Top 10 Behavioral Health Denial Codes
Understanding why claims get denied is the first step to recovering your revenue. Here are the most common denial codes we see in Illinois behavioral health practices.
What It Means
The service you billed doesn't match the modifier attached, or a required modifier wasn't included. Common with time-based CPT codes like 90837.
Common Causes
Missing modifier (95, GT for telehealth), incorrect place of service, or billing a 53-minute code (90837) for a 45-minute session.
Velden Approach
We audit your modifier usage patterns, identify systematic errors, and submit corrected claims with proper documentation to support the service level billed.
What It Means
The payer couldn't process your claim because required information was missing or incorrect. This is a catch-all code for data entry issues.
Common Causes
Missing NPI, incorrect subscriber ID, wrong date of birth, missing diagnosis code, or referral/authorization number not included.
Velden Approach
We cross-reference your claims against payer requirements, identify the specific missing element, correct and resubmit with complete documentation.
What It Means
The payer believes another insurance should be billed first (primary vs. secondary confusion).
Common Causes
Patient has multiple insurance policies, incorrect order of billing, or payer records don't match your information about coverage primacy.
Velden Approach
We verify COB status with both payers, obtain updated coverage information, and resubmit claims in the correct order with proper COB documentation.
What It Means
The claim was submitted after the payer's timely filing deadline (usually 90-180 days from date of service, varies by payer).
Common Causes
Claims stuck in denial loops, delayed charge entry, or waiting too long to follow up on initial rejections.
Velden Approach
We document the original submission attempt, gather proof of timely filing, and submit appeals with evidence showing the claim was originally filed within the deadline.
What It Means
Your billed amount is higher than what the payer allows. This results in a partial payment, not a full denial.
Common Causes
Billed charges exceed contracted rate, out-of-network adjustments, or payer fee schedule updates you weren't aware of.
Velden Approach
We verify correct payment per your contract, identify underpayments vs. contractual adjustments, and appeal when payments don't match agreed rates.
What It Means
The payer doesn't consider the service medically necessary based on the documentation or diagnosis provided.
Common Causes
Insufficient clinical documentation, diagnosis doesn't support the level of service billed, or missing treatment plan justification.
Velden Approach
We gather supporting clinical documentation, craft medical necessity appeals citing payer-specific criteria, and work with your clinicians to strengthen future claims.
What It Means
The payer considers this service bundled with another service you billed, so they won't pay separately.
Common Causes
Billing E/M with therapy on same day, not using modifier 25 when appropriate, or payer-specific bundling rules you weren't aware of.
Velden Approach
We review bundling edit logic, determine if unbundling is appropriate with documentation, and resubmit with proper modifiers or appeal with clinical justification.
What It Means
This portion of the claim is applied to the patient's deductible – it's patient responsibility, not a true denial.
Common Causes
Patient hasn't met their annual deductible yet. Common at the beginning of the year when deductibles reset.
Velden Approach
We ensure the adjustment is accurate, verify remaining deductible amounts, and help you implement effective patient collections processes for these balances.
What It Means
This is the patient's coinsurance portion – their share of the cost after deductible. Not a denial.
Common Causes
Standard cost-sharing per the patient's plan. Usually 10-30% of the allowed amount.
Velden Approach
We verify the coinsurance calculation is correct based on contracted rates and help you identify when payers are incorrectly calculating patient responsibility.
What It Means
The payer required prior authorization for this service and didn't receive it, or the auth number wasn't included on the claim.
Common Causes
Service required prior auth that wasn't obtained, auth number typo, auth expired, or provider wasn't aware auth was needed.
Velden Approach
We obtain retroactive authorizations when possible, appeal with clinical urgency documentation, and help you implement auth tracking systems to prevent future denials.
Seeing These Codes in Your A/R?
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