• Specialty billing guide Behavioral health

Behavioral health billing: codes, prior authorization, denials, and appeals

Last updated: August 2026

By Mindy Corbett, CSPO, CPC, CPB, CPPM · 15 years RCM leadership · Updated 2026 · 18 minute read

What this guide covers

Two federal rules apply to behavioral health that don't apply to other specialties: the parity statute, MHPAEA, and the substance use privacy regulation at 42 CFR Part 2. Both are covered because both change what you can do when a claim is denied.

Definitions and frequently used terms

These are defined because many times the only things preventing a successful appeal are understanding what happened, and why. Something as simple as having a glossary that defines terms you might see on your remits is the key to increasing your appeal success rate. 

Adjustments: CARCs, RARCs, and Group Codes

CARCs

Claim Adjustment Reason Code (CARC) A standardized code that explains why a payer paid a service line differently than expected. These will be on your 835 file in the CAS segment. 

CARCs are used to communicate the high-level reason, or the category of denial. They explain why a claim or service line was paid less than was expected, but they do not always provide the full detail. Most CAN come with additional information in the form of a RARC, and some are REQUIRED to be reported with a RARC, such as CARC 16.

The CARC will always have a group code, which informs you who is responsible for the adjustment amount. 

Group Codes

NOTE: Always read the adjustment codes in order: Group Code first, followed by the CARC, then any RARC. CO-97 and PR-97 have the same definition, but different responsibility.

RARCs

Remittance Advice Remark Code (RARC). RARCs are supplemental alpha-numeric codes that provide additional clarity to help you understand what the CARC code means. For example, CARC 16 on its own means "Claim/service lacks information or has submission/billing error(s)" which is not terribly helpful, but with a RARC such as M20, you know that the issue is there is a missing or invalid HCPCS on the claim.

The main difference between a CARC and a RARC is the level of detail. Think of the CARC as the folder, and the RARC as the files that live inside the folder. If the CARC tells you the claim is denied because something is missing, you need the RARC to tell you WHAT is missing.

If the RARC indicates that there is a missing modifier, then your next step is to figure out what to do to correct it.

NOTE: There are two kinds of Remark Codes (RARCs), Supplemental RARCs and Informational RARCs. 

Supplemental RARCs: These provide additional information to further explain the CARC. These are used to clarify the reason for the adjustment and explain what is missing or required. 

Informational RARCs: These are general, informational RARCs that do not change payment amounts. The description is always prefaced with "Alert:." These RARCs often start with the letter "N." These can frequently be used for notifications about policy changes, system updates, or general billing guidance.

Pitfall: if a CARC 96 or CARC 16 arrives with no supplemental RARC, or only an Alert-type RARC, you do not have enough information to work the denial. Your EHR could be suppressing or hiding the RARC code. Look for "Remark" or "Remark Code" or similar. If you can't find the remark codes, check with your EHR vendor to see if that field can be uncovered. If you are not able to successfully locate it in the EHR, these can also be found in the raw 835 file in the MOA (Outpatient claims)/MIA (Inpatient claims) or LQ segment.

MHPAEA. The Mental Health Parity and Addiction Equity Act. The federal law requiring that mental health and substance use benefits be covered no more restrictively than comparable medical and surgical benefits.

Other Terms

NQTL. Non-Quantitative Treatment Limitation. Any limit that isn't a number: prior authorization requirements, medical necessity criteria, network composition, step therapy, fail-first rules. Most behavioral health denials fall in this category.

QTL. Quantitative Treatment Limitation. Limits you can count, like visit caps and day limits.

Comparative analysis. The written analysis a plan must conduct and keep, showing it doesn't apply its NQTLs more strictly to behavioral health than to medical and surgical benefits. You will probably never see one. It matters because the plan is required to have it, and that requirement is what a parity appeal leans on.

MBHO. Managed Behavioral Health Organization. The separate company administering behavioral health benefits when a plan carves them out. Optum Behavioral Health, Magellan Healthcare, and Carelon Behavioral Health are the ones you'll see most.

