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Part 7 of 7: Elevance Health Addiction Treatment Coverage: A Comprehensive Guide for Treatment Providers

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Part 7 of 7: Elevance Health Addiction Treatment Coverage: A Comprehensive Guide for Treatment Providers

DISCLAIMER: This content is for general information only and not medical, clinical, legal, financial, compliance, or regulatory advice. No professional relationship is formed. Consult qualified professionals before acting. We disclaim liability for reliance on this content. Use of this page constitutes acceptance of these terms.

Introduction

Navigating insurance coverage for substance abuse treatment can be complex. Elevance Health (formerly Anthem, Inc.) is one of the nation’s largest health insurers, and understanding its policies is crucial for addiction treatment facilities. This guide is tailored for administrative staff, billing specialists, and clinicians at rehab centers. We’ll break down Elevance Health’s addiction treatment coverage policies – from verifying a patient’s benefits and meeting medical necessity criteria (ASAM guidelines), to obtaining prior authorizations, handling concurrent reviews, and ensuring proper billing and coding. With up-to-date information from Elevance Health’s provider manuals and industry best practices, this pillar article will help your facility stay compliant, maximize reimbursement, and avoid common pitfalls in claims processing.

This article covers key topics like verification of benefits, ASAM criteria, prior authorization for detox, residential, IOP, PHP, MAT, peer support, continued stay reviews, in-network provider credentialing, utilization review compliance, denial trends, appeals, provider enrollment, and coding best practices.

Verification of Benefits: First Step to Successful Treatment Authorization

Before admitting a patient or rendering services, verification of benefits (VOB) is essential. Elevance Health requires providers to confirm member eligibility and coverage details before providing care . This step ensures the patient has active coverage and that the planned addiction treatment services (detox, rehab, etc.) are included in their plan.

Procedures for VOB:

  • Use Elevance Health’s Provider Portal (Availity): Elevance Health (Anthem) partners with the Availity portal to provide real-time eligibility and benefits information. Providers can log in and use the Eligibility and Benefits Inquiry tool to check a member’s coverage instantly (NYBCBS-CD-PM-068223-24 NY Medicaid Prov Manual Annual Review_DASH.docx). Enter the patient’s member ID, date of birth, and select the appropriate plan to view their SUD (Substance Use Disorder) benefits, deductible, and copay details.

  • Call the Provider Services Line: If portal access is not available or if clarification is needed, contact Elevance Health’s provider services phone line. Be ready with the member’s ID number, full name, date of birth, and your facility’s NPI. The representative can confirm eligibility, in-network vs. out-of-network benefits, and whether any notification or prior authorization is required for the intended level of care.

  • Verify Specific Benefits for SUD Treatment: Ask specifically about coverage for detoxification, inpatient or residential rehab, partial hospitalization (PHP), intensive outpatient (IOP), medication-assisted treatment (MAT), and peer support services. Different plans (e.g., commercial PPO, HMO, Medicaid, Medicare) may have different benefits or limitations. Ensure the member’s policy covers the level of care you plan to provide and note any exclusions or day limits.

  • Check Network Status & Referrals: Confirm whether your facility or clinicians are in-network for the member’s plan. In-network services usually have higher coverage. If you are out-of-network, verify if the plan has out-of-network benefits for substance abuse treatment. (Some Elevance plans require special approval or won’t cover out-of-network SUD services except emergencies.) Also verify if a PCP referral is needed; most Elevance plans allow direct access to behavioral health services, but it’s wise to confirm.

Key Requirements: Elevance Health’s provider manual emphasizes that providers are responsible for verifying the patient’s eligibility and benefits and obtaining any required pre-service authorization before rendering non-emergency services . Failing to do so can result in claim denials that are difficult to appeal. Always document the reference number of your benefits inquiry (whether done via portal or phone) and record the details provided. This documentation is useful if there’s later a dispute about what benefits were quoted.

Internal Tip: Consider creating an internal checklist or form for intake staff to complete during the VOB process. Include fields for member ID, plan type, SUD benefits confirmed (yes/no), prior auth needed (yes/no), deductible/copay, and representative name/reference number. This ensures consistency and provides a paper trail.

