Behavioral health billing services built around time, license and carve-outs
Fastora provides behavioral health billing services for practices that treat mental health and substance use conditions, from solo therapists to multi-clinician groups and psychiatry clinics. We treat behavioral health medical billing and mental health medical billing as one discipline with its own rules, and every claim is handled by certified medical billing and coding professionals.
Most medical specialties bill by procedure. Behavioral health bills largely by time, by who delivered the service and by where the benefit sits. A 45-minute session and a 55-minute session are different codes, a counselor may not be able to bill a service a psychiatrist can, and the plan named on the member card is often not the plan that pays the claim.
Federal parity law under the Mental Health Parity and Addiction Equity Act limits how health plans can restrict mental health and substance use benefits compared with medical and surgical benefits. Even so, authorization rules, network requirements and telehealth policies still vary widely between plans and states, which is why a medical billing company for behavioral health needs to know carve-outs and time rules as well as it knows the claim form.
Who we bill for
Our team covers every license type commonly found in an outpatient behavioral health billing setting. Each group below has its own code set, enrollment path and denial patterns, and each has a dedicated page with more detail.
Psychiatry & psychiatric NPs
Psychiatrists and psychiatric mental health nurse practitioners combine E/M visits, psychotherapy add-ons, medication management and, in some practices, TMS, esketamine treatment or collaborative care. Our page on psychiatry and PMHNP billing explains how those rules fit together.
Psychologists & testing
Psychologists bill diagnostic evaluations, psychotherapy and time-based psychological and neuropsychological testing, which usually needs authorization and careful tracking of hours by code. Read more about billing for psychologists.
Therapists, LPCs, LCSWs, LMFTs
Licensed professional counselors, clinical social workers and marriage and family therapists face license-specific payer rules, including Medicare enrollment that opened to marriage and family therapists and mental health counselors on January 1, 2024. Our therapist and counselor billing page covers each license type, solo and group setups, and self-pay estimates.
Substance use disorder programs
Addiction programs bill across levels of care with HCPCS H-codes, per diem program codes and concurrent review, under federal confidentiality rules for substance use disorder records. See IOP, PHP and MAT program billing. Eating disorder programs face a parallel coverage split — our eating disorder billing page explains when the medical benefit, rather than the behavioral benefit, pays the claim.
ABA providers
Applied behavior analysis practices bill adaptive behavior codes in 15-minute units, usually under authorizations that set hours per code for a treatment period. The same authorization tracking and unit checks we use for therapy and testing apply to ABA claims.
Behavioral health billing challenges we solve
The problems that slow cash in this field are predictable, which means most can be prevented upstream. These are the ones we see most often when a practice first asks for help with mental health insurance billing.
| Challenge | What goes wrong | How we address it |
|---|---|---|
| Carve-out routing | Claim goes to the medical plan on the card instead of the behavioral administrator | Payer ID and claims address confirmed at intake and stored on the client account |
| Authorization limits | Sessions delivered after approved visits or dates run out | Remaining visits tracked per client, with renewal requests before the limit |
| Time documentation | Billed code does not match documented minutes | Code checked against session time before submission |
| Add-on pairing | 90833, 90836 or 90838 billed without a valid same-day E/M | E/M and psychotherapy reviewed together by certified coders |
| Enrollment gaps | New clinician sees clients before the payer has linked them to the group | Credentialing status checked before a clinician’s schedule opens |
| Small-balance AR | Low-dollar weekly session claims age past timely filing | Open claims worked by age and payer, small ones included |
Behavioral health coding and billing errors rarely come from one person. They come from gaps between the front desk, the clinician and the billing team, so our fixes target the hand-off where the error started.
Benefits verification for carve-out plans
Many health plans do not manage behavioral benefits themselves. They carve them out to a separate behavioral health administrator, for example Optum Behavioral Health, Evernorth Behavioral Health or Magellan Healthcare, depending on the plan. The administrator issues its own authorizations, keeps its own provider network and often has its own claims address and payer ID.
Sending a claim to the medical plan on the card is one of the most common reasons an otherwise clean claim is rejected. Before a first visit, our Virtual Assistant team confirms:
- Whether behavioral benefits are carved out, and to which administrator
- Network status for the rendering clinician’s license type, not only for the group
- Outpatient mental health copay, coinsurance and remaining deductible
- Visit limits or session caps, and how many sessions have been used this benefit year
- Whether authorization is required from the first visit or after a set number of visits
- Telehealth coverage for the services being scheduled, including audio-only where relevant
Verification is repeated when a plan year resets, when a client reports new coverage and before any change in level of care. Copays are collected upfront, which cuts down on the small patient balances that pile up in weekly therapy.
