If you're running a behavioral health practice in Illinois, you've likely encountered claim denials that seem confusing or arbitrary. Understanding what these denial codes meanâand more importantly, how to prevent themâcan significantly impact your bottom line.
The Cost of Denials
According to the Healthcare Financial Management Association (HFMA), Illinois behavioral health practices see denial rates between 15-18%. Each denied claim costs an average of $25-$35 to rework, not including the lost revenue if the appeal fails.
Most Common Denial Codes
CO-4: The procedure code is inconsistent with the modifier used
What it means: The CPT code doesn't match the modifier. Common with telehealth (modifier 95/GT) and group therapy sessions.
Prevention: Verify modifier requirements for each payer before submission. BCBS IL and UHC have different telehealth modifier preferences.
CO-16: Claim/service lacks information needed for adjudication
What it means: Missing or invalid informationâoften related to prior authorization numbers or diagnosis codes.
Prevention: Implement a pre-submission checklist. Verify all required fields are completed, especially auth numbers for intensive outpatient (IOP) services.
CO-97: Payment adjusted based on medical necessity
What it means: The payer doesn't believe the service was medically necessary based on the documentation provided.
Prevention: Ensure clinical documentation clearly supports the level of care. Include specific symptoms, functional impairments, and treatment goals.
PR-204: This service is not covered under the member's plan
What it means: Eligibility verified, but the specific service isn't a covered benefit.
Prevention: Verify benefits before each session, especially for specialized services like psychological testing or EMDR.
Payer-Specific Patterns
BlueCross BlueShield Illinois
BCBS IL commonly denies claims for:
- Missing or expired prior authorizations for IOP/PHP
- Incorrect place of service codes for telehealth
- Bundling issues with E&M codes and therapy
UnitedHealthcare
UHC's most common denial reasons include:
- Timely filing violations (often 90 days from DOS)
- Medical necessity for extended therapy sessions
- Out-of-network claims submitted to in-network
What To Do When Claims Age Past 60 Days
Once claims enter the 60-180 day "death zone", recovery rates drop significantly. At this point, internal billing teams are often too overwhelmed with current claims to give aged A/R the attention it needs.
This is where specialized A/R recovery becomes valuable. Rather than writing off these claims, a dedicated team can apply focused attention to recover what's rightfully owed to your practice.
Struggling with Aged Claims?
Our team specializes in recovering 60-180+ day aged A/R for Illinois behavioral health practices.
Start Free 20-Claim Pilot âKey Takeaways
- Track denial patterns by payer to identify systemic issues
- Implement pre-submission checklists to catch common errors
- Document thoroughly for medical necessity claims
- Don't ignore aged claimsâthey represent real revenue
- Consider specialized help for 60+ day aged A/R
Understanding denial codes is the first step toward reducing them. For more resources, check out our complete denial code glossary.