Meeting Medical Necessity Criteria: ASAM Levels and Documentation Best Practices

To secure Elevance Health’s approval for addiction treatment services, providers must demonstrate medical necessity. Elevance Health utilizes nationally recognized guidelines – primarily the American Society of Addiction Medicine (ASAM) Criteria – to evaluate if a patient meets the requirements for a given level of care . Understanding ASAM levels of care and thoroughly documenting clinical justification are key to obtaining authorizations and avoiding denials.

ASAM Criteria Overview: The ASAM Criteria is a set of guidelines that match patients to the appropriate level of substance use treatment based on a multidimensional assessment. Elevance Health (through its behavioral health arm, often branded as Carelon or Anthem Behavioral Health) uses ASAM criteria for all substance use services across its plans (Medical Necessity Criteria | Carelon Behavioral Health of California) . The ASAM levels commonly referenced include:

  • Level 0.5: Early Intervention services

  • Level 1: Outpatient Services

  • Level 2.1: Intensive Outpatient (IOP)

  • Level 2.5: Partial Hospitalization (PHP)

  • Level 3.1: Low-Intensity Residential (e.g., halfway houses)

  • Level 3.5: High-Intensity Residential/Inpatient Rehab

  • Level 3.7: Medically Monitored Intensive Inpatient (could include residential detox)

  • Level 4: Medically Managed Intensive Inpatient (hospital-level detox)

Each ASAM level has specific criteria related to the patient’s needs across six dimensions (Acute Intoxication/Withdrawal, Biomedical conditions, Emotional/Behavioral conditions, Readiness to change, Relapse potential, and Recovery environment).

Medical Necessity and ASAM Level Requirements: When you request authorization for a given level of care, Elevance will assess if the patient’s clinical profile meets the ASAM criteria for that level. For example, a request for residential inpatient rehab (ASAM 3.5) must show that the patient has significant impairment that cannot be safely treated at a lower level (such as failed IOP or lack of a stable living environment) and that 24-hour structure is medically necessary. Similarly, a detox (ASAM 3.7 or 4.0) authorization must demonstrate evidence of significant withdrawal risk or medical instability requiring 24-hour medical monitoring. Elevance Health’s internal guidelines note that ASAM criteria are the basis for determining necessity for SUD treatment ; if the patient does not meet those clinical benchmarks, the service may be denied as not medically necessary.

Documentation Best Practices: Robust documentation is your best defense to prove medical necessity. Every authorization request should include a comprehensive clinical assessment addressing all ASAM dimensions. Outline the patient’s substance use history, withdrawal symptoms, medical conditions, psychiatric symptoms, readiness or resistance to treatment, relapse triggers, and living situation in detail. Clearly state why a lower level of care would be insufficient for safety or effective treatment. For instance: if asking for residential treatment, document any outpatient treatment attempts and why they failed, or describe the lack of a supportive home environment that makes outpatient care unsafe.

Elevance Health often requires providers to submit specific documentation forms or narratives. In many cases, the ASAM assessment itself must be provided. For example, Elevance’s authorization request forms for SUD services (such as for Medicaid plans) explicitly instruct providers to “provide all supporting clinical documentation to justify your assessment in [each ASAM] dimension and your recommended ASAM Level” . This means attaching psychosocial assessments, withdrawal scale scores (CIWA, COWS if applicable), treatment plans, and notes from physicians or therapists that support the need for the requested care level. Insufficient detail is a common pitfall – avoid generic statements. Instead of simply saying “patient needs residential treatment due to relapse,” detail the frequency of use, prior treatment episodes, and specific relapse circumstances demonstrating the need for 24-hour support.

Tip for Clinicians: Align your intake assessment and ongoing notes with ASAM language. Use phrases like “Patient exhibits moderate withdrawal risk (ASAM Dimension 1) with daily alcohol use and a history of seizures, warranting medically monitored detox” or “Dimension 6 (recovery environment) is poor – patient is homeless, making outpatient treatment unviable.” This framing directly corresponds to the criteria reviewers look for, making it easier for Elevance’s utilization reviewers to see that criteria are met.

Common Documentation Pitfalls to Avoid:

  • Missing ASAM dimensions: Ensure all six dimensions are addressed. Omitting information (e.g., not commenting on Dimension 2 biomedical conditions) can raise questions.

  • Lack of objective evidence: Whenever possible, include objective findings – vital signs showing withdrawal, lab results (e.g., positive tox screens, abnormal LFTs), DSM-5 diagnoses, etc.

