Top 20 BH Insurance Denial Reasons — 2026 Fix Guide
Category 1: Coverage (5)
- Not medically necessary → Add DSM-5-TR justification + measurement scale
- Not covered benefit → Verify BH benefit before service
- Deductible not met → Collect from patient before service
- Out-of-network → Panel enroll or transfer patient
- Age cap exceeded → State-specific check on state autism mandate
Category 2: Authorization (5)
- Prior auth not obtained → Verify before service every time
- Prior auth expired → Track expiration + reauth 30 days out
- Units exceeded → Track cumulative units per patient
- Wrong level of care → ASAM justification for SUD
- Wrong provider type → Match CPT to credential
Category 3: Documentation (5)
- Missing signature → Sign within 24 hours
- Wrong CPT/POS combination → Verify per payer
- Missing modifier → 95 vs 93 for telehealth
- Missing time doc for 90837 → Document 53+ min actual therapy
- Copy-paste flagged → Fresh documentation per session
Category 4: Coding (5)
- Wrong CPT code → Verify per session type
- Missing add-on code (90833/90836/90838) → Med management + psychotherapy
- MHPAEA 90837 downcoded to 90834 → Appeal with time doc
- ASAM level down-coded → Appeal with ASAM assessment
- MAT J-code strength mismatch → Verify exact strength billed
– KD, Revenant Care