Coverage That Doesn’t Add Up
PHP benefits may have their own day limits, copays, or network rules, separate from outpatient therapy. And a plan that shows active coverage may still cap the program.
A PHP claim must be matched to a 20 hour per week plan of care, signed certifications, and a daily count of services. Mental Health Billing manages that paper trail so every day billed gets to the payer with the support it requires.
Medicare requires that a physician certify that a PHP patient requires at least 20 hours per week of therapeutic services and would otherwise require inpatient psychiatric treatment. Commercial payers have their own criteria and each will review your documentation against it.
Mental Health Billing deals with the revenue cycle behind that, including benefit checks, authorisation tracking, claims built by program day, payment posting, denials and A/R. We agree what we handle and what remains with your staff, prior to starting work.
Every day on which a bill is rendered has a record behind it.
One PHP day uses authorisations, attendance logs, group notes, and physician certifications. Any gap in one of these can delay the claim.
PHP benefits may have their own day limits, copays, or network rules, separate from outpatient therapy. And a plan that shows active coverage may still cap the program.
Days approved expire, concurrent review to determine whether they are extended or not. A frequent cause for denial by payers is a service date outside the approved window.
Plan of care specifies 20 hours/week. A drop in attendance may result in Medicare remittances with alert code N787 and other payers may question the level of care.
Medicare only counts a PHP day if there are at least three services on that day. If a group note or unsigned entry is missing, the day may not be counted.
First Medicare recertification is due on day 18 and at least every 30 days thereafter. If a form is late or not signed, later claims may be at risk.
A denied PHP claim typically needs corrected information, extra documentation, or an appeal, and each payer has its own timeframe. If you wait, you lose the opportunity to respond.
Worth knowing: No billing company can promise all PHP claims pay or all denials reverse. A steady process identifies problems early and keeps valid claims flowing.
Select your assignments from your desk. We write down the scope before we start, and it changes as your program changes.
We’ll confirm that the patient is actively covered, PHP day limits, copays and network status prior to day one of the program and flag any items that will require a conversation with the patient. A benefit cheque is not a guarantee of payment.
Ask about verification ↗We track the days we approve, the dates for review, the reference numbers, and mark the day-18 and 30-day recertification markers for Medicare patients. Your doctors and the payer still make the clinical decisions.
Ask about tracking ↗We compile each day's services, revenue codes and HCPCS codes against your records and the payer's format using the 13X, 85X or 76X bill type appropriate for your setting.
Claim review enquiries ↗We file the completed claim, monitor the status and follow up on rejections, edits and record requests. Hospital-based Medicare PHP claims include condition code 41.
Enquire about submission ↗We read the remark codes, identify the reason and determine if the fix is a correction, missing records or a written appeal under the payer’s own process.
Talk about denialsWe post payer payments, contractual adjustments and patient balances and then compare each remittance to what was billed and flag short payments.
Ask about posting ↗We work unpaid and ageing PHP claims, call payers when a claim stalls, and log the next step on every open account so nothing goes unowned.
A/R support? ↗Requirements depend on payer, state and program setting. These are the checkpoints we apply to each claim.
Medicare requires a physician's certification and a plan of care showing 20 hours per week.
Dates of service must be within the authorised period and concurrent reviews must be on file.
Payment for a Medicare PHP day is contingent upon three or more documented services.
Hospital outpatient departments, critical access hospitals and CMHCs generate Medicare PHP claims.
Some plans want per diem codes such as H0035 or S0201 rather than Medicare’s per service.
Commercial payers use MCG or InterQual or their own criteria to approve and extend days.
Every stage has an owner and a next step so you can see the status of a claim. It’s up to the scope you select what we run.
Create a map of your billing flow, payer mix, and program type.
Confirm coverage, PHP limits and authorisation rules.
Log approved days and recertification due dates.
Compare services and hours to the record before billing.
Submit claims on the correct bill type with payer specific codes.
Identify the reason and then fix, document or appeal it.
Reconcile payments and work ageing balances.
Just need help with one stage?
Define your planWe don’t do every stage for every client. Responsibilities are written down before work begins.
When your claim volume exceeds your billing staff or when denials and ageing claims start to accumulate, outside help can pay off.
Doesn't your program fit any? Send us the details and we’ll let you know if we are a fit.
Talk through your programThe PHP day is charged from attendance sheets, group notes, physician signatures and authorisation letters. We read each of those against the payer’s rules before the claim goes out and then again when the remittance comes back. We cannot guarantee reimbursement results.
You receive simple updates on what claims are denied, not paid or ageing, with the next step defined for each.
Tell us about your billing needs
Verification of records against payer rules before and after submission.
Denials, unpaid claims and ageing balances all have a named next action.
You see where all the claims are, and which decisions need you.
Fast answers to certification rules, authorisations, denials and outsourcing.
They cover PHP's revenue cycle, from benefit checks to A/R follow-up including authorisation tracking, claim building and submission, payment posting and denial work. At Mental Health Billing, the exact list depends on what scope you sign off on.
Outpatient therapy per session bills. A PHP bills a program day consisting of multiple services, linked to a plan of care that requires 20 hours per week under Medicare. Authorisation spans and recertifications add steps a typical therapy claim never has.
Generally, payers want to see the physician certification, plan of care, daily attendance, signed notes for each service, and the authorisation on file. Medicare requires recertification at day 18 and every 30 days thereafter at a minimum. There are other payers who publish lists of their own.
It is contingent upon who’s paying. Original Medicare is based on physician certification, not prior authorisation. Many commercial and Medicare Advantage plans do require approval. Some do not. A benefit check will tell you which rule applies.
Typical causes are no authorisation or expired authorisation, service dates outside the approved range, Medicare days with less than three services, and notes not supporting medical necessity. The right fix could be a correction, added records or an appeal.
Yes. We read the reason for denial, correct billing errors, pull records from your team, and file appeals with the payer’s process. No one can promise a reversal and we do not promise a reversal.
Yes, they do. Medicare dictates the 20-hour minimum a week, the day-18 recertification and the three-service day. States have different Medicaid rules . Commercial plans have their own levels of care and sometimes use per diem codes like H0035 or S0201 . We check each payer’s current policy.
Yes, that is within the agreed scope. We work unpaid and ageing claims, call payers on a stalled claim and note the next step on each open account.
Look for real behavioural health experience, a written scope of services, a clear process for denials and ageing claims, careful handling of patient information and reports you can read.” Watch out for any company that offers you a refund.
Use the form at the top of this page or email us at info@mentalhealthbilling.com.Tell us your program type, main payers and biggest billing problem. We will get back to you with the tasks we can take on.
Tell us about your program, your primary payers and the claims that keep getting stuck. We’ll tell you what we can handle for you and what should be kept in-house.