  • Not updating documentation for continued stays: The initial evaluation is crucial, but for concurrent reviews (discussed below) you must also update the documentation to reflect current status and progress. Using the same information without updates can lead reviewers to conclude the patient no longer needs that level of care.

Key Takeaway: Elevance Health follows ASAM Criteria closely for addiction treatment authorization. By providing thorough, criteria-based documentation – essentially painting a clear picture of why the patient meets medical necessity for the requested level – providers can significantly improve their chances of approval . Always err on the side of too much detail rather than too little. It’s far easier to justify a service upfront than to fight a denial later by scrambling to produce missing documentation.

Prior Authorization Processes for All Levels of Care

Prior authorization (PA) is required by Elevance Health for most intensive addiction treatment services. Obtaining PA approval before admitting a patient or starting a program is critical. In this section, we’ll outline the PA procedures for various levels of care – from detox and residential treatment to outpatient programs like IOP/PHP, medication-assisted treatment, and peer support.

Elevance Health’s general policy is that inpatient and high-intensity outpatient behavioral services require prior authorization, while routine outpatient therapy may not . Providers are expected to initiate the authorization process and receive approval before delivering non-emergency services, otherwise the claim may be denied for lack of precertification. Below we break down the process by level of care:

Detoxification (Detox) – Inpatient and Residential

What Requires PA: All detox admissions typically require prior authorization, whether the detox is occurring in a hospital setting (medically managed inpatient detox, ASAM Level 4.0) or a standalone licensed detox facility (medically monitored detox, ASAM 3.7). Elevance often treats detox as an inpatient service, meaning authorization is mandatory for coverage . In some cases, health plans might differentiate between hospital detox and residential detox. (For example, one Anthem Medicaid guideline noted “Residential substance use disorder detox requires prior authorization and is only available for members under age 21”  – indicating a specific benefit limit in that plan.) Always confirm the member’s detox benefits during VOB as noted earlier.

How to Obtain PA for Detox:

  • Timing: Submit the authorization request before or at the time of admission if possible. Detox is often urgent, so if a patient presents in severe withdrawal, stabilize and initiate treatment, but contact Elevance for authorization within 24 hours if it’s an emergency admission. Many Elevance plans allow retroactive authorization for emergency detox admissions when notified promptly. Non-urgent detox admissions (e.g., a scheduled elective admission) should be pre-approved a few days in advance.

  • Submission Method: Use Elevance Health’s preferred electronic authorization portal. Through Availity, providers can access the Interactive Care Reviewer (ICR) or an equivalent tool to submit PA requests online . This allows uploading clinical documents and checking status. Alternatively, you can call the Utilization Management number or fax a detox authorization request form (Elevance often has dedicated Behavioral Health PA request forms for detox/rehab). For instance, the Nevada Medicaid quick reference tells providers: “submit behavioral health requests via Availity (preferred) or fax using the correct forms” .

  • Information Needed: Be prepared to provide patient demographics, insurance details, facility information, requested level of care (detox), and most importantly, the clinical justification. Include the initial clinical assessment (detox rating scales, substances used, last use, withdrawal symptoms, vitals), ASAM dimensional summary, and planned detox protocols (medications, monitoring). Specify if the detox is ambulatory or inpatient and anticipated length (e.g., 3-5 days). Providing the ASAM level (e.g., “Requesting ASAM 3.7 detox”) signals to the reviewer the intensity of service.

  • Approval and Next Steps: If approved, Elevance will authorize a certain number of days for detox. For example, an approval might say 3 days of inpatient detox authorized. If the patient needs to stay longer, you will need to request a concurrent review (see next section on Concurrent Review) to extend the authorization.

Pearl: Always get an authorization/reference number and note the approved length of stay. For detox, approvals are often short (24–72 hours) with expectation of step-down to rehab or outpatient afterward. Plan discharge or transfer early, and communicate with Elevance if the patient transitions to another level of care (you may need a new authorization for the next level, such as inpatient rehab following detox).

Residential Inpatient Treatment (Rehab)

What Requires PA: Residential treatment programs (ASAM 3.1, 3.5, etc.), which provide 24-hour live-in care for substance use disorder, absolutely require prior authorization under Elevance Health policies . This includes short-term residential (typically a few weeks) and long-term residential programs. Even though these are not hospital services, they are considered inpatient for authorization purposes.