Carve-out. The arrangement where a health plan hands behavioral health administration to an MBHO. The patient has one insurance card, but claims go to two different places depending on the service.

IRO. Independent Review Organization. The outside reviewer who decides an appeal after the plan's internal appeals are exhausted.

Typical Procedure Codes

Psychotherapy is selected by face-to-face time

What "documenting time" actually means

This gets stated vaguely everywhere, so here is the specific list. A compliant note for a timed psychotherapy code contains:

  1. The start time, as a clock time. "2:05 PM," not "started at the top of the hour."
  2. The stop time, as a clock time.
  3. The total face-to-face minutes, stated as a number.

What counts toward that time: face-to-face time with the patient, and in family or couple sessions, face-to-face time with the patient and the family member together.

What does not count: writing the note, reviewing the chart before or after, coordinating care, contacting collateral sources, phone time, or time the patient spent in the waiting room. If your clinicians are including documentation time in the session total, your 90837s are overstated and that is a repayment exposure rather than a coding preference.

IMPORTANT: the CPT descriptor for 90837 reads "Psychotherapy, 60 minutes with patient." It does not itself require clock times. Capture them anyway, because payer manuals commonly require them and because a note saying "60-minute session" is trivially easy to down-code. Just don't tell a payer that the descriptor requires clock times, because they will pull the descriptor, see that it doesn't, and you'll have damaged your credibility mid-appeal over a point you didn't need to make.

Diagnostic evaluations

The add-on structure, where most coding errors happen

When a prescriber performs both an E/M service and psychotherapy in the same encounter, you do not bill an E/M code and a standalone psychotherapy code side by side. You bill the E/M, and the psychotherapy goes on as an add-on:

Billing 90834 next to an E/M instead of using 90836 reads as unbundling.

IMPORTANT, and this one costs money quietly: when you report psychotherapy with an E/M, you cannot use time to select the E/M level. The E/M must be selected on medical decision making, because the time is already being counted toward the psychotherapy add-on. You can't use the same minutes twice. Practices that select E/M by time out of habit will either overstate the E/M or understate the psychotherapy, and both show up on audit.

The psychotherapy time documented for the add-on is the psychotherapy time only, tracked separately from whatever time the E/M service took.

HCPCS H-codes for substance use programs

Pitfall: H0015 and H2035 get swapped for each other constantly because the descriptors read similarly. They are not interchangeable and the units are different. Check the descriptor before either one goes into a charge master.

Workflow: verifying carve-out routing

When a plan carves behavioral health out to an MBHO, a claim sent to the medical payer denies. It comes back looking like a network denial, which is the trap, because you would work a network denial completely differently than a routing error.

Do this at intake, and again at each authorization renewal and each plan year rollover.

  1. Call the benefits number on the back of the patient's card.
  2. Ask directly: "Is behavioral health administered by the plan, or is it carved out to a separate organization?" Ask it in those words. "Do you cover behavioral health" gets you a yes and tells you nothing about routing.
  3. If it's carved out, get the MBHO name, the claims mailing address or payer ID, and the authorization phone number.
  4. Record the representative's name, the reference number for the call, and the date.
  5. Put the payer ID in the patient's account before the first claim goes out, not after the first denial.

Pitfall 1: employers change MBHO vendors between plan years, and nobody notifies you. A patient you verified in November can route somewhere else in January. This is not a one-time verification.

Pitfall 2: the medical payer's representative will sometimes not know the benefit is carved out. If the answer sounds uncertain, ask them to check the member's benefit configuration rather than accepting a general answer.

When you catch one after the fact: resubmit to the correct MBHO. It's fully recoverable as long as you're inside timely filing, which is the reason to catch it in days rather than months.

Workflow: authorization tracking

Most CARC 197 denials are tracking failures, not clinical disagreements.