Behavioral health prior authorization, authorizations and visit limits
Routine outpatient psychotherapy often needs no authorization with commercial plans, but many Medicaid managed care plans and carved-out administrators require it, sometimes after an initial block of visits. Psychological testing, intensive outpatient programs, partial hospitalization, residential treatment, TMS and some psychiatric treatments are commonly authorized in advance.
Approvals in this field usually cover a set number of sessions or units within a date range. We track both limits, flag clients who are close to either one and request extensions with updated clinical information before the approval runs out, so sessions are not delivered without coverage in place.
Plan visit limits work differently from authorizations. A plan may cover a set number of sessions a year with no authorization at all, and once that number is used, claims deny as benefit maximum reached. We count used sessions against the limit and tell the practice before the last covered visit, so the clinician and client can plan for self-pay or a medical necessity review.
Codes we bill every day: psychotherapy billing codes and add-ons
Psychotherapy CPT codes are chosen by face-to-face time with the patient and by whether an evaluation and management (E/M) service was provided on the same day. These are the core codes our coders work with in mental health coding and billing across behavioral practices.
| Code | Descriptor | Billing note |
|---|---|---|
| 90791 | Psychiatric diagnostic evaluation | No medical services; used by psychologists, therapists and counselors |
| 90792 | Psychiatric diagnostic evaluation with medical services | Used by prescribing clinicians such as psychiatrists and psychiatric nurse practitioners |
| 90832 | Psychotherapy, 30 minutes with patient | Reported for 16 to 37 minutes |
| 90834 | Psychotherapy, 45 minutes with patient | Reported for 38 to 52 minutes |
| 90837 | Psychotherapy, 60 minutes with patient | Reported for 53 minutes or more |
| 90833 / 90836 / 90838 | Psychotherapy of 30, 45 or 60 minutes with an E/M service (add-on codes) | Reported only with a same-day E/M by the same clinician; E/M time is not counted toward psychotherapy time |
| 90839 / 90840 | Psychotherapy for crisis, first 60 minutes / each additional 30 minutes | Not reported with interactive complexity (90785) |
| 90846 / 90847 | Family psychotherapy without / with the patient present | Billed under the identified patient |
| 90853 | Group psychotherapy (other than of a multiple-family group) | Billed for each patient in the group |
| 90785 | Interactive complexity | Add-on only; used when communication factors complicate the service |
Time ranges follow CPT time conventions, and Medicare contractor guidance expects start and stop times or total time in the note. Some payers review 90837 more closely than shorter sessions, so the note should show why the longer session was clinically needed. Our mental health CPT code guide covers each code in more depth.
Medical necessity per session and the treatment plan
Payers that audit behavioral claims look for two things: a current treatment plan and a note for each session that ties the service to it. A note that records only a time and a code is weak support even when the minutes are right.
Each session note should show:
- The diagnosis being treated, consistent with the ICD-10-CM code on the claim
- Total psychotherapy minutes, or start and stop times
- The intervention used and the client’s response
- Progress toward measurable treatment plan goals
- For add-on codes, the E/M work and the psychotherapy described separately
Treatment plans should be reviewed and updated on the schedule the payer or state Medicaid program sets. Our Scriber phase records visit documentation in the EHR in real time, which helps keep times, goals and interventions in the note when the claim is coded.
Telehealth billing for therapy
Medicare uses place of service (POS) 02 for telehealth delivered somewhere other than the patient’s home and POS 10 for telehealth delivered in the patient’s home. CMS describes mental health telehealth with the patient at home as permanent, and allows audio-only delivery when the patient cannot use or does not consent to video, reported with modifier 93.
Commercial and Medicaid plans do not all follow Medicare. Some want modifier 95 with the in-person place of service, others want POS 02 or 10 with no modifier, and a few still use older modifiers such as GT. We keep each payer’s telehealth rules in the claim setup, so the same session is coded the way each payer expects.
Clinicians who see clients across state lines also need a license in the state where the client is located during the session, and payers may check that the rendering clinician is enrolled for that state. We flag out-of-state telehealth addresses during scheduling.
