PHP billing services

PHP billing services for partial hospitalization programs.

Health Revenue Intelligence (HRI) bills PHP days from verification through appeals. We handle authorization, claims built to each payer's codes and hour rules, payment posting and denials.

Updated October 2026

Request a Billing Review → Where PHP claims break →

Or call 802-424-2455

What PHP billing runs on

Revenue codes 0912 / 0913, payer-specific
Per diem or hourly, minimum daily-hour thresholds
Notice or prior authorization at admission, then a review for more days; the payer sets when
Status, age and next action on every PHP claim, reported each Friday

How PHP claims get paid

A per diem is one payment for a whole program day rather than a payment for each group or session. Medicare pays PHP that way. Other payers write their own definition of a day. Blue Cross and Blue Shield of Mississippi, in a coding policy last revised in 2023, expects members to attend at least six hours a day. New York's Medicaid managed care manual pays a PHP day of at least four hours and no more than seven.

Medicare covers PHP when a hospital outpatient department or a Medicare-certified community mental health center provides it. The statute requires such a center to provide at least 40 percent of its services to people who are not eligible for Medicare. The rate within that per diem depends on how many services the day held. Medicare sorts each PHP day into one of four payment classes: 5853 and 5854 for community mental health centers, 5863 and 5864 for hospital-based programs. The first of each pair pays a day of three or fewer services, the second a day of four or more. Even a day with fewer than three services is paid at the three-service rate.

A facility bills the day on the UB-04 institutional claim, and practitioners bill their own services on the CMS-1500 professional claim. Each UB-04 line carries a revenue code and an HCPCS code.

Where PHP claims break

A level-of-care denial means the payer decided PHP was not the right setting for a day, and that day's claim goes with it. Authorization is the second failure point. A claim goes out before enrollment or review is confirmed, or a review lapses mid-stay. The days after are unpaid, regardless of how the patient was doing.

Admission notice and authorization. Tufts Health RITogether wants the admitting PHP to notify the plan on the first business day after the first day of treatment, and Tufts says it administratively denies payment when an in-network provider fails to get the required authorization or notice.
Concurrent review. A concurrent review is utilization review done 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. Each payer sets the timing: Magellan asks facilities to contact it before the current authorized period ends if they expect to need more services, and New Mexico Medicaid asks for continued-stay authorization only once a PHP stay passes 45 days.
Days short of the minimum. Under Ohio Medicaid, a substance use PHP day below the per diem minimum is billed as group counseling, H0005, for the time attended, and four straight weeks under the 20-hour weekly minimum converts the member to IOP, the intensive outpatient program.
Recertification. Medicare wants the physician's recertification to say that the patient would otherwise need inpatient psychiatric care. It also has to describe the response to treatment, the symptoms that still put the patient at risk of hospitalization and the treatment goals for coordinating services toward discharge. The physician who signs it has to be treating the patient.
Unit logic. Tufts Health Together, RITogether and One Care take H0035 with revenue code 912 and count a half day as one unit and a full day as two. Medicare counts a hospital unit as the number of times the service was performed, and returns the claim if any HCPCS code lacks a line date.
Same-day services. Medicare splits the day: physician, nurse practitioner, clinical nurse specialist, physician assistant and clinical psychologist services bill separately, and social worker, family therapist, counselor and occupational therapist services are bundled into the PHP claim. Ohio Medicaid's substance use per diem is unbundled: other medically necessary individual services are allowed beside it, plus up to one hour of separate, distinct group service.
Missing notes. For Medicare, a progress note has to describe the treatment service, the patient's response and how it relates to the treatment plan goals, and a hospital must keep each service's beginning and ending time. Our note on medical-necessity denials covers the response when the record falls short.

The codes and the minimum hours

PHP bills on UB-04 revenue code 0912 or 0913, paired with an HCPCS code that varies by payer and diagnosis. Medicare is the exception.

Revenue code 0912: Partial hospitalization, less intensive
Revenue code 0913: Partial hospitalization, intensive
HCPCS H0035: Mental health partial hospitalization, treatment, less than 24 hours
HCPCS S0201: Partial hospitalization services, less than 24 hours, per diem
Billing unit: One payer's published policy requires 0912 or 0913 on every date of service, one unit per date.
Medicare's minimum: 20 hours per week of therapeutic services in the plan of care, plus physician certification at admission, first recertification by day 18, then at least every 30 days
Condition code 41: Medicare uses it on the UB-04 to mark a claim as partial hospitalization.
Medicare bill types: 13X for a hospital, 85X for a critical access hospital and 76X for a community mental health center.

The hours behind the two codes differ by payer. Blue Cross NC's commercial reimbursement policy, last reviewed in March 2024, defines 0912 as three to five hours and 0913 as six or more. Blue Cross Blue Shield of Michigan's program requirements, revised in November 2025, define 0913 as 21 or more hours a week and 0912 as 20 or fewer.

On Medicare, the claims manual's list of acceptable PHP revenue codes includes 0900 for behavioral health treatment, 0914 for individual therapy and 0915 for group therapy, and it does not include 0912 or 0913. Medicare builds the claim from components, a revenue code and a charge for each covered service, each with its HCPCS code and line date. Neither S0201 nor H0035 appears in its PHP code tables. CMS says S codes are used primarily by private insurers and also by Medicaid programs, and that Medicare does not pay them.