  1. At the first visit, record the authorization number, the covered date span, the number of authorized visits, and the specific CPT codes authorized. Authorizations are frequently code-specific, and one covering 90834 will not cover 90837.
  2. Enter the expiration date in a structured field in the practice management system, not in a note field and not in a spreadsheet.
  3. Set an automated alert at 15 days before expiration, at minimum.
  4. On the alert, submit the renewal with current clinical documentation attached, not a bare request.
  5. Track the renewal to a decision. A submitted renewal is not an approved renewal, and the gap between them is where the denials live.
  6. If the renewal has not come back within 7 days of expiration, call. Do not let the clinician keep seeing the patient against an expired authorization without somebody knowing that's the situation.

Pitfall 1: a shared spreadsheet breaks the first day the person who maintains it is out sick. Use a structured field or a dedicated authorization tool.

Pitfall 2: authorizations that cover a visit count rather than a date span run out early when a patient increases frequency. Track both the date span and the remaining visit count.

Pitfall 3: retroactive authorization requests are rarely granted. Once the date of service has passed without an active authorization, you are usually appealing rather than authorizing.

Denial patterns and what to do about each

CARC 197: prior authorization missing or expired

What it means: "Precertification/authorization/notification/pre-treatment absent."

Why it happens here: behavioral health authorizations turn over fast. A 60 or 90 day authorization for weekly therapy expires quickly, and if the renewal wasn't submitted the clinician keeps seeing the patient while claims stack up behind a wall nobody has noticed.

What to do:

  1. Check whether an authorization actually existed for the date of service. Sometimes one exists and wasn't attached to the claim, which is a straightforward corrected claim.
  2. If one existed but covered different codes or a different date span, appeal with the authorization attached and the span highlighted.
  3. If none existed, request retroactive authorization, understanding it's usually denied, then appeal on medical necessity with the clinical record.
  4. Regardless of outcome, audit for the process gap. The recovery is a one-time win. The process fix keeps paying.

CARC 50: medical necessity not established

What it means: "These are non-covered services because this is not deemed a 'medical necessity' by the payer."

Why it happens: the reviewer couldn't find language in the record connecting the patient's current functional impairment to the level of care billed.

What to do: see the medical necessity appeal workflow below. The short version is that you obtain the payer's own criteria and map the record to each criterion the denial cited, rather than restating that the service was necessary.

CARC 55: experimental or investigational

What it means: "Procedure/treatment/drug is deemed experimental/investigational by the payer."

IMPORTANT: this is not a documentation problem and not a place-of-service problem, though it gets described as both. In behavioral health it lands on ketamine, certain TMS protocols, and neurofeedback.

What to do: this is a coverage policy dispute, not a chart dispute. Sending clinical notes will not move it. Obtain the payer's written coverage policy for the specific service, check the evidence base and effective date it relies on, and argue the policy. If the policy is out of date relative to current clinical evidence, that is the appeal.

CARC 96: non-covered charge

What it means: "Non-covered charge(s). At least one Remark Code must be provided."

IMPORTANT: CARC 96 by itself does not tell you why. It is a category, not a reason. The RARC on that line is the actual explanation.

What to do:

  1. Find the supplemental RARC on the line. It will begin with M, MA, or N.
  2. If there is no supplemental RARC, or only an "Alert:" RARC, request a corrected remittance or call the payer. Do not appeal on a guess.
  3. Once you have the RARC, determine whether the service is genuinely excluded from the benefit or has been classified into a category a parity argument reaches. If the plan covers chronic disease management or medical specialty visits but excludes the behavioral health equivalent, that classification is worth challenging.

CARC 204: not covered under the current benefit plan

What it means: "This service/equipment/drug is not covered under the patient's current benefit plan."

What to do: pull the Summary Plan Description or Evidence of Coverage and confirm the exclusion is written. If it's written and applies, this is a patient financial conversation rather than an appeal. If the exclusion isn't written, or covers a category the service doesn't actually fall into, appeal with the plan language attached.

CARC 18: duplicate claim

What it means: "Exact duplicate claim/service."

Why it happens: staff resubmit a pending claim unchanged, trying to push it along, and both submissions deny.

Prevention, which matters more than the fix here:

  1. Train the difference between the three actions. A status inquiry asks what's happening. A corrected claim fixes an error. A resubmission sends the same thing again and generates CARC 18. Most staff who create these do not know there are three options.
  2. Set a hold rule in the clearinghouse or PM system that blocks resubmission of a claim with the same patient, date of service, and CPT code within a set window unless someone overrides it deliberately.
  3. Give staff a status inquiry path. If checking status is harder than resubmitting, people will resubmit. Make the 276/277 inquiry or the payer portal lookup the easy option.
  4. Set an expectation for pending claims. Publish how long each major payer normally takes, so a claim sitting for eight days doesn't get "helped along" when eight days is that payer's normal.

When you already have one:

  1. Determine whether there is a genuine error to fix. If yes, submit a corrected claim with frequency code 7 and the original claim number referenced, rather than a fresh claim.
  2. If there is no error and the original is simply pending, run a claim status inquiry (276/277) and let the original adjudicate.
  3. If both denied as duplicates, one usually needs to be voided before the other will process. Call and confirm which one the payer is holding.

CARC 140: member identification mismatch

What it means: "Patient/Insured health identification number and name do not match."

IMPORTANT: this is a demographic and eligibility error, not a credentialing error, and it gets filed under credentialing in a lot of denial taxonomies where it doesn't belong. Sending it to the credentialing queue wastes a cycle and delays a fix that takes two minutes.

What to do:

  1. Compare the name and member ID on the claim against the card and the eligibility response, character by character. Suffixes, hyphenated surnames, and middle initials are the usual culprits.
  2. Check whether the patient is a dependent billed under the subscriber's ID, which is a frequent cause.
  3. Confirm the name matches what the payer has on file, not what the patient prefers to be called. A legal name change that hasn't reached the payer will keep producing this.
  4. Correct the demographic record first, then resubmit. Correcting only the claim means the next claim denies the same way.

CARC B7 and CARC 185: provider eligibility and credentialing

What they mean: CARC B7 is "This provider was not certified/eligible to be paid for this procedure/service on this date of service." CARC 185 is "The rendering provider is not eligible to perform the service billed."

NOTE: B7 is a CARC, not a RARC. It appears on the remit as CO-B7 or PR-B7. The related RARC is N570. The mislabel is common, and citing it wrong in an appeal gives the reviewer a reason to discount the rest of the letter.

Why it happens: a clinician sees patients while credentialing is still pending. Practices with therapist turnover are exposed, because every new hire creates a window.

What to do:

  1. Confirm the effective date of the provider's participation with that payer, not the date the application was submitted.
  2. If the date of service falls before the effective date, check whether the payer allows retroactive effective dating to the application date. Many do, and it is worth asking specifically.
  3. Determine whether provisional billing under a supervising provider's NPI is permitted. This varies by state and by contract and must be verified at the contract level before you bill that way.
  4. Going forward, don't schedule new-hire clinicians with a payer until participation is confirmed effective, or schedule them knowing those claims will hold.

Same-day concurrent services

What happens: a patient has a therapy session and a psychiatric evaluation or medication management visit on the same day from different clinicians in the same practice, and the payer denies one as duplicative.

What to do: document that the services were distinct, medically necessary, and performed by different clinicians in different treatment roles, then submit that note with the appeal. A brief statement of the clinical rationale for both services on that date resolves most of these at first-level review.

Careful with modifier 59. For two different clinicians on the same day, 59 is usually the wrong tool. The right answer is more often correct add-on code selection, modifier 25 on the E/M, or no modifier at all with a clear note. NCCI guidance discourages 59 as a default, and habitual 59 use is something reviewers look for specifically.

Parity: what the law requires and how to use it

What MHPAEA covers

MHPAEA requires that a plan offering mental health or substance use benefits cover them no more restrictively than comparable medical or surgical benefits, across three categories:

Enacted 2008. Applies to group health plans with more than 50 employees. Some states expanded their small employer definition to 100, making the practical threshold 101 or more in those states.

NOTE: MHPAEA does not apply directly to small group plans. Parity reaches individual and small group coverage indirectly through the ACA's essential health benefits requirements, and it reached Medicaid managed care, CHIP, and alternative benefit plans through a 2016 CMS regulation rather than through legislation.

