Eligibility and Benefits Verification
We verify that coverage is active, locate where the behavioral health benefits are administered, and make a note of the copays, visit limits, and authorization rules prior to billing the visit.
PMHNP claims break differently than physician claims: enrollment dates, supervision rules, add-on codes, telehealth modifiers.
With these things in mind, we bill solo nurse practitioners and group practices across the country.
Evaluations, medication follow-ups, therapy added to the same visit, video sessions, denials, balances past 90 days – they all come through our team. You continue to see patients and we keep claims in motion.
A visit by a PMHNP touches four systems at once: the clinical note, the code set, the payer’s enrollment file, and the claim form. If you disagree with the others, the claim stops.
Different reporting for intake evaluation, 20 minute medication check, and another visit with 45 minutes of therapy. If you have two services provided at one appointment, your note must show where one service stopped and the next service started.
With that in mind, Mental Health Billing takes care of coding review, claim preparation, payer follow-up and payment matching. We’ll take your visit mix and payers and build the workflow around it.
Billing help based on how BH practices actually work.
All stages of a PMHNP claim, from the first benefit check to the last unpaid balance.
We verify that coverage is active, locate where the behavioral health benefits are administered, and make a note of the copays, visit limits, and authorization rules prior to billing the visit.
We help with payer applications, CAQH profile updates and Medicare enrollments and then verify the effective date of each approval.
The note is compared to diagnoses, CPT codes, modifiers and visit details and each payer’s rules.
The first visit and any follow-up visits are billed with 90792 or the appropriate E/M level, based on documentation and who performed the service.
90833, 90836 or 90838 that are for therapy minutes that are documented separately from the E/M work.
We check rendering and billing provider IDs, place of service, diagnosis pointers and modifiers before each claim goes out.
We read the reason for the denial, find the cause and send a fix, records request or appeal.
Payments, contractual write-offs and patient balances are posted from the remittance advice so your accounts will match what payers actually paid.
Unpaid claims aged out by balance and by payer. Every account has monitored filing deadlines and a next step is recorded.
Modifier, place of service, patient location, and payer coverage are verified for video and audio-only encounters.
We figure out which administrator, like Optum or Carelon, is running the benefit and then check participation and authorization.
Want a team at every stage? We can scope the work from eligibility to final payment.
Caption should match what was done and what the note says.
PMHNPs do prescribe, so the first evaluation is usually a 90792, psychiatric diagnostic evaluation with medical services. Follow-up visits are coded as E/M. There is no code for medication management.
If therapy is part of the same visit, an add-on code can be used with the E/M: 90833 for 16 to 37 minutes, 90836 for 38 to 52 minutes, and 90838 for 53 minutes or more. Interactive complexity (90785) is attached to the evaluation or psychotherapy component, not E/M alone.
A visit does not get coded as a medication check or therapy session. Time does. The work done does. The billing provider does. The payer policy does.
Claim issues are not always tied to procedural code selection but may be related to enrollment, documentation, authorization, benefit administration, or payer responses.
Claims may be denied if the provider’s enrollment is not complete or not effective for the date of service. Checking the status and effective dates can help identify issues.
Documentation supporting each component of both services and compliance with applicable coding rules is required to report both services.
For time based add on codes, documentation must support the psychotherapy service and qualifying time.
Authorization requirements vary by payer, plan and service. Review available benefit/authorization information before billing.
Medicare, Medicaid and commercial plans may have different rules for patient location, place of service codes, modifiers and coverage.
Unanswered payer requests and short payments lie silent until the filing limits run out. Medicare's window is within 12 months from date of service.
A lot of PMHNP schedules involve a lot of telepsychiatry, and each payer has their own way of paying for it.
Medicare telehealth for mental health with the patient at home (audio-only permitted if video is not feasible)
Current law suspends the federal in-person visit requirement, but it could come back. Place of service and audio-only coverage rules, and modifiers vary for Medicaid and commercial plans. The NP also has to have a license in the state the patient is sitting in.
We are looking at every telehealth claim to the payer it is going to, not just one habit such as modifier 95 with place of service 02.
