary insurance plan is indicated by the parent whose birthday falls earlier in the year. For example, if one parent's birthday is in February and the other parent's birthday is in June, the parent with the February birthday plan would be considered primary for the children.

  8. The Longer-Shorter Rule: This rule is used to determine the primary insurance plan when an individual has dual coverage through their own employer and their spouse's employer. Under the Longer-Shorter Rule, the primary insurance plan is indicated by whichever employer you started with first. If you've been covered under your own employer's plan longer than your spouse's, your own plan is considered primary.

  9. These rules are important in coordinating benefits between multiple insurance plans to ensure that claims are processed correctly and that policyholders receive the maximum coverage available to them. However, it's worth noting that these rules may not apply in all situations, and the specific coordination of benefits may be governed by the terms and conditions of the insurance plans involved.

Types of insurance plans

  1. HMO (Health Maintenance Organization): An HMO is a type of managed care plan that usually requires policyholders to choose a primary care physician (PCP) and obtain referrals from the PCP to see specialists. HMOs typically have lower premiums but limit coverage to in-network providers.

  2. PPO (Preferred Provider Organization): A PPO is another type of managed care plan that offers more flexibility in choosing healthcare providers. You can see specialists without a referral, both in-network and out-of-network, but you'll usually pay less when using in-network providers.

  3. EPO (Exclusive Provider Organization): EPO plans are similar to PPOs but do not cover any out-of-network care, except in emergencies. They often have lower premiums than PPOs.

  4. Medicare: A federal health insurance program primarily for individuals aged 65 and older, as well as some younger individuals with certain disabilities. It consists of several parts, including Part A (hospital insurance) and Part B (medical insurance).

  5. Medicaid: A joint federal and state program that provides health insurance to low-income individuals and families. Eligibility and coverage can vary by state.

  6. Catastrophic Health Insurance: This type of plan is designed for young, healthy individuals and provides minimal coverage for major medical expenses. It typically has low premiums but high deductibles.

  7. COBRA (Consolidated Omnibus Budget Reconciliation Act): COBRA allows eligible employees and their dependents to continue their group health insurance coverage for a limited time after leaving a job or experiencing certain qualifying events. However, the policyholder is usually responsible for the full premium cost.

Common Insurance Plans in Arizona

Blue Cross Blue Shield

  1. Please note that Anthem, Medica, and all state BCBS plans are accepted under the BCBS contract.

  2. For Mayo Clinic Medica plans: Plan ID (A0021); Group ID (MAY001)

  3. Make sure to select Blue Cross Blue Shield of Arizona regardless of their plan. All BCBS claims are submitted through Blue Cross Blue Shield of Arizona.

  4. For reimbursement equivalent to an in-person visit for members with commercial plans (note that we only accept commercial BCBS plans), please bill with the procedure code you normally use and add telemedicine modifier 95 or GT. These modifiers work for both audio/video and telephone-only visits. For professional claims, use place of service (POS) 02 (note that all our claims are considered “professional” claims).

Aetna

  1. Please note that all Aetna commercial plans and Meritain Health are accepted under Aetna contracts.

  2. Meritain is submitted under EDI #64157.

  3. For commercial members non-facility telemedicine claims must use POS 02 with the GT or 95 modifiers.

  4. Aetna EAP will mail you an authorization with the approved number of sessions. You must use this form to submit billing for Aetna EAP.

Cigna

  1. Please note that all Cigna commercial plans are accepted under the Cigna contract.

  2. HealthPartners of Minnesota is submitted under EDI #55764.

  3. For commercial members non-facility telemedicine claims must use POS 02 with 95 modifier.

  4. For Cigna EAP, use CPT code 99404.

Optum/United Healthcare

  1. Please note that UMR, Student Resources, Golden Rule, Harvard Pilgrim, Oxford, and Oscar are accepted plans under the Optum contracts.

