Processing Behavioral Health Claims

Billing for behavioral health claims is a complicated and sensitive matter. In order to get your claims paid, you need detailed and error-free clinical notes, dependable billing processes, and ample time to follow up with insurance companies. However, one wrong code can render your claims null and have them rejected. 

Processing the claims from the patient’s appointment to when the practitioner receives payment can be a long journey. To date, some billing processes use outdated methods like keeping paper records. 

However, there are several important steps that you must take to ensure you file correct claims to the payer. These steps ensure accurate records and efficient processing.

What Is A Behavioral Health Claim?

A behavioral health claim is a medical claim submitted to an insurance company. The claim is a request for payment for health care services that have been provided to a patient. The patient’s health plan is responsible for reviewing the claim and determining if the services were medically necessary and covered by the plan. 

However, the patient’s healthcare plan is generally not responsible for performing an independent medical review (IMR) to determine if the claim is valid. Instead, this is the responsibility of the provider who provides the services to the patient.

What Are Behavioral Health Codes?

Behavioral health codes are guidelines that help individuals working in the behavioral health field treat clients, patients, and others efficiently and thoroughly within the field. In addition, the codes are used to establish guidelines and policies within the behavioral health field.

To process a behavioral health claim, you have to look at the diagnosis and procedure codes to ensure they match up with the patient’s plan of care.

You must submit your claim with the correct diagnosis and procedure codes or risk the claim being rejected by the payer.

Codes to Note

It is critical to know the correct codes that would help you correctly diagnose cases and bill them for efficiency. Some of these codes include;

Current Procedural Terminology

They are also called CPT codes and are the standard medical set of codes by the American Medical Association (AMA). They allow a medical practitioner to correctly understand the present medical terms in order to describe them easily. 

Each code consists of 5 numerical digits covering every disease from brain cancer to anxiety. Note that these CPT codes are different from diagnostic codes that help with billing. 

International Classification of Diseases

The International Classification of Diseases (ICD-11) is a worldwide categorization system for physical and mental illnesses developed by the WHO in 2018. The ICD-11 is the updated version reviewed to reflect present-day issues and has been in effect since January, 2022.

ICD-11 has an improved coding structure from ICD-10, which was in use prior to this time. It boasts over 55,000 detailed codes for classifying diseases, disorders, and causes of death. These codes cover everything from billing for physical therapy to every health issue imaginable.


ICT-11 has additional diagnoses, including Attention-Deficit Hyperactivity Disorder (ADHD), Complex Post-Traumatic Stress Disorder (PTSD), Compulsive Sexual behavior Disorder, and Gaming Disorder. 

ICD-11 also features deleted diagnoses, including Acute Stress Disorder, which is now classified as a reaction to trauma. It also no longer categorizes Personality Disorder as a mental health issue or Gender Incongruence, which is now labeled a sexual health condition to avoid stigma. 

While ICD-11 is still in the relatively new stages, some countries around the world have adopted its use. 

Some ICD-11 codes 

Anxiety or Fear-Related Disorders (1336943699)

Binge Eating Disorder (Icd-11: 6b82)

Bipolar Type II Disorder (Icd-11: 6a61)

Body Dysmorphic Disorder (Icd-11: 6b21)

Hoarding Disorder (Icd-11: 6b24)

Depressive Symptoms (6a25.2)

Steps in Processing Behavioral Health Claims

These are the steps in processing Behavioral healthcare claims simplified;

  • The patient is at a clinic to receive treatment from a practitioner, and then the services and appointment will be coded and sent electronically or via paper.
  • Once the receiver gets the claims, they scan them or enter them into the system manually. 
  • Next is the internal review of the claims, where they would check the dates, spelling, and other information to ensure it’s all correct.


  • Check files and records to ensure that the patient had insurance at the time of service.
  • An in-network review will ensure that the patient’s insurance package covers the doctor and facility.
  • The next step is price negotiation. How much payment will the doctor receive, and how much will the patients pay themselves?
  • Check to see what is covered in the patient’s benefits.
  • Confirm medical necessity to ensure the eligibility of the insurance coverage.
  • Assess the claim risk to check for fraud or abnormally high charges.
  • Next, the doctor or practitioner receives payment, and the patient receives an explanation of benefits (EOB). This tells the patient what they can expect in their bill and what was covered.
  • The member or patient is then billed for what was not covered by their insurance plan.

For businesses to improve efficiency and quality in such a complicated process, there are a few strategies you should put in place.

Modernize Health Claims Processing Approach

Streamlining processes is key to improving business and optimizing operations. There are a few helpful ways to simplify the insurance claims process in your facility. These include outsourcing, consolidation, advancements in Artificial Intelligence, and more. 

All of these solutions have their own set of benefits. Nevertheless, developing an efficient system will allow you to avoid any hold-ups or lags in time that can occur when everything isn’t aligned during the claims process.

Limit the Departments Involved

As displayed above, a Behavioral healthcare claims goes through several steps before reaching its destination. Processing claims can be tedious and lengthy if they aren’t organized properly. In your hospital, you should limit how many transferals of a claim take place. 

Although HIPAA has regulations and rule sets on how one should process claims electronically, there is still the need to process some aspects manually. Unfortunately, the more hand-offs that occur on any claim, the more susceptible it is to human error. This is why outsourcing comes in handy.

Outsourcing Claims Management

Using the right healthcare claims management agency can allow your facility to focus on its core mission while it helps to process medical claims for your members. It is best to outsource this process to a business with a proven track record of excellent results. 

Working with a qualified Behavioral healthcare claims management agency will help your facility earn more from its outgoing payments and reduce administrative overheads. This will also ensure timely services for paying members without sacrificing quality or agility.

Better IT Systems

Automation is the most crucial step in improving the accuracy and efficiency of healthcare and other industries. For example, breakthroughs in optical character recognition (OCR) ease the problem of using different templates for different forms. 

Through some cutting-edge features, users can now leverage machine learning and artificial intelligence to recognize provider information with little manual input. This new approach will also match patients to claims as well as decrease operational costs while increasing efficiency and accuracy.


The two most common claims forms are the UB-04 and CMS 1500, according to HIPAA. Larger institutions like hospitals use UB-04s. In comparison, small clinics and private practices would be more inclined to fill out a CMS 1500 form. 

Once you’ve determined your preferred claim form, you can automate the submission with document recognition. If you scan or upload your documents into the proper format – complete with payment information – a human never has to review them. 

What’s more, machine learning makes the process more efficient because the algorithm learns what to look for during scans.

Auto-Decisions Can Enhance Claims Efficiency

There are several other advantages to working with adjudicating claims – not the least of which is their ability to make the process faster and more accurate. To put it simply, adjudicating claims means automating the process regarding who pays for a claim and how much they pay. 

This is a far less burdensome process for you and your customers than waiting for insurance companies or providers to settle on price amounts. Certainly good for everyone involved!

By implementing automatic adjudication into your claims processing workflow, payers, providers, and members will see a significant increase in the number of processed claims. This is because they are faster and more accurately handled by the parties. 

This will benefit not only them but also every other party involved. For example, the member’s claim will be processed faster, the healthcare provider will get their payment sooner, and the insurance company can have fewer outstanding claims, which is always a welcome change.


This blog post is meant to help behavioral health care providers process insurance claims and know what information to submit to ensure the claims are processed quickly and accurately. 

The behavioral health industry has changed quite a bit in the last decade. While it used to be that most of the claims were manual, today, most of the claims are electronic.

Behavioral Health claims require special attention because these claims often contain complex medical questions requiring highly personalized treatment plans. Behavioral health professionals are trained to handle these types of claims on time.

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