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Authorisations and continued-stay reviews
An admission approval is only for named days. We track dates, requests and payer decisions; because one missed review or thin clinical update can put the next stretch of days at risk.
Billing for 24/7 operating programs: tracking eligibility & authorisation, per-diem claims, denials, and A/R follow-up for each day a resident is in your program.
For residential programs for mental health, substance use, eating disorders and co-occurring conditions, including adolescent and young adult units.
Benefit checks and authorisation support
Billable day and continued stay tracking during stay
Denials, posting and A/R follow up.
A residential claim is not a single event at discharge. Authorisation, reviews of ongoing stay, documented days and payer specific charges accrue during the stay and any of them can delay payment.
Residential care, when it is provided outside of a hospital, is typically billed on a per diem rather than per visit basis. What codes are used? What claim form is used? What are the review rules? These decisions are made by the payer, the licence, the setting, and the contract.
We help your team keep approvals, billable days and claims data in line with the care that’s actually being delivered.
Concurrent review deadlines, non-billable days and changing payer criteria require consistent, payer-by-payer oversight.
An admission approval is only for named days. We track dates, requests and payer decisions; because one missed review or thin clinical update can put the next stretch of days at risk.
Payers may use ASAM criteria, LOCUS, CALOCUS-CASII, or their own. We find documentation gaps and coordinate appeals. Clinicians maintain all care decisions.
All rates, authorised days, admit and discharge dates, and leave or pass days must match the payer’s rules. A day off can change what you get paid.
Some payers require a UB-04 (837I) with revenue codes such as 1001 for psychiatric or 1002 for chemical dependency residential care. Others require a CMS-1500 (837P). Mismatch with the authorisation delays the payment.
We assist with agreement requests, payer paperwork and follow-up on claims. Approval and the rate are determined by the payer.
We compare remittances to authorised days and contract rates. We then rank open balances by payer response, claim size and deadline.
Tailor the revenue cycle segments you want covered to your program and payer mix.
Before admission, verify residential benefit, patient cost share, authorisation requirements, and plan limitations. Payment not guaranteed upon verification.
Monitor approved dates, authorisation numbers, review deadlines and payer requests in the agreed scope of services.
Verify the billed method, HCPCS or revenue codes, units and covered days as approved by the payer. Depending on the contract, H0018, H0019 and T2048 may apply.
Prepare claims with correct dates, codes and authorisations. Track rejections and responses from payers after claim submission.
Research technical denials and level-of-care disputes, collect supporting records, and coordinate appeals as needed.
Compare paid days, contract rates, remittances and adjustments to identify discrepancies for review.
Track ageing balances, payer status, follow-up actions and appeal due dates so that open claims do not go dark.
Look at rejections, outstanding balances, authorisations shortfalls and recurring payer problems that are part of the project’s reporting.
Billing rules are different for different populations served, different licenses held and different payers.
Authorisation and continued stay records, to include LOCUS or other payer criteria that apply.
ASAM-based review where required, payer-specific billing and 42 CFR Part 2 handling of covered records.
Coverage checks, level of care records, and claim filing methods that work for the payer and the program
Benefit checks and authorisation rules for age specific, including Medicaid psych under 21 benefit where a state offers it, and commercial plans.
Documentation and claims related to mental health and substance use co-occurring disorders.
Specific transition dates and billing rules that vary depending on the level of care.
We review coverage, authorisation rules and claim requirements for each plan prior to billing.
Original Medicare does not cover H or T codes, and has no benefit for non-hospital residential treatment. There are different rules for inpatient and outpatient psychiatric care. Some Medicare Advantage plans include extra benefits so it’s worth checking them out.
Covered services differ by plan and state, including codes, rates and authorisations. In general, adults ages 21 to 64 who are in an institution for mental diseases (a facility with more than 16 beds that primarily treats mental illness) are not covered by federal funds, but there are exceptions and state waivers.
Plans may require admission certification, concurrent reviews, and specific clinical evidence. Network status and rules for single case agreements and billable days may vary, and some payers may require licensure and accreditation documents.
Current payer guidance and your facility contract apply to codes, forms and payment terms.
Complete records support authorisation reviews, accurate claims and appeals. The most important ones:
42 CFR Part 2 records for substance use have confidentiality rules that exceed HIPAA, so check consent and disclosure terms with your compliance team before sending them out for billing.
We flag gaps in records related to billing. Your providers and compliance staff retain responsibility for clinical decisions and regulatory oversight.
Matching dates, records and claims
From admission planning to A/R follow-up, how it works for your program.
Review your current billing process, payer mix and program.
Confirm benefits and monitor payer requirements for authorisations.
Match records, billable days and claim data.
Submitting and tracking payer response.
Investigate denials, payments, and variances.
Follow up on A/R and appeals. Trace repeat problems.
NOTE: Each step is in accordance with your program, your payer contracts, and the services in your engagement.
We handle the billing details that vary within a stay, from approved days to unpaid balances.
Talk about your billing needs ↗Let us know what EHR you use and we will confirm workflow and scope. We do not guarantee authorisations, payments or appeal outcomes.
Brief answers for coverage, codes, authorisation and records.
They may include benefit checks, authorisation tracking, per diem claim preparation, submission, denials, posting, reporting and A/R follow-up, depending on the agreed scope.
Outpatient claims are per encounter. Non-hospital based residential care is typically billed on a per diem basis and has different payer, record and claim rules.
Each eligible day is billed based on the payer’s contracted methodology. Check rates, codes, units, dates of admission and discharge, leave-day rules.
H0018 is a per diem code for short term non-hospital residential treatment and H0019 is for long term residential treatment, usually stays over 30 days. Both exclude room and board. T2048 describes long term care with room and board included. States and payers decide which of these codes to accept, and Medicare does not pay them.
Authorisations have time limits and level of care limits. Even if you miss a continued stay review, have a documentation gap, or bill days and codes that don’t match the approval, the claim can still be denied.
Original Medicare does not have a separate benefit for this. There are separate rules for psychiatric inpatient and outpatient benefits. Medicare Advantage extras vary by plan and must be verified .
Covered services and billing rules are determined by states and managed care plans. Changes in coverage can occur due to the IMD exclusion for adults 21-64, its exceptions and state waivers, with the psych under 21 benefit being available to younger patients when a state provides it.
We can assist with administrative single case agreement requests, payer follow-up and claims review. Terms of approval and payment are at the discretion of the payer.
42 CFR Part 2 has a major effect on billing for substance use services. Additional rules apply to the confidentiality of covered treatment records. Your compliance team needs to verify consents and disclosures for billing partners and payers.
Give us your most important residential billing problem: