Debra Pietsch 7 years ago in Accounting/Collections Modules updated by sarah 7 years ago 14

Is anyone having trouble with UBH denying claims for no authorization when no authorization is needed?


The one problem we have had with that is in billing 90837.  Is that what you are billing?

No it was actually billing for our IOP program and the policy specifically states no authorization needed.

We have the same issue, with IOP (DBT codes). We bill S9480 per our contract and when we call and a rep says no auth is required, the vast majority of the S9480s deny, saying an auth is needed or another generic denial, something about this is a non payable code for reporting only. When my co worker calls about the denials, they usually say the will send the claims back to reprocess. It's VERY annoying and time consuming to call for E&B, use the code they say is covered with no auth, then get a denial and have to spend time on the phone.

My co worker also sometimes ASKS for a auth # when they say one is NOT needed and they will not give it to her. We are trying to avoid denials.  If anyone has any ideas on how to work around this for Medica to actually pay from the start, I'll take them! Thanks!

We tried the same thing to just get authorization but they refused to give us one too!  We too are billing per our contract.  We have had them send them through again and they deny for something else.

5 digit group numbers typically don't require authorization for 90837; 6 digit group numbers always require auth for any sessions over 45 minutes


I created a UBH payer (UBH 6 Digit Plans) in Pro. The payer does not contain the CPT Code 90837. This prevents staff from entering 90837 when a client has a 6 digit UBH plan that does not allow 90837 without a prior authorization. 

The only time we run into a problem is when the client has a secondary plan that allows billing 90837 without a prior auth. Pro will automatically look for any other payers on the client account. If there is and if this other active payer allows the code, Pro will automatically bill this 2ndary payer.

Hope this helps

It could be how you're facility or clinic is contracted with UBH and which CPT code is being billed??  I would call claims to find out why...

We have been having issue all year long when it comes to our contracted IOP/Intensive Group codes.

We have sent multiple emails with documented information to the MN provider Rep for OPTUM without any response.

We actually have a Provider Rep. calling us or emailing but they just give you the same run around and ask us to be patient over and over again.  We are so frustrated with them sitting on our money that we are probably going to be contacting our attorney because they are in violation of our contract.  We submitted correctly, appealed their decision and still they have not reprocessed the claims which is added up to a lot of money.  It is truly frustrating. It is good to know that we are not the only ones that they are doing this to. 

We had a similar issue with CTSS in the past that ended up going to a UBH national team to correct.  Kyle Miller (who was an analyst at the time but is now the CS /Claims Assistant Director I believe (was Paula Decker)), entered in billing notes regarding those codes on how to properly deny, although claim processors do not always read the notes.  We have had to call on each claim and ask to specifically correct each DOS and also to put a note on the client's file that they need to check the notes in regards to these codes.  They need to deny as PR instead of CO. 

All claims for our UBH clients have reprocessed dating back to 2015.  Most were covered by a Medica PMAP, MA, and grant funding.  However, our Blue Plus claims denied and they also denied our appeals for timely filing as the rule change and reprocessing did not occur timely.  It wasn't enough to continue to fight it or allowable because of the monetary amount of each claim with BP.

You might try calling the OptumHealth Behavioral Solutions team for your state.  I do have a number if you need one for MN.

I would love to have the MN number, please! I have been dealing with this with MA since February. They had me participate in a web meeting with AUC, DHS and as many payers as were willing to attend. They addressed this issue specifically. I am going to let my DHS rep (Andrea Aggerly) know that this is an issue we are all having difficulty with, so she can see that it is not just Lighthouse. Thank you for your comment!

Sarah, can you email me and I'll forward you back all the info I have?