PA Process for Residential Rehab:

  • Submission: Similar to detox, submit via the portal or by phone/fax the initial authorization request as soon as you plan to admit the patient. Ideally, obtain approval before admission. If the patient is stepping down from detox (and already in the facility), coordinate with the UM reviewer to seamlessly transition authorization to residential treatment once detox is complete (often a new authorization is needed even if the patient stays at the same facility but changes level of care).

  • Clinical Info: Provide the comprehensive intake assessment demonstrating why residential care is required. Highlight any high-risk factors: e.g., repeated relapses at lower levels, co-occurring mental health issues requiring structured setting, lack of outpatient support, or severe cravings that necessitate a controlled environment. The insurer will look for ASAM criteria for 3.5 or 3.7 – ensure your notes clearly reflect those. For instance, document if the patient has “demonstrated repeated inability to remain sober outside of a 24-hour facility (relapse within days when not in structured care), meets ASAM 3.5”. Also outline the initial treatment plan (therapy modalities, medication if any, involvement of family, etc.).

  • Authorization Outcome: Initial authorizations for residential care might grant a certain number of days (e.g., 7 or 14 days to start). The provider will then have to submit concurrent reviews for additional days (discussed later). Note that many Elevance Health plans are subject to the Mental Health Parity and Addiction Equity Act – meaning they cannot impose arbitrary day limits if medically necessary – but they will still conduct medical necessity reviews at intervals.

  • Special Requirements: If your facility is out-of-network and the plan normally doesn’t cover OON residential treatment, a single-case agreement or exception would be needed. That is beyond standard PA – involve Elevance’s network management or case management in such scenarios. But if the patient only has OON options (e.g., no in-network facilities available timely), document that as part of the auth request.

Partial Hospitalization Program (PHP)

What Requires PA: Partial Hospitalization Programs (ASAM 2.5), which are structured treatment programs typically 5 days a week for 6+ hours per day, also require prior authorization in nearly all cases . PHP is considered an intensive outpatient service bridging inpatient and traditional outpatient.

PA Process for PHP:

  • Requesting Authorization: Submit a request for “Partial Hospitalization” level of care. Some plans may use the term “Day Treatment” for PHP. Make sure to use the correct terminology and coding (as we’ll cover in the coding section, common codes for PHP include H0035 or S0201 – but for authorization you can simply say “PHP”).

  • Clinical Criteria: Demonstrate that the patient does not need 24-hour care but still needs intensive daily structure. For example, an ideal PHP candidate might have stable vitals and no need for round-the-clock supervision (so not residential), but still has significant behavioral health issues or relapse potential that require near-daily therapy and monitoring. Provide details such as: patient has a safe living environment to return to in evenings, but needs daily medical/therapy support due to persistent withdrawal symptoms each morning or strong daytime cravings. If stepping down from inpatient, note progress and why PHP is the appropriate next step.

  • Authorization: Elevance may authorize PHP in chunks (e.g., 5 program days at a time). Ensure you track the authorized days and submit continued stay reviews if the patient needs more PHP days beyond the initial approval.

Intensive Outpatient Program (IOP)

What Requires PA: Intensive Outpatient Programs (ASAM 2.1), which typically involve 3-5 days per week of treatment for 3 hours per day (often totaling 9-15 hours a week), also generally require prior auth . IOP is a step down from PHP or an alternative to residential for some patients.

PA Process for IOP:

  • Submission: Request “Intensive Outpatient Program” authorization through the usual channels.

  • Justification: Clarify why IOP is needed rather than standard outpatient therapy. For example, patient may have relapsed in standard outpatient and now needs more structure, or patient is stepping down from PHP/residential but still requires a structured program to maintain momentum in recovery. Use ASAM language: IOP corresponds to ASAM 2.1 – patient should meet criteria such as moderate stability but needing close monitoring. Document any ongoing symptoms (cravings, mild withdrawal insomnia, anxiety) that necessitate more than once-a-week therapy. Also, outline the components of your IOP (e.g., group therapy, individual counseling, family therapy, medication management) to show it’s a comprehensive treatment.

  • Approval: IOP might be authorized in segments (e.g., 2 weeks at a time). Be prepared to do concurrent reviews to extend, showing the patient’s progress and continued needs.

Note: In some markets, state mandates may simplify authorization for certain outpatient levels (for instance, California parity law SB855 often requires using specific criteria but still typically PA is enforced). Always follow the Elevance plan’s requirements even if state law influences the criteria – you still must notify/authorize as required.

