Before the first session, check six things with the client's plan and write down who told you. They are the plan's dates, who manages its mental health benefit, the clinician's network status, what the client pays, any visit limit or authorization and any second plan. A client who won't use insurance needs a Good Faith Estimate instead. Its clock starts when the session is booked.
Each of the six is a denial you can see coming. A plan that ended last month comes back as code 27, and a second plan the intake form missed comes back as code 22. A missing authorization is 197 and a used-up visit limit is 119 (the post on claim denials has the table). Every one of them is cheaper to find on the phone before the session than in a remittance after it. And a client told the wrong copay at intake is the client who stops coming when the first statement arrives.
This post reads federal rules, the X12 code list, the Texas Medicaid manual and Texas insurance rules as they stood on the day it was published.
What should the check ask?
Write down the date, the name of the person you spoke with and the call reference number. A benefits quote you cannot trace to a call is hard to rely on in an appeal.
How do you ask for the mental health benefit?
By its own code. An electronic eligibility request (an X12 270) names a service type. The answer (a 271) comes back for that type. Code 30 asks for "plan coverage and general benefits". Code MH asks for mental health, A6 for psychotherapy, and A8 for outpatient psychiatric services. X12 describes A6 as "individual or group therapy by providers such as psychiatrists, psychologists, clinical social workers, or psychiatric nurses" (X12 service type codes).
So ask for MH or A6 along with 30, whether you use a portal, a clearinghouse or the phone. On the phone, say "outpatient mental health, office visit" and name the codes you bill, such as CPT 90791 for the first session and 90837 after it. If the answer names another company or phone number for mental health, the plan has carved out that benefit, and the rest of the check happens with that company.
Is the plan fully insured or self-funded?
Look at the card. The Texas Department of Insurance says "If your plan is fully insured, your ID card will say 'TDI' or 'DOI'". TDI regulates fully insured plans, and the federal Department of Labor regulates self-funded ones (TDI, mental health parity).
This tells you which rules apply when something goes wrong. Why does that matter? A Texas fully insured plan "must provide benefits and coverage for mental health conditions and substance use disorders under the same terms and conditions applicable to the plan's medical and surgical benefits" (Texas Insurance Code §1355.254). The same section bars limits on mental health treatment that are generally more restrictive than the limits on medical care. TDI adds that self-funded plans "aren't required to cover MH/SUD services", and must cover them on equal terms if they do. A visit limit on therapy with no matching limit on office visits for physical care is a question for TDI on a fully insured plan, and for the Department of Labor on a self-funded one.
The card also tells you which prompt-pay rules apply to a claim, which the post on insurer clawbacks covers.
What changes for a Texas Medicaid client?
Eligibility can change from month to month, so check it for the date of service. The Medicaid manual names four ways to check. They are TMHP's electronic data interchange, the Medicaid Client Portal for Providers, TexMedConnect and the Automated Inquiry System at 1-800-925-9126 (TMHP, Texas Medicaid Provider Procedures Manual, Client Eligibility, §4.1). The number on the back of the client's Your Texas Benefits card also shows whether the client is in Medicaid managed care. If they are, check with their plan too, because its network and its authorization rules are the ones that apply. And ask whether they have seen another therapist this year, because the Medicaid limit of 30 psychotherapy visits a year before authorization counts per person, not per practice.
The manual is plain about the cost of skipping it. "If a person is not eligible for medical services under Texas Medicaid on the date of service, reimbursement for all care and services provided must be resolved between the provider and the client receiving the services." In our view, check a Medicaid client before the first session and again before the first session of each month.
And a Medicaid client cannot be charged a missed-appointment fee, which the post on missed appointments covers.
What if the client will not use insurance?
Then they're self-pay, and they're owed a Good Faith Estimate. The federal rule counts as self-pay a client who has coverage "but who does not seek to have a claim for such item or service submitted to such plan or coverage" (45 CFR 149.610(a)(2)(xiii)(B)). So a client with insurance who would rather pay cash, or whose plan has the clinician out of network and who will not file, is owed the estimate too. That half of the definition leaves out Medicare and Medicaid, so it does not make a Medicare or Medicaid client who declines to file a self-pay client.
The deadline runs from the booking. The rule gives a session booked at least 3 business days ahead an estimate "Not later than 1 business day after the date of scheduling", and a session booked at least 10 business days ahead one within 3 business days. Read together, a session booked 3 to 9 business days out gets the estimate within 1 business day, and one booked 10 or more out within 3. A session booked fewer than 3 business days ahead needs one only if the client asks, and a client who asks gets it within 3 business days.
Weekly therapy does not need a new estimate every week. The rule allows a single estimate for recurring services if it states their expected scope, such as how often and how many, and covers no more than 12 months. The guide to the Good Faith Estimate covers what it has to say.
When do you check again?
Check again when the client tells you their job or plan changed, at the start of each plan year, and whenever a claim comes back with code 27, 109 or 22. Many employer plans start their year on January 1, in our experience, and that is when deductibles reset and a client's copay can change. A client who paid only a copay in December can owe the plan's full allowed amount in January until the deductible is met. Tell them before their first January session, not after.
What to do this week
- Write the six questions into the script your front desk uses for every new client, with a place to record the date, the person and the call reference number.
- Add MH and A6 to every eligibility check you run, and check that the answer covers outpatient mental health and not only medical benefits.
- List your Medicaid clients and check each one's eligibility for their next session date.
- Find every client who pays out of pocket, including insured clients who chose not to file, and check that each one has a current Good Faith Estimate.
- Put a reminder for the first week of December to tell every client whose plan renews in January that their deductible resets, and to check each one for their first January session date.
Sources
- Service type codes, X12.
- Insurance coverage and parity for mental health and substance use disorder services, Texas Department of Insurance.
- Texas Insurance Code §1355.254, coverage for mental health conditions and substance use disorders.
- Texas Medicaid Provider Procedures Manual, Client Eligibility, TMHP, §4.1.
- 45 CFR 149.610, requirements for good faith estimates for uninsured or self-pay individuals.
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