Authorizations continued stay
Prior auth to admit, then concurrent review every few days for more days. Miss a review deadline and you lose payment for days already delivered.
Per diem coding, prior authorizations, level-of-care appeals, and AR follow-up for behavioral health residential programs. The work that decides whether a stay gets paid happens while the patient is still admitted, and that is exactly where we work.
A residential program isn't a hospital, so it can't bill the way an inpatient psychiatric unit does. It isn't an outpatient clinic either, so the familiar 90837 and 90853 workflow only covers part of the picture. Programs treating substance use, eating disorders, trauma, or serious mental illness in a 24-hour setting end up billing per diem rates, chasing continued-stay authorizations, and defending medical necessity on almost every admission.
Most medical billing bills discrete services: a visit happened, a code describes it, a claim goes out. Residential bills a day of care room, board, clinical programming, staffing, supervision bundled into a per diem rate. And payment is never guaranteed by the code. A clean claim with a valid authorization still gets denied when the concurrent review team decides the patient no longer meets criteria for that level of care.
Days are billed on HCPCS codes like H0018 and H0019, both defined without room and board.
Depending on payer and licensure, days may go out on institutional claims with revenue codes, not a CMS-1500.
Payers keep reassessing whether they'll pay while the patient is still in your building.
Programs rarely fight one of these at a time. They usually have several running at once.
Prior auth to admit, then concurrent review every few days for more days. Miss a review deadline and you lose payment for days already delivered.
Payers apply ASAM criteria for substance use and LOCUS/CALOCUS for mental health. If the record doesn't map to their dimensions, the days get denied.
Many programs are out of network, which pushes billing into single case agreements, gap exceptions, and slower reimbursement.
Admission and discharge days, therapeutic leave, and passes each affect billable days and every payer counts them differently.
Traditional Medicare has no standalone residential benefit, and Medicaid runs into the IMD exclusion for facilities over 16 beds.
Denials that would never happen on the medical side are common on residential behavioral health claims — and many are appealable under federal parity law.
Billing here isn't a back-office task that starts after discharge. The money is won or lost during the stay, so we work alongside your clinical and admissions staff in real time.
Confirm before admission whether residential is a covered benefit, at what level, and what the patient responsibility looks like.
Obtain the initial auth and set up the concurrent review calendar so no continued-stay deadline slips.
Keep documentation and level-of-care evidence aligned to the payer's criteria while the patient is still admitted.
Match form type, auth number, and billed days to authorized days before the claim ever leaves.
Peer-to-peer reviews and appeals built on the clinical record and the exact criteria the payer applied.
Post against the expected per diem, catch short-pays and denied days buried inside paid claims.
Work the aging report by value and appeal deadline on a schedule, not just when someone asks.
Track denials by payer over time so you hear about a mass level-of-care denial early, not months later.
The right mix depends on how your program is structured and licensed. Here's the territory we live in.
Short- and long-term residential per diems, plus the revenue codes that carry days on a UB-04 when the payer wants an institutional claim.
Diagnostic evals, individual and group therapy, and family sessions billed inside the per diem or separately depending on the contract. Med management runs on E/M with 90833/90836/90838 add-ons.
Diagnosis coding supports medical necessity, so severity and remission specifiers matter. We watch place-of-service and the HF/HG modifiers some Medicaid programs require.
A denial gets read, not just resubmitted. Continued-stay denials call for a peer-to-peer or an appeal built on the record and the exact level-of-care criteria applied. For denials that look like parity violations, we cite the plan's own criteria and the Mental Health Parity and Addiction Equity Act — and years of litigation over medical-necessity criteria give programs real footing to challenge them.
Every payment is posted against the expected per diem or contracted amount, not just recorded as paid. When a payer authorizes some days and denies others in the same stay, posting has to catch short-pays, denied days inside a paid claim, and incorrect rates. We reconcile line by line and flag underpayments instead of letting them absorb into the total.
A single denied stay can represent tens of thousands of dollars, so we prioritize follow-up by value and by where the claim sits in the appeal timeline. Claims past a payer's expected turnaround get called on, appeals get tracked to their deadlines, and genuinely uncollectible balances get identified honestly.
We tell you when the record won't support the claim before it becomes a denial — level-of-care assessment present, daily notes showing active treatment, physician certification in the chart. And we handle substance use records under 42 CFR Part 2's stricter confidentiality rules, not just HIPAA, so billing never becomes a disclosure problem.
We're not a general medical billing company that added a mental health line. Residential, PHP, IOP, and outpatient behavioral health are the work and that focus shows up in the details.
Whether a program runs 20 beds or several hundred, the billing logic is the same and the attention doesn't change.
Traditional Medicare has no standalone residential treatment benefit for mental health or substance use the way commercial and many Medicaid plans do. It covers inpatient psychiatric care and outpatient services like PHP, but a typical residential per diem generally isn't reimbursable. We verify this up front so programs don't admit Medicare patients expecting coverage that isn't there. Some Medicare Advantage plans differ, so we check each one.
An authorization approves specific days at a specific level of care, and the payer keeps reviewing whether the patient still meets criteria while admitted. A concurrent review can deny continued days even though the initial auth was valid. Most of these are appealable and many should be, especially when the payer applies stricter standards than parity law allows.
Both are per diem behavioral health residential codes. H0018 covers short-term residential and H0019 covers longer-term residential, both defined as without room and board. Which one applies depends on the program's structure and the payer's rules, and some payers or state Medicaid programs use entirely different codes contract terms decide it.
Yes. Many residential programs are out of network, and we handle SCA requests, gap exceptions, and the slower reimbursement cycle that comes with out-of-network billing — including negotiating rates before admission where the payer allows it.
We treat substance use records under Part 2's stricter confidentiality rules, not just HIPAA, and manage claims and records so billing doesn't create an improper disclosure. Consent and disclosure limits are built into how we handle those accounts.
Generally a level-of-care assessment (ASAM for substance use, LOCUS or CALOCUS for mental health), a current treatment plan, daily progress notes showing active treatment, and physician involvement or certification. When the record doesn't support the level of care, we flag it before the claim goes out rather than after the denial.
Setup depends on payer enrollments, clearinghouse connections, and access to your EHR, but most programs are submitting through us within a few weeks. We can start working aged AR and open denials while enrollment finishes.
Usually, yes. We work in the behavioral health systems residential programs commonly use and in general platforms, and the billing rules stay the same regardless of software.