Archive
August 2026
Medicare gives you 120 days to appeal a denial, an ERISA plan 180, and a claim returned as unprocessable gives you none
A working guide to the two appeal tracks a behavioral health biller actually works — Medicare's five levels and the ERISA commercial ladder — with the filing deadlines, the decision clocks, what a peer-to-peer is really worth, and a reusable letter structure.
Analysis — Aug 24Ohio Medicaid pays $25.33 or $7.32 for the same H2019 unit — the modifiers decide
A working reference to the 27 HCPCS Level II H-series modifiers behavioral health lives on, why HO and HP mean different things in different states, and what NCCI actually says about 59 and the X modifiers in a specialty with no anatomic sites.
Analysis — Aug 24Medicare backdates a new clinician's billing privileges 30 days from the filing date, not the hire date
The enrollment rules that decide which of your claims get paid: PECOS filing dates, the 30-day retrospective window, why MFTs and MHCs still check an 'Undefined' box on the CMS-855I, and what a revalidation lapse costs mid-cycle.
Analysis — Aug 24Original Medicare never concurrently reviews a PHP stay — it recertifies on day 18, then every 30 days
Concurrent review is where residential, PHP and IOP revenue is actually decided. The federal recertification cadence, the 24-hour ERISA clock on an extension request, what a reviewer reads, and who eats the days already delivered when authorisation lapses.
Deal Watch — Aug 23Beach House Behavioral Health raised $3.2M
The Florida treatment operator sold $3.2M of a $3.5M offering, disclosed in an SEC filing rather than an announcement.
Denial Decoder — Aug 23CARC 16 with MA130 is a returned claim, not a denial — and it carries no appeal rights
A working reference to the CARC and RARC combinations that actually land on behavioral health remittances: what each code says, why it fires in a BH context, and whether the answer is resubmit, correct, or appeal.
Analysis — Aug 23Medicare draws the IOP line at 9 hours a week and PHP at 20 — then prices both off the same per diem
Levels of care as payers actually adjudicate them: the hour thresholds in 42 CFR, the condition codes and APCs that separate PHP from IOP, the codes states use for residential and withdrawal management, and the four places the boundary gets fought.
Analysis — Aug 23A CCBHC's rate is its own cost report divided by its own visits: $188 to $389 a day in year four
How PPS-1 and PPS-2 actually pay: the formula, what the cost report drives, when states must rebase, why quality bonus payments are optional under one model and required under the other.
Analysis — Aug 23POS 10 pays $31.73 more than POS 02 on a Medicare telehealth therapy hour
One digit on the claim moves a 60-minute session from $135.27 to $167.00. The place-of-service rule, what CMS actually instructs for each telehealth modifier, and why behavioral health keeps flexibilities that general telehealth loses at the end of 2027.
Analysis — Aug 23DOL has not enforced the 2024 parity rule since May 15, 2025 — the statute behind it still applies
What MHPAEA actually requires, what an NQTL comparative analysis contains, and what two years of federal enforcement produced — read against a final rule that is codified, effective, and deliberately not enforced.
Analysis — Aug 22Medicare pays $167.00 for a 60-minute therapy session in 2026
The full behavioral health fee schedule, pulled from CMS: every psychotherapy and testing code, work RVUs, and what the 2026 conversion factor actually does to your rate.
Deal Watch — Aug 21Advanced Recovery Systems bought Promises, creating a 24-facility operator across 14 states
Two sponsor-backed addiction platforms combined in a market where the exit door has closed. If you compete with them, refer to them, or bill for them, three things change.
Analysis — Aug 21Medicaid psychotherapy spending hit $6.68 billion, up 156% in seven years
Higher payment per service drove most of it, not more providers. That is the detail that decides whether your rates hold when utilization review catches up.