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Top 4 denial reasons in pediatric behavioral health

May 9, 2019

Productivity and utilization of authorized hours are key reporting functions when running a therapeutic practice.  Your success as a company is dependent on these functions and when you are optimizing your therapeutic team, you expect to be reimbursed for the care provided.  However, often insurance will deny visits for various reasons which will often require double the work for your administrative team. Below are 4 of the top denials reasons for pediatric behavioral health and how to avoid these denials.

  1. Credentialing
    • Ensuring each provider’s individual CAQH, NPI and license is up to date and current.
      • Common errors include
        1. The provider needs to update CAQH system with renewed licensure
        2. Expired licensure
        3. The provider needs to update the CAQH system with the company’s updated malpractice insurance
    • Ensuring that each provider is credentialed with each payor they will be billing services for.
    • Every 6  months to a year asking the payor for an updated roster to ensure that your providers are credentialed.
  2. Coding
    • Education around any code changes for your clinical team to ensure they are coding sessions appropriately.
    • Within your software system, making sure the codes are uploaded appropriately and match the providers who can bill those specific codes.
    • Applying appropriate modifiers when needed for various codes.
    • Updating the place of service (POS) if the location changes.
      • If the location of the service is going to change, it is important to ensure that the client’s plan approves the POS and no authorization is required for varying POS.
  3. Authorizations
    • It is critical that prior to beginning services, if an authorization is required the authorization is on file. The purpose of the authorization is for the payor to provide authorization for those services including the CPT code, diagnosis code and POS.
    • Along with the authorization, it is important to utilize the full authorization that is written in the plan of care (POC).  If the authorization is not fully utilized, the provider risks being denied for ongoing services for lack of medical necessity.
  4. Medical Records
    • Payors are beginning to request medical records on a more frequent basis.  Along with the requests of medical records, they are not only looking for medical necessity but specific guidelines including:Appropriate amount of units billed for and matches the time in and time out of therapeutic services
      • Signature from provider
      • Signature from caregiver
      • Place of service

By putting processes in place to avoid denials, groups will improve collections and cash flow. If your group is struggling with denials, Coronis is here to help. Click below to schedule a call with our pediatric behavioral health billing experts.


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