Texas Medicaid & MCO behavioral health billing
Most Texas Medicaid clients are enrolled in managed care through STAR, STAR Kids, STAR+PLUS or STAR Health. The Texas Medicaid Provider Procedures Manual states that claims for services administered by a managed care organization (MCO) must be submitted to that MCO, and some MCOs subcontract behavioral health to a behavioral health organization with its own processes.
The same manual lists the professionals who may bill outpatient mental health services, including licensed clinical social workers, licensed marriage and family therapists, licensed professional counselors, psychologists, physicians and advanced practice registered nurses. It also limits certain psychotherapy codes to 30 visits per calendar year in fee-for-service, with prior authorization for additional visits; MCOs can set their own authorization rules.
Texas Medicaid’s published filing rule is 95 days from the date of service, whether the claim goes to TMHP or an MCO, so Medicaid claims sit at the front of our work queue. Our Texas Medicaid billing guide explains enrollment, MCO claims and appeals in more detail.
Mental health billing and credentialing services
Enrollment is the first step of mental health revenue cycle management. A clinician who is not enrolled with a plan, or not linked to the group’s contract, cannot be paid no matter how clean the claim is. That makes behavioral health credentialing services part of billing, not a separate project. Our credentialing services for mental health providers cover psychiatrists, psychiatric NPs, psychologists, LPCs, LCSWs, LMFTs and mental health counselors.
Fastora follows a tracked nine-stage process: consultation, document collection, state licensing, NPI and CAQH setup, payer applications, panel submissions, follow-ups, final approval and ready to bill. Carved-out administrators often need their own application, and since 2024 Medicare enrollment is open to marriage and family therapists and mental health counselors who meet CMS requirements. See our credentialing and payer enrollment service.
Behavioral health denial management and mental health claims management
Mental health claims management starts before submission: each claim passes through Advanced Pre-Submission Claim Review, our claim scrubbing step, where coders check the payer, rendering clinician, code, time and authorization. Denials that still come back cluster around a handful of causes, and our team works each one back to the step where it started instead of simply resubmitting.
- Wrong payer: the claim went to the medical plan when behavioral benefits are carved out.
- No or expired authorization: sessions were delivered after the approved units or dates ran out.
- Time and code mismatch: the billed code does not match documented minutes.
- Add-on without a valid primary: 90833, 90836 or 90838 billed without a same-day E/M, or with the E/M level chosen by time.
- Clinician not credentialed: the rendering provider is not yet enrolled with the plan or its administrator.
- Same-day conflicts: two services on one date that the payer treats as bundled or duplicate.
- Benefit maximum reached: the plan’s annual visit limit was used up.
Mental health denial management also means watching patterns. Each denial is logged by reason, payer and clinician, so a recurring problem, such as one administrator rejecting 90837, shows up in monthly reporting and gets fixed at the source. That feedback loop is the difference between mental health RCM and simply sending claims out.
Outsourced behavioral health billing: how Fastora works
Behavioral health revenue cycle management covers the whole path from the first call to the final payment, and our three-phase workflow follows it. Fastora works inside your existing EHR/PM system under the user access you grant, with no software to install and no hidden setup fees.
- Virtual Assistant: scheduling, registration, carve-out and benefits checks, and copays collected upfront.
- Scriber: visit documentation recorded in the EHR in real time, including session start and stop times.
- Fastora Medical Billing: claim submission, payment posting, denial management, AR follow-up and patient billing.
Mental health billing outsourcing works best when the practice keeps visibility. Each practice has a dedicated account contact, transparent dashboards, monthly performance reporting and a monthly review call, with 24/7 support. Mental health billing for group practice adds rendering-provider setup and per-clinician reporting; a mental health billing service for private practice focuses on keeping a solo clinician’s small claims moving and their weekly time free for clients.
Practices often compare RCM for behavioral health with keeping billing in-house. Behavioral health billing outsourcing is usually considered when denials rise, AR ages past 90 days or a biller leaves, and outsourced mental health billing gives those practices a full team without hiring one.
Pricing: what drives mental health billing service cost
Practices often ask how much do mental health billing services charge before anything else. The honest answer is that it depends on claim volume, payer mix, the share of Medicaid and carve-out claims, whether credentialing and prior authorization are included, whether old AR needs cleanup, and whether you want full behavioral health RCM or only claims and denial work.
Fastora quotes after a free billing assessment. Depending on scope, pricing may be a percentage of collections, a flat fee per claim or a hybrid. There are no hidden setup fees. Our pricing page explains how each model works and which practices each one tends to suit.
