Denial library
Guides for the denials behavioral-health teams see most, across IOP, PHP, residential, inpatient psychiatric, SUD and ABA care. Each one answers the question first, shows the deadlines by plan type, works through a fictional case and links its primary sources.
13 guides · free to read, no account · updated
What a “not medically necessary” decision means for IOP, PHP, residential, SUD and ABA care, what to request from the plan, the deadline by plan type, and how to answer each stated reason.
When a payer says a lower level of care is enough, find the criteria set it applied, what it approved instead, and the record facts that show the lower level will not work.
When a payer stops authorizing days or sessions mid-treatment, the clock is short. Here is what the plan owes you before it cuts care, the fast paths by plan type, and what to send.
A peer-to-peer can reverse a denial in one call, but windows are short and payer-specific. Here is who should be on the call, what the one-page brief needs, what to ask, and how to document it.
When a plan says a residential, detox, PHP or IOP admission does not meet ASAM criteria, find the edition and the dimensions it applied, then answer each one with dated evidence.
When a reviewer’s LOCUS, CALOCUS-CASII or ECSII ratings point to a lower level than the one you requested, get the ratings, compare them with your own dated assessment and answer each disputed dimension.
When a patient is in care or waiting to start it, the plan must decide an urgent appeal within 72 hours. Who can make a request urgent, how to file it by phone or fax, and what comes next.
Missing, expired, exceeded or refused authorizations need different fixes. Here is how to tell them apart, the decision clocks payers must now meet, and when it is really a medical-necessity appeal.
CO-50 says the payer found the service not medically necessary and the provider, not the patient, carries the adjustment. Here is how to read it with its remark codes, when to correct instead of appeal, and the Medicare ABN angle.
What goes into a review-ready appeal for IOP, PHP, residential, SUD or ABA care: the cover letter, the crosswalk, the clinician's statement, the right records and nothing more, and proof that it arrived.
The federal content rules for an adverse benefit determination notice by plan type, a five-minute check a biller or UR lead can run on every letter, and how to ask for what is missing.
Psychotherapy time codes, add-ons with E/M, per-diem program codes, ABA units and provider-type rules cause most behavioral-health coding denials. Here is how to tell a fix from a fight.
A practical process for billing companies, RCM teams and in-house billing and UR at PHP, IOP, residential, SUD and ABA programs: triage every denial, pick the right path, control deadlines and fix the cause.
Inspect before you draft.