Medication-Assisted Treatment (MAT)

What Requires PA: Medication-Assisted Treatment refers to the use of FDA-approved medications for opioid or alcohol use disorders (like buprenorphine (Suboxone/Subutex), methadone, naltrexone (Vivitrol), etc.) usually in conjunction with counseling. The authorization requirements for MAT can vary:

  • Outpatient Office-Based MAT (OBOT): Office visits to a waivered physician or addiction specialist for buprenorphine induction and maintenance generally do not require prior authorization for the visits themselves under many plans (these are treated as regular outpatient visits) . The buprenorphine medication might require a pharmacy prior authorization, however, depending on formulary.

  • Opioid Treatment Programs (OTP/Methadone clinics): Methadone maintenance provided in a certified OTP setting is often covered through a bundled weekly or monthly rate. Some Elevance plans require an authorization for OTP enrollment, especially for Medicaid plans. Others may consider OTP services as in-network benefits that need registration. For example, one Elevance guideline suggests prior auth is only needed for out-of-network opioid treatment program services ([PDF] Review Process and Clinical Requirements (PA) 201 - Providers), implying that if the OTP is in-network, the patient can access it without special auth aside from initial referral. Always check the specific plan – some Medicaid MCOs do require PA for starting methadone treatment.

  • Ancillary MAT Services: If your facility administers Vivitrol injections on site or runs a structured MAT program, check if a prior auth is needed for the medication administration. For instance, extended-release injectable naltrexone (Vivitrol) may require authorization under the medical benefit (HCPCS J2315 for the drug per dose) and documentation of opioid/alcohol dependence diagnosis. Many insurers preauthorize Vivitrol to ensure criteria (e.g. opioid-free period) are met.

PA Process for MAT:

  • For office-based buprenorphine: Typically no PA for the doctor’s services, but ensure the physician is credentialed for MAT. Check pharmacy PA requirements for Suboxone/Subutex; if required, the prescribing physician will need to submit a form with diagnosis and prior treatment history.

  • For OTP (methadone): Contact Elevance Health to see if the member requires an authorization to enroll. Provide information like the patient’s opioid dependency diagnosis, any previous treatment attempts, and the treatment plan (daily methadone dosing with counseling). In some states, Medicaid plans ask for an initial service authorization for OTP which then covers a certain period (e.g., 6 months) of treatment.

  • For naltrexone (Vivitrol): Request auth for the medication if needed, including documentation that patient has opioid or alcohol dependence and no contraindications. Often a simple form or even an electronic pharmacy PA submission by the prescriber suffices.

  • For other MAT like acamprosate or disulfiram (which are oral meds), usually no auth needed; those are just pharmacy benefits.

Important: Even if formal PA isn’t required for the service, document medical necessity in the chart. Elevance Health may later request records to ensure MAT was indicated (especially for long-term OTP treatment). Additionally, some plans require periodic re-authorization – for example, a re-certification of medical necessity for methadone maintenance every year. Clarify this with the plan.

Peer Support Services

What Requires PA: Peer Support Services involve certified peer recovery specialists providing support and mentorship to individuals in recovery. Coverage for peer services is more common in Medicaid plans, though some commercial plans may cover it as well. Elevance Health’s Medicaid plans in certain states do cover peer support, but often with prior authorization or service plan approval due to the non-clinical nature of the service. For instance, peer services might fall under “rehabilitative services” that require authorization as noted: “Certain rehabilitation services (such as … psychosocial rehabilitation, and day treatment) require prior authorization or notification” . Peer support could be grouped in this category.

PA Process for Peer Support:

  • Verify Coverage: First, confirm that the member’s plan covers peer support. Medicaid plans increasingly do, often using HCPCS code H0038 (Peer support, per 15 min) or similar. If covered, ask if a prior auth is needed. Many plans will require an authorization akin to therapy services, where you submit a treatment plan for peer support.

  • Submit Request: If required, submit a request describing the peer support service: frequency (hours per week), setting (individual or group), and goals (e.g., “assist patient in developing recovery skills, attending 12-step meetings, building sober network”). The peer’s services should be tied to the patient’s recovery plan and ideally recommended by a clinician. Include the peer support treatment plan or service plan if you have one.

  • Qualifications: Elevance may require that peer support is delivered by a certified peer specialist. Make sure to note the credentials of the provider and that they meet any state requirements.