For substance use PHP, the American Society of Addiction Medicine now calls Level 2.5 High Intensity Outpatient and says PHP is a misnomer because the services are not delivered in a hospital. Optum's July 2025 notice moves adult commercial substance use PHP from revenue code 912 or 913 to 907 under High Intensity Outpatient where contracts carry the change.

PHP versus IOP on a claim

Medicare separates the two by hours and by need: PHP needs at least 20 hours of services a week and a physician's certification that the patient would otherwise need inpatient psychiatric care. IOP needs at least 9 hours a week, and its patients would not need inpatient care without it. Those figures are Medicare's, and commercial and Medicaid payers write their own hours.

On the claim, Medicare marks PHP with condition code 41 and IOP with 92, and it returns an IOP claim to the provider when it overlaps a PHP claim. On a step-down to IOP, the last PHP date and the first IOP date have to be set so the two claims never overlap. More is on the IOP billing page.

Medicaid PHP

Ohio Medicaid pays substance use PHP as H0015 with the TG modifier, a per diem that needs at least 3 hours and 1 minute of group counseling that day and prior authorization for adults and adolescents. In Iowa, mental health partial hospitalization sits under H0035 on the Medicaid fee schedule, and Iowa Total Care requires prior authorization for that code and for revenue codes 912 and 913 across its Medicaid products.

Rhode Island puts its rule in licensing: a PHP has to offer 20 hours of programming a week and operate at least five full days a week, in full-day increments of six hours or half-day increments of three. Utah Medicaid's September 2026 bulletin says that from January 1, 2027, PHP claims go on the 837I, the electronic institutional claim, at one unit a day, 0912 with H0035 for the less intensive program and 0913 with H0037 for the intensive one. Our pages on Ohio, Iowa, Rhode Island and Utah go further.

What we do about it

PHP accounts run under HRI Managed. We verify benefits and track every stay against its authorization and concurrent review dates. Each PHP claim is held until its authorization is confirmed. Each claim is built to the payer's revenue code, HCPCS pairing and documented hours before it goes out. Denied and stuck PHP claims go through our seven-point diagnostic.

In that diagnostic we check our own claim build before we put a problem on the payer. Many carriers and Medicaid plans hand behavioral health to a separate manager such as Optum, Carelon or Magellan. Confirming at eligibility who processes the claim heads off routing denials.

Opening a PHP

One rule holds for every payer, Medicare included: no claim goes to a payer until that payer confirms enrollment and an effective date. The enrollment work is provider credentialing, payer applications, and contracting where a network contract applies. The order of work and what to have ready are on the new-program billing page.

What it costs

Your exact numbers are set on a written quote after a billing review.

PHP billing, answered

What providers ask about PHP claims.

How is PHP billing different from IOP billing?

PHP bills per diem or hourly, depending on the payer, against a minimum daily-hour threshold. IOP is usually paid by the program day, and the payer sets the minimum hours for a day to count.

What codes are used for PHP billing?

The payer decides. Some commercial and Medicaid payers pair revenue code 0912 or 0913 on the UB-04 with H0035 or S0201. Medicare is different: it marks the claim with condition code 41, builds it from component revenue codes and HCPCS lines, and does not list 0912, 0913, H0035 or S0201 for PHP.

Does Medicare cover PHP?

Yes, when a hospital outpatient department or a Medicare-certified community mental health center provides it. A physician certifies at admission that the patient needs at least 20 hours of services a week and would otherwise need inpatient psychiatric care.

Do you bill Medicaid PHP claims?

Yes. Medicaid PHP codes, hour thresholds, and prior-authorization rules are set state by state, so we confirm your state's current rules before any claim goes out.

Can we bill individual therapy or a psychiatry visit on the same day as the PHP per diem?

It depends on the payer. Under Medicare, a physician, nurse practitioner, clinical nurse specialist, physician assistant or clinical psychologist bills their own services, while social worker, family therapist, counselor and occupational therapist services are bundled into the PHP claim. Ohio Medicaid, for its substance use per diem, allows additional individual services as medically necessary and up to one hour of separate group service on the same day.

What if PHP denials are already piling up?

Aged AR recovery is part of the engagement. We score every open PHP claim for what can still be collected, short-hour days and lapsed reviews included. Then we correct and re-file the ones worth working while they are still inside their filing and appeal windows.

Do you track authorization and concurrent review for us?

Yes, as part of HRI Managed. We watch each authorization and concurrent review date, so a lapse shows up before it becomes a denial.

Does the billing review cost anything?

No. Tell us your PHP volume and payers, and where claims stall, and we come back with what to fix first.

Running PHP claims today?

Start with a billing review.

We can begin without any of your patient data.

Request a Billing Review → See PHP billing detail →

A Business Associate Agreement is in place before any PHI is exchanged. For addiction-treatment programs, we also sign a 42 CFR Part 2 qualified service organization agreement before handling any records. Security & Compliance

Last updated: October 25, 2026