  2. UMR and Golden Rule claims are submitted under EDI #39026.

  3. Student Resources claims are submitted under EDI #74227. Student Resources requires a referral from the campus medical in order to bypass the deductible payment. Make sure to ask clients if they have completed the referral process prior to starting sessions.

  4. Oxford is submitted under EDI #06111.

  5. Harvard Pilgrim is submitted under EDI #04271.

  6. Use a POS 10 – Telehealth Provided in Patient’s Home for all Optum/UHC telehealth claims.

  7. If the plan has separate rates for facility and non-facility outpatient counseling, use the 11-POS and 95-modifier to avoid being billed under facility rates.

  8. The HJ modifier is used for Optum EAP.

  9. Wellness Assessment instructions

    1. The first step is for the member to complete the Wellness Assessment (WA) on or before their initial session with the provider. The Wellness Assessment can be obtained by the provider via the clinical forms area of provider express. A member can also receive a blank Wellness Assessment by calling the number on the back of their card and requesting a Wellness Assessment Education Packet.

    2. A second Wellness Assessment should be completed and submitted between the third and fifth sessions. Finally, at 4 months, a final member follow-up Wellness Assessment will be mailed to the member with a stamped, pre-addressed envelope. Providers are encouraged to utilize Wellness Assessments in conjunction with the Wellness Assessment Dashboard at other points in treatment to monitor risk and progress.

Triwest

  1. Coordination of care with the VA

  2. The provider must have an Approved Referral/Authorization from VA or TriWest BEFORE an appointment can be set

    1. Referral/Authorization Number in Field 23 Prior Authorization Number field box

  3. If you determine additional care is needed, submit a Request for Service (RFS)- directly to VA and as soon as it is identified

  4. Request for Service (RFS) is a provider-generated request for new or additional care outside the scope of the current authorization/referral

    1. Submit SAME DAY you determine it’s needed BEFORE you deliver care, and DIRECTLY to the authorizing VA Medical Center (VAMC)

    2. Submit if you need to extend service.

  5. For Beneficiary ID use one of the following

    1. 10-digit Electronic Data Interchange Personal Identifier (EDIPI)

    2. 17-digit Veteran ICN as found on VA authorization letter

    3. Social Security number (SSN)

    4. Last 4 digits for SSN with preceding 5 zeros (i.e., 00000XXXX)

  6. Triwest Payer ID: TWVACCN

  7. VA requires providers to submit medical documentation directly to the authorizing VAMC (through HSRM) within the first 30 days of the first appointment and within 30 days of the final appointment, and include:

    1. All medical documents must be signed (written or electronic), and/or initialed by the submitting provider or practitioner

    2. Veteran Unique Identifier

    3. Veteran’s full name (including suffix)

    4. Veteran’s date of birth

    5. Referral number

    6. Provider/Practitioner Authentication

  8. VA defines Critical Findings as a test result value or interpretation that, if left untreated, could be life-threatening or place the Veteran at serious risk

    1. Providers are required to report Critical Findings to the VA within the earlier of two (2) business days of the discovery or the timeframe required to provide any necessary follow-up treatment to the Veteran

    2. Communication shall be either verbal or written

  9. Never charge a Veteran for not keeping a scheduled appointment or for care you didn’t have an Approved Referral/authorization to deliver

    1. Payment to your office for authorized services is deemed payment in full

    2. Do NOT balance bill Veterans or TriWest for services provided under the CCN

  10. Each individual provider within a practice or group with a DEA number and who treats Veterans under the VA Community Care programs must take the VA-required opioid safety course.

    1. Go to https://train2serve.com/

    2. Select Register Now

    3. Complete the registration process

    4. Download the Opioid Safety Initiative information

    5. Have your individual NPI available

    6. Also take Recommended Military/Veteran Culture Training

Compsych

  1. Confirm that sessions have been approved prior to services. You will either receive confirmation via email from Compsych, or may look up through the Compsych provider portal.

  2. Please note that Compsych sessions are expected to be 45 minutes in length, but you may see the client for longer. However, Compsych is only reimbursing for 45 minutes regardless of time spent in session.