Telehealth coding discussion
Every telehealth claim is checked against the rules of the plan paying it.
The same PMHNP visit can be billed three different ways depending on who pays. We check the rules for each plan, before we decide how to charge.
An enrolled NP can bill covered services under their own NPI, and Medicare pays 85% of the physician fee schedule amount for most of those services.
Incident-to can pay 100% but there are conditions. A plan of care must have been initiated by a physician, the physician must be in the office suite, and a new patient or new problem will not qualify. Some auxiliary staff services are in the area of general behavioral health services supervision.
Each state’s Medicaid program and private insurers have their own rules around NP enrollment, supervision, covered services, telehealth and rates.
Behavioral health benefits are often administered by a different administrator, so we find out who that is and where claims should be sent.
Note: Validate each billing decision with the payer’s current guidance and the facts of the visit. This page is solely for informational purposes and does not guarantee coverage or payment.
Each step connects the visit to the claim, the payer response, and the payment.
We’ll review your services, provider set up, payers, current workflow and what you want off your plate.
The benefits, the rules of authorization and the enrollment status of each NP are checked within the agreed scope.
We read what the claim needs: diagnoses, services and therapy minutes, if applicable.
Charges are validated against the note and payer rules and submitted.
Acknowledgments and rejections are checked as they happen, so problems come to light early.
After payment, remittances are used to post payments and adjustments and the remaining balances are checked for errors.
Denials and unpaid claims are corrected, payer inquired or appealed as appropriate.
Your team can view the claim status and all subsequent actions.
PMHNP billing is where the clinical note, enrollment records, and payer rules meet. That’s where we work.
Evaluations, Medication Visits, Therapy Add-ons and Telehealth are reviewed individually.
Eligibility, coding, claims, posting, denials and A/R can be kept with one team under one scope.
We plan for it, because Medicare, Medicaid and commercial plans treat NP services differently.
We can manage the whole cycle or only denials, claim submission or old balances.
When we take on your agreed-upon tasks, your team spends fewer hours on hold with payers.
Scope changes. Depends on size of practice, services, payer mix, what staff you already have.
Independent providers who’d rather treat patients than chase insurers.
Practices adding providers or visit types requiring enrollment and follow-up to keep up.
Groups where each provider who provides care has their own enrollment status, documentation habits and payer requirements.
Virtual-first practices that require careful handling of modifiers, place of service, and patient location.
Agencies that bill multiple programs and payers under one umbrella.
environments in which the billing practitioners and coverage rules vary by discipline.
Programs billing for buprenorphine and other substance use disorder visits that follow payer-specific rules.
Practices with unpaid claims over 90 days that need to be reviewed against filing deadlines.
Teams that just need coding review, denials, posting or follow up included.
Get straight answers on PMHNP billing, enrollment, add-on codes, telehealth and claim follow-up.
Yes. Mental Health Billing is for solo PMHNPs, psychiatric groups, telepsychiatry providers and other behavioral health practices.
Yes. “Code selection is based on the service documented, who performed it and the rules of the payer so we compare the note to those details.
Yes, if the visit is supportive to them. Codes 90833, 90836 and 90838 are billed with an E/M service and require therapy minutes documented: 16 to 37, 38 to 52, and 53 or more minutes.
We help with payer applications, CAQH updates and effective date checks. We can also track the CAQH re-attestation which is 120 days. Each payer determines approvals and turnaround times.
Medicare, Medicaid and commercial plans are all different. So we check each of those for the service, place of service, modifier, provider details and payer policy.
Carve out means the mental health benefits are handled by a company other than the medical plan. Then claims go to that administrator, so we confirm who it is before billing.
Yes, for Medicare, once the NP is enrolled and the service is covered. State practice authority may influence Medicaid and commercial plans may add requirements.
Only if Medicare conditions are met: physician initiated plan of care, supervision rules are followed, patient has an established problem. No PMHNP visit is to be assumed.
Solo clinic, psychiatric group, or telepsychiatry practice, let us know how billing works for you now and we will tell you what we would take on and what we would leave with you.
Contact Mental Health Billing