The Consolidated Appropriations Act of 2021 added the requirement that plans conduct and document a comparative analysis of their NQTLs, which is what makes a parity argument actionable rather than theoretical.

Where enforcement stands in 2026

The Departments of Labor, Health and Human Services, and Treasury released a final rule amending the MHPAEA regulations on September 9, 2024, published in the Federal Register September 23, 2024 at 89 FR 77586, effective November 22, 2024.

On May 15, 2025, following litigation filed by the ERISA Industry Committee in January 2025, the Departments announced they would not enforce the provisions new relative to the 2013 rule. That relief runs until a final decision in the litigation plus 18 months.

IMPORTANT: the pause covers the newer enforcement machinery, not the parity obligation. Still in force: the 2013 regulations, the statutory obligation as amended in 2021, and the comparative analysis requirement. Plans must still conduct and document the comparative analysis and produce it on request. If the Departments make an initial determination of noncompliance, the plan has 45 days to specify corrective action and submit an updated analysis.

Enforcement actions you can cite

On January 8, 2026, the Georgia Insurance Commissioner signed orders fining 11 commercial health insurers nearly \$25 million for parity violations, announced January 12. Twenty-two insurers were examined and 11 were fined. Oscar Health Plan of Georgia received more than \$10.2 million, Blue Cross Blue Shield Healthcare Plan of Georgia \$4.6 million, Kaiser Foundation Health Plan of Georgia \$2.5 million, and Cigna \$2.1 million. In August 2025 the same Commissioner announced more than \$20 million in fines from Georgia's first mandatory parity data call, which identified over 6,000 violations involving improper prior authorization requirements, inconsistent benefit classification, and unclear post-service medical necessity review.

What to do with it: referencing the regulatory record moves a parity appeal from "we think this is unfair" to "this specific category of conduct has been examined and penalized."

Workflow: building the parity comparison file

Do this once per payer, before you need it.

  1. Pull the payer's prior authorization requirement list for medical and surgical services. It's usually on the provider portal.
  2. Identify medical services with comparable clinical characteristics to the behavioral health service being restricted. Comparable means similar frequency, similar duration, similar level of clinical judgment involved. Weekly psychotherapy compares reasonably to weekly wound care, chiropractic, or diabetic education.
  3. Document which of those medical services do not require prior authorization, with the date you checked and where you found it.
  4. Save the plan language from the Summary Plan Description or Evidence of Coverage describing how authorization requirements apply across benefit types.
  5. Update it annually at plan year rollover, and whenever the payer publishes a policy change.

Pitfall: a weak comparison hurts you. Comparing weekly psychotherapy to an annual physical is not a parity argument and a reviewer will say so. The comparison has to be defensible on clinical intensity and frequency, not just on the fact that both are covered services.

42 CFR Part 2

Part 2 applies to any federally assisted program that holds itself out as providing substance use disorder diagnosis, treatment, or referral. Inside a general medical facility, it reaches an identified SUD unit or personnel whose primary function is SUD care, rather than the whole facility.

The February 2024 final rule was published February 16, 2024, aligned Part 2 more closely with HIPAA, and allows a single patient consent to cover treatment, payment, and health care operations. Full compliance was required by February 16, 2026. Heightened protections remain for civil, criminal, administrative, and legislative proceedings.

What to do:

  1. Confirm your consent form allows a single consent covering treatment, payment, and operations, rather than requiring a separate consent per disclosure.
  2. Confirm your notice of privacy practices reflects the 2024 revisions.
  3. Confirm that any release of records for billing purposes is operating under a current consent and is logged.

The compliance date has passed. If nobody has checked, that's an open exposure in your intake packet right now.

Appeals

A 2026 JAMA Internal Medicine analysis of more than 51,000 closed New York external appeals from 2019 through 2025 found 60.6% of mental health denials and 61.5% of substance use disorder denials overturned on independent review. The all-cause overturn rate in that dataset rose from 38% in 2019 to about 53% in 2025.

That rate describes claims that were appealed, not denials generally.

