Payor Guidelines for Each Level of Care

As insurers receive more claims for addiction treatment and behavioral health care, they are becoming more stringent on what counts as medical necessity. To receive reimbursement, you must ensure each patient at each level of care is received evidence-based treatment that aligns with the patient’s diagnoses.

While each private insurer may have different standards when it comes to proving medical necessity, each starts with the basic Medicare guidelines. These guidelines offer an outline for what care a patient should receive. With every patient, whether or not they use Medicare coverage, you should follow these guidelines to reduce your risk of denied claims.

For patients with private insurance, you’ll need to follow even more specific guidelines. Each payor is different, making it complicated to correctly code and bill for your patient’s care. Review the private payor guidelines by clicking on the links below:

• Aetna (last updated April 2018)

• Beacon/Value Options (last updated February 20, 2018)

  • Residential Treatment Services

  • Partial Hospitalization Program

  • Intensive Outpatient Treatment

  • Outpatient Program

• Blue Shield/Magellan

• Cigna – (last updated January 1, 2018)

• Optum/UBH – (last updated May 9, 2018)

• Anthem

Anthem and Humana use the same guidelines for behavioral health care. These guidelines come from MCG Health, a company that provides evidence-based care guidelines used by health systems and private insurers. These guidelines are similar to the BlueShield/Magellan guidelines above.

Datapro experts can help you adhere to all of these different guidelines and requirements, ensuring better, faster reimbursement. Our team can also help train your in-house billing and coding staff to use the most updated codes and reduce your risk for denied claims. Contact us today to learn more about our services.