Insurance Billing

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Part 3 of 7: CVS Health (Aetna): Medical Necessity Criteria for Addiction Treatment Services

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In Part 3 of our 7-part series, we detail CVS Health’s Aetna guidelines for addiction treatment services. This post breaks down key elements—from detox and inpatient rehab to PHP/IOP and MAT—highlighting the use of ASAM Criteria, precertification protocols, and essential billing codes to ensure medical necessity and optimal reimbursement.

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Part 2 of 7: UnitedHealth Group: Medical Necessity Criteria for Addiction Treatment Services

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Explore UnitedHealth Group’s evidence-based approach to substance use disorder (SUD) treatment. Our blog breaks down how ASAM Criteria guides decisions for detox, residential rehab, outpatient programs, and medication-assisted treatment, with essential billing codes and prior authorization tips to ensure smooth reimbursement.

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Part 1 of 7: Understanding Medical Necessity Criteria in Addiction Treatment (Introduction)

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Welcome to our comprehensive blog series on navigating medical necessity criteria for addiction treatment by insurers. This series unpacks how leading payers—from UnitedHealth Group to Kaiser Permanente—determine coverage for detox, rehab, and therapy services. Discover in-depth analyses of ASAM guidelines, insurer-specific requirements, prior authorization protocols, and key billing codes. Whether you’re a treatment provider or healthcare administrator, our expert insights will empower you to align your documentation with industry standards and overcome coverage hurdles. Dive in to transform insurance challenges into pathways for effective patient care.

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The Definitive Guide to Verifying Therapist Licenses: A State-by-State Resource for Treatment Centers and Providers

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Discover the definitive state-by-state guide to verifying therapist licenses. This resource empowers treatment center staff and providers to access official licensing and complaint filing information for mental health professionals across the United States, ensuring regulatory compliance and quality care.

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Comprehensive Guide to Mental Health & SUD Treatment Credentialing

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Credentialing is the backbone of professional practice in mental health and substance use disorder (SUD) treatment. It refers to the rigorous process of verifying and validating a provider’s qualifications, licensure, training, and experience before they are allowed to deliver care or receive reimbursement.

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Comprehensive Eating Disorder Treatment Planning for Behavioral Health Professionals

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Eating disorders are among the most challenging conditions in mental health – not only because of their complex clinical presentation and high mortality rate, but also due to the myriad compliance and reimbursement hurdles that providers face.

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Insurance Reimbursement Rates for Addiction Treatment & Mental Health Facilities in the U.S.

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Struggling with low insurance reimbursement rates for addiction treatment and mental health services? Our comprehensive guide breaks down the essential CPT & HCPCS billing codes, payer reimbursement strategies, and expert tips to reduce denials and increase revenue. Learn how to navigate Medicaid, Medicare, and private insurance billing effectively and ensure your facility gets paid what it deserves.

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Mastering IOP Billing: CPT Codes, Insurance Reimbursement, and Licensing

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What is IOP Billing and How Does It Work? IOP (Intensive Outpatient Program) billing involves using HCPCS codes like H0015 (substance use IOP) and S9480 (mental health IOP) to submit claims for bundled daily services. Most insurers require pre-authorization, condition code 92 (for Medicare), and a minimum of 9 hours of weekly treatment to qualify for reimbursement. Proper coding, medical necessity documentation, and adherence to payer guidelines help ensure claim approval and avoid denials.

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2024 Update! Mastering CPT Codes for Residential Addiction Treatment Services: H0017, H0018, H0019

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The Centers for Medicare and Medicaid Services, also known as CMS, released their annual update to CPT/HCPCS codes on September 8th, 2023. 

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Medicaid Billing for Massachusetts Addiction Treatment Programs 

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You can find the entire range of CPT codes accepted for addiction treatment billing at MassHealth in Subchapter 6 of the MassHealth Substance Use Disorder Treatment Manual, under the header, “Substance Use Disorder Treatment Service Codes.”

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Medicaid Billing Secrets for Addiction Treatment in Tennessee

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Medicaid in Tennessee is called TennCare. According to a recent study, well over 65% of all addiction treatment centers in Tennessee accept Medicaid. That number is growing about .1% every year, with a total of 297 facilities treating SUD in Tennessee.   

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Medicaid Billing for Addiction Treatment in Arizona

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Medicaid in Arizona is called the Arizona Health Care Cost Containment System, or AHCCCS, for short. The vast majority of services delivered through AHCCCS are delivered by managed care health plans, rather than fee-for-service providers.

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Secrets of Medicaid Billing for Addiction Treatment in Washington

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The Medicaid program in Washington State is nicknamed Apple Health. Washington Medicaid will reimburse for a wide variety of addiction treatment services.

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Medicaid Billing for Addiction Treatment in Georgia

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Learn what treatment service categories are covered under Georgia Medicaid, as well as some of the most common CPT codes you’ll encounter when billing Medicaid for addiction treatment services in Georgia. 

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Six Frequently Asked Questions About Billing Medicaid for Addiction Treatment in Florida

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While Florida will cover inpatient, residential, and outpatient treatment for Medicaid patients with SUD, there are a number of services that are not covered under Medicaid rules.

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Secrets of Billing Medicaid in Pennsylvania for Addiction Treatment Services

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Finding information about billing Medicaid for addiction treatment services in Pennsylvania can be difficult. This post contains some tips and tricks - as well as some handy resources - to point you in the direction of the answers you need.