IMPORTANT: external review is the claimant's right, meaning the patient's. A provider pursues it as the member's authorized representative, with the member's designation on file. A billing team filing in its own name will have the appeal dismissed on procedure without anyone reviewing the merits.

Do this at intake: have the patient sign an authorized representative designation as part of the standard packet, so it exists before you need it. Chasing a signature from a patient who has since left treatment is how these deadlines get missed.

Under ACA rules you generally have four months from receipt of the final internal denial to request external review. Parity and NQTL compliance questions have been within scope for plan years beginning on or after January 1, 2022, and that is unaffected by the 2025 enforcement pause.

Prior authorization appeal

Run two arguments together.

The parity argument: identify a medical service the plan covers with equal or lesser clinical justification for requiring authorization that doesn't require it. Cite the comparability standard and the plan's own language on how authorization applies across benefit types.

NOTE on which citation to use. 45 CFR 146.136 is the HHS regulation, correct for issuers and non-federal governmental plans. For an ERISA-governed self-funded plan, which is a large share of a commercial book, the parallel citation is 29 CFR 2590.712. The Treasury parallel is 26 CFR 54.9812-1. Determine which type of plan you're dealing with before you cite, because using the wrong one signals a template.

The clinical argument: current diagnosis with specificity, standardized assessment scores, and the treating clinician's statement on why the requested frequency is the minimum needed to prevent deterioration.

Medical necessity appeal

  1. Request the payer's behavioral health clinical criteria in writing, whether InterQual, MCG, or proprietary. They're required to provide them under MHPAEA disclosure rules.
  2. Read the denial letter for the specific criterion cited. Denials name a criterion far more often than people notice, and appeals that don't answer it get denied again.
  3. Map the record to that criterion, point by point. If the denial says "lack of documented functional impairment," send PHQ-9 and GAD-7 scores plus the clinician's statement of how symptoms limit occupational, social, or daily functioning. If it says "absence of treatment plan goals," attach the treatment plan showing measurable goals.
  4. Attach the source documents, not a summary of them.

Pitfall: never answer a medical necessity denial by asserting the service was medically necessary. That is the assertion under dispute, and restating it gives the reviewer nothing new to act on.

Down-coding appeal

When 90837 is down-coded to 90834, the appeal turns on documentation.

  1. Confirm the note contains start time, stop time, and total face-to-face minutes supporting 53 minutes or more.
  2. Attach the note and reference CPT's time rule for the code. Say "CPT's time rule," not "the code descriptor," for the reason in the code set section.
  3. If the note is genuinely missing times, the down-code was correct. Fix the template rather than appealing.

When a psychotherapy add-on is bundled with an E/M, explain how the two were distinct with separate documentation for each, and confirm you used the add-on code rather than a standalone psychotherapy code.

Timely filing appeal

CARC 29 is "The time limit for filing has expired." Winnable with proof of a timely attempt: a clearinghouse confirmation number, a 277CA acceptance transaction, or a certified mail receipt.

Do this now, before you need it: keep every clearinghouse acknowledgment permanently. If your clearinghouse purges transaction history after 90 days, download and archive confirmation reports monthly. This is the one appeal category where the outcome was decided months ago by whether somebody saved a file.

Documentation that holds up on review

Every session note should carry these.

If your EHR allows clinicians to submit notes without start and stop times, that's a configuration problem worth fixing before the next post-payment review rather than after it.

NOTE on psychotherapy notes. Psychotherapy notes in the HIPAA sense are a protected category, and they specifically exclude session times, modalities, and other administrative elements. What payers review is the medical record, not the psychotherapy notes. Keeping the two genuinely separate protects the clinical material and keeps the billing record cleaner.

Frequently asked questions

What's the difference between 90834 and 90837? Face-to-face time. 90834 covers 38 to 52 minutes, 90837 covers 53 minutes or more. Both require documented start time, stop time, and total minutes. Documentation time, chart review, and care coordination do not count toward the total.