How to compare mental health billing companies
When you compare mental health billing companies for your practice, ask the same questions of each one, including us. A behavioral health billing company should be able to answer them in specifics, not general promises.
- How do you identify carve-outs and store the correct payer ID for each client?
- Who checks psychotherapy time against the note, and are they certified coders?
- How do you track authorizations and annual visit limits?
- Do you credential clinicians as part of the service, including carve-out administrators?
- Will we have one named contact, and what reports will we see each month?
- Do you sign a Business Associate Agreement before accessing PHI?
A mental health billing company that works in your own EHR and reports monthly lets you check the answers against your own numbers. Fastora signs a BAA before accessing PHI, and our workflows are aligned with HIPAA and HITECH, with encryption, secure server environments, strict access controls and regular internal audits.
Comparing behavioral health billing companies
The general questions to ask any billing company are covered above. In this specialty, three answers matter more than the rest:
- Specialty focus: do they bill psychotherapy codes, carve-out plans and telehealth sessions every day, or is behavioral health one line on a long specialty list?
- Authorization handling: who tracks visit limits and concurrent reviews, and how do you see the status?
- Carve-out experience: can they name the behavioral administrators and their separate rules, and show how a claim is routed?
On outsourcing versus in-house: a practice that can staff steady follow-up may do well keeping billing inside, but session-based billing with visit limits punishes gaps in follow-up quickly. To outsource behavioral health billing is to buy that steady routine — claims, authorizations and denials worked on a daily rhythm. For a solo clinician, mental health billing for private practice usually comes down to one question: is the time you spend on claims and authorizations worth more spent with clients?
Related reading: behavioral health billing guide, therapist billing, medical billing services.
Behavioral health billing and coding: what the work actually includes
Behavioral health billing and coding is session-based work: timed psychotherapy codes, diagnostic interviews, add-on codes and the authorization that usually sits behind them. Our behavioral health coding services code from the session note against the treatment plan, and the billing team submits with the authorization number attached so claims do not deny for a missing auth.
Mental health documentation for billing has to support medical necessity visit after visit — the note must show why this session happened, not just that it did. Mental health modifiers change how a payer reads the code, and the Z codes for mental health explain context, such as factors influencing health status, without overstating a diagnosis. Both are used carefully and tied back to the note.
Behavioral health insurance billing also means dealing with carve-out administrators and separate behavioral networks. Our mental health insurance billing services verify benefits against the right administrator, track visit limits and handle concurrent review when a plan requires it. See common psychotherapy claim denials for the patterns we watch.
Billing by payer and setting: Aetna, Cigna, Optum, Medicaid and Medicare
Payer rules differ more in behavioral health than in most specialties. Aetna behavioral health billing and Cigna mental health billing each run through their own behavioral networks with their own authorization portals; Optum behavioral health billing has its own visit-limit and concurrent-review rules as well. Our Optum billing services team works those rules daily — checking the authorization before the session, not after the denial.
Public programs have their own playbook: medicaid billing for behavioral health varies by state plan and managed-care contractor, and medicare mental health billing covers specific provider types and telehealth rules. In higher levels of care, PHP billing behavioral health, eating disorder treatment billing, and community mental health center billing bring bundled or per-diem rates, and utilization review behavioral health requirements decide whether the next week of care is approved — so the documentation has to arrive before the review date, not after. CCBHCs bill under a prospective payment system — our CCBHC billing page covers the PPS rate and cost-report basics.
Mental health billing for group practices, telehealth and psychotherapy
Mental health billing for group practices has to handle many providers under one tax ID: each clinician enrollment, their visit limits and their notes, rolled into one A/R report. For mental health billing for telehealth, the work adds place-of-service and modifier rules plus multi-state licensing to track. Our mental health billing services cover both — in-person and virtual — with the same daily routine of claims, authorizations and denials. Related reading: behavioral health billing guide, therapist billing.
Our work as a mental health billing company and a behavioral health billing company covers the full cycle: eligibility against the carve-out, authorizations by visit count, claims, denials and A/R follow-up. The best behavioral health billing companies — and the best mental health billing companies — are the ones that run this routine daily, with carve-out rules and visit limits built into the workflow rather than handled as exceptions. A psychotherapy billing company label describes part of the work; a behavioral health RCM company label describes the whole cycle. Practices looking for a medical billing company for mental health practices usually need both: specialty knowledge and the full revenue cycle.