Detox billing services for withdrawal management programs.

Detox, which payers also call withdrawal management, is billed by the day. One commercial coding policy defines medical detoxification as a set of interventions aimed at managing acute intoxication and withdrawal, and requires a physician to certify the treatment as medically necessary. The claim is a per diem, one flat payment for a day of stay and treatment, not a bill for each service: Tufts Health Plan's payment policy lists inpatient detox as an all-inclusive per diem, one unit a day, and Ohio Medicaid's manual shows its residential withdrawal management codes, H0010 and H0011, each with a per diem unit.

The days are counted the payer's way. Blue Cross and Blue Shield of Mississippi reports acute medical detoxification as a number of days on the accommodation line and says not to include the discharge day in that count. Ohio counts a member's withdrawal management use by episode, not by calendar year.

Which form carries the day depends on the payer and the setting. Residential, detox and many PHP programs bill on the UB-04, the institutional claim form, and whether your program belongs on it or on the CMS-1500 depends on your licensure and your payer contracts. Washington's Medicaid guide bills secure withdrawal management on an institutional claim and its H0010 and H0011 days on a professional claim.

There is no single code set for detox. The payer, the setting and the claim form decide, and the published sources use different pairs. Here is what each one says. Confirm a plan's current codes and units before you submit.

Each payer sets its own notice and review dates, some as early as two business days after admission and some after the seventh day. Magellan's facility handbook says to call for preauthorization before the member is admitted or non-emergency services are rendered; in an emergency, manage it first and then notify the plan.

Tufts Health RITogether's grid has the admitting facility fax an admission notification form within two business days for non-hospital detoxification at ASAM 3.7, then call the plan for a continuing-stay medical necessity review for days eight and later. For inpatient Level 4 detox the facility notifies within two business days and calls on the last covered day. Ohio Medicaid requires authorization after the seventh consecutive day for H0010 and H0011, and UnitedHealthcare applies that rule only to H0011.

A concurrent review is utilization review conducted while the patient is still in treatment: the payer approves a set number of days, and your clinical team has to support a continued stay to get more. In detox billing that makes each review a point where covered days can be lost. Magellan asks to be contacted before the end of the current authorized period when more services will be needed.

A detox claim needs a physician's certification of medical necessity and the documentation the payer's review looks for. Indiana's Medicaid manual requires all appropriate documentation demonstrating medical necessity with the prior authorization request for inpatient treatment, and its review of inpatient detoxification considers whether a need for safe withdrawal from alcohol or other drugs is indicated. Magellan's handbook says the level of service and level of care authorized must match the care billed, and a preauthorized service can still be denied when the CPT codes, revenue codes or place of service differ from the authorization.

In every case below the care was delivered and the claim still failed.

Medicaid detox rules are set state by state. Before any claim goes out we confirm four things for your state: the code, the unit, whether the claim goes to a managed-care plan or to the state on a fee-for-service basis, and the notice or authorization rule for the level of care.

Ohio pays H0010 for ASAM 3.2-WM and H0011 for 3.7-WM as per diems, requires authorization after the seventh consecutive day, and counts withdrawal management use by episode. Washington bills H0010 and H0011 on a professional claim and secure withdrawal management on an institutional one, and tells facilities to split a secure withdrawal management claim into covered and noncovered days when a patient's coverage changes mid-stay. Utah pays H0012 social detox and H0014 medically managed outpatient withdrawal management as per diems, only for a date with at least one included service. We do not assume that a rule from one state holds in yours. Our Ohio and Utah pages have each state's rules.

HRI runs detox billing under HRI Managed, our billing engagement. That means benefit verification before the bed is filled, the payer's admission notice and continued-stay review tracked to the date, and claims built to the payer's revenue code, H code and room type before they go out. It also means a running check of days in your census against days authorized, days billed and days paid, by payer, so a gap shows up in the week it opens. A denied or stuck claim runs through the same seven-point diagnostic we apply to every claim. Every claim is reported to you every Friday, with its status, its age and the next action.

On the claim, each step is its own level: the level billed has to be the level authorized, and the last detox date and the first residential date have to be clean. New Mexico, for one, requires concurrent authorization before a member moves to a different level of care than the one admitted to. Where a payer bills detox on 1002, the residential chemical dependency code, as Tufts Health Plan does for Level 3.7 acute treatment services, the H code and the authorization tell detox from residential. The next steps have their own pages: RTC and residential treatment billing, PHP billing services and IOP billing services.

License and certification come first. Ohio requires certification by its Department of Behavioral Health for residential and withdrawal management substance use services before a program can bill, and Utah licenses social detoxification as its own category, R501-11, through its Office of Licensing. After that the work is enrollment: Medicaid enrollment, then a contract with each plan you want to bill, with the code set and the notice rule confirmed while the application is in and not after the first denial.

One rule is fixed: no claim goes to a payer until that payer confirms enrollment and an effective date. The order of work, what to have ready and the first 90 days are on the new-program billing page.

Detox billing is priced the same way as every level of care, by who pays the claim. Claims Medicaid pays, in whole or in part, carry a flat fee per claim, set per program day or per encounter where that fits, with a monthly minimum. The Medicaid fee is never a percentage of what is billed or collected, and it is owed whether or not the claim pays. Commercial insurance and Medicare claims carry a monthly minimum or a percentage of what payers pay, whichever is greater, never both. Every rate is fixed in writing before the first claim. Payers pay you directly, and we never receive payer money. Ending the agreement early outside its own exit terms carries an early-exit fee, set in the agreement. There is no setup fee when your operation is ready as it stands. Your exact numbers are set on a written quote after a billing review.