How do I bill psychotherapy and an E/M in the same visit? Bill the E/M and add 90833, 90836, or 90838 based on psychotherapy time. Do not bill a standalone psychotherapy code alongside an E/M. Select the E/M level on medical decision making, not time, because the time is counted toward the psychotherapy add-on.

Why does CARC 96 not tell me anything? Because it isn't supposed to on its own. CARC 96 requires at least one Remark Code, and the RARC carries the actual reason. If the RARC is missing or is only an Alert, request a corrected remittance rather than guessing.

What's the difference between a corrected claim and a resubmission? A corrected claim uses frequency code 7 and references the original claim number, telling the payer to replace what it already has. A resubmission sends the same claim again and generates CARC 18. If you only want to know the status of a pending claim, use a 276/277 status inquiry instead of doing either.

What's the difference between H0015 and H2035? H0015 is intensive outpatient, defined as at least 3 hours per day, at least 3 days per week, on an individualized treatment plan. H2035 is a treatment program billed per hour.

Is parity enforcement paused? The provisions added by the 2024 final rule are under a non-enforcement policy announced May 15, 2025. The 2013 regulations, the statutory obligation as amended in 2021, and the comparative analysis requirement remain in force, and parity disputes remain eligible for external review.

How long do I have to file for external review? Generally four months from receipt of the final internal denial. Calculate the deadline the day each internal denial arrives, because missing it forfeits the IRO entirely.

Does 42 CFR Part 2 apply to us? If you're a federally assisted program holding yourself out as providing SUD diagnosis, treatment, or referral, yes. Inside a general medical facility it reaches an identified SUD unit or staff whose primary function is SUD care. Full compliance with the 2024 revisions was required by February 16, 2026.

How we work on this at ROI

The revenue health assessment is free if you want to see where your own denials concentrate before deciding whether any of this would help.

Sources

  1. X12.org. Claim Adjustment Reason Codes. https://x12.org/codes/claim-adjustment-reason-codes
  2. X12.org. Remittance Advice Remark Codes. https://x12.org/codes/remittance-advice-remark-codes
  3. U.S. Department of Labor. Mental Health Parity and Addiction Equity Act guidance and resources. https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/mental-health-and-substance-use-disorder-parity
  4. U.S. Department of Labor. Statement Regarding Enforcement of the 2024 MHPAEA Final Rule (May 15, 2025). https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/mental-health-parity/statement-regarding-enforcement-of-the-final-rule-on-requirements-related-to-mhpaea
  5. Federal Register. Requirements Related to the Mental Health Parity and Addiction Equity Act, Final Rule, September 23, 2024 (89 FR 77586). https://www.federalregister.gov/documents/2024/09/23/2024-20612/requirements-related-to-the-mental-health-parity-and-addiction-equity-act
  6. eCFR. 45 CFR 146.136, Parity in mental health and substance use disorder benefits. https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-146/subpart-C/section-146.136
  7. eCFR. 29 CFR 2590.712, parity requirements for ERISA-governed plans. https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XXV/subchapter-L/part-2590/subpart-C/section-2590.712
  8. eCFR. 45 CFR 147.136, Internal claims and appeals and external review processes. https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-147/section-147.136
  9. Centers for Medicare & Medicaid Services. Mental Health Parity and Addiction Equity Act, applicability and small group coverage. https://www.cms.gov/marketplace/private-health-insurance/mental-health-parity-addiction-equity
  10. Georgia Office of Commissioner of Insurance and Safety Fire. Commissioner King Issues Nearly \$25 Million in Fines for Mental Health Parity (January 12, 2026). https://oci.georgia.gov/press-releases/2026-01-12/commissioner-king-issues-nearly-25-million-fines-mental-health-parity
  11. JAMA Internal Medicine. Analysis of closed New York external appeals, 2019 to 2025. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2847657
  12. U.S. Department of Health & Human Services. Fact Sheet: 42 CFR Part 2 Final Rule. https://www.hhs.gov/hipaa/for-professionals/regulatory-initiatives/fact-sheet-42-cfr-part-2-final-rule/index.html
  13. eCFR. 42 CFR Part 2, Confidentiality of Substance Use Disorder Patient Records. https://www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-2