  • Approval: Authorization, if granted, might approve a certain number of hours per week or month. Monitor usage so you don’t exceed the authorized amount without extension.

State Variations: In some states, instead of H0038, a temporary code like S9475 has been used for peer support in opioid treatment contexts. Elevance Health’s reimbursement policy notes that in certain markets (e.g., Kentucky, Ohio, Virginia), code S9475 is used for peer support services related to opioid abuse treatment (REIMBURSEMENT POLICY MEDICAL DEPARTMENT). This was a special billing guideline indicating those states contract with behavioral health providers to bill S9475 for peer support in opioid programs. Thus, be aware of unique code or auth requirements per state. (We will cover coding more in a later section, but ensure your authorization request aligns with the correct service code the plan expects.)

Routine Outpatient Therapy (for completeness)

Although the focus is on higher levels of care, it’s worth noting that standard outpatient services (ASAM Level 1 or less) typically do not require prior authorization under Elevance Health. The quick reference explicitly states that “no prior authorization is required for traditional office-based outpatient services such as individual, group and family therapies, and medication management” . So if a patient is just seeing a therapist once a week or an addiction psychiatrist monthly, you generally do not need to obtain PA. However, ensure the provider is in-network and the patient has benefits for outpatient behavioral health.

Summary of Prior Auth Needs: In short, always assume that any addiction treatment beyond weekly therapy needs an authorization. Detox, residential, PHP, IOP – yes, get an approval . MAT – check specifics (likely yes for OTP, pharmacy auth for meds). Peer support – yes if covered. Outpatient therapy/med checks – not usually. When in doubt, call Elevance’s precertification line or use their online PA look-up tool to verify if an auth is required for a particular service or CPT/HCPCS code.

Internal linking suggestion: For detailed workflows on submitting prior authorizations, see our [Prior Authorization Guide for Behavioral Health Providers] (link to an internal how-to page) which includes step-by-step instructions and screenshots of the Availity submission process. (Make sure all your clinical and admin staff are trained on these processes to prevent delays in patient care.)

Concurrent Review and Continued Stay Authorizations

Getting the initial authorization is only half the battle for inpatient and intensive outpatient levels of care. Concurrent review (also known as continued stay review) is the process by which Elevance Health evaluates ongoing medical necessity for a patient to continue at the current level of care. Providers must regularly submit updates to justify continued stay beyond the initially authorized period. Understanding Elevance’s concurrent review process and having the required documentation ready will help avoid sudden coverage cutoffs.

When Are Concurrent Reviews Required?
 Whenever Elevance Health gives an authorization for a limited time or number of days, you will need to request an extension if the patient still needs treatment past that point. For example, if 7 days of residential treatment were authorized initially, on day 6-7 you should prepare a concurrent review request for additional days. Similarly, PHP/IOP might be authorized in blocks (e.g., 10 program days) and require review for more. Inpatient hospitalizations (detox or psychiatric) often require daily or every few days updates by phone with a utilization reviewer. The frequency of review is typically communicated in the authorization approval (e.g., “Authorized through 3/15; concurrent review required for extension”). Always note the last covered day and plan to submit an update at least a day before that expires.

How to Submit Concurrent Reviews:

  • Method: Elevance may allow concurrent review submissions via the same online portal (ICR) or by faxing a concurrent review form. Often, a care manager from Elevance will reach out to your facility concurrent review contact (utilization review nurse or therapist) to schedule a phone review or to prompt a fax. For instance, Anthem provides a Behavioral Health Concurrent Review Form for inpatient, residential, PHP, and IOP, which can be faxed on the last authorized day . That form guides you on the information needed.

  • Timing: Always submit your continued stay request before the current authorization expires. The Anthem concurrent review form instructs providers to send it “on the last authorized day” . In practice, it’s wise to send a day or two ahead if possible, to allow time for review and prevent gaps in auth. If a review is not submitted on time, coverage for days after the last auth day could be denied as late notification.

  • Information Required: Concurrent reviews generally require updated clinical information about the patient’s status, progress, and ongoing needs. Key areas to cover:

    • Patient Progress: Describe how the patient is responding to treatment. Are they engaging in therapy? Gaining insight? For example, “Patient has attended all groups, is now completing assignments, but continues to experience cravings and urges to leave against medical advice.” This shows both progress and continued need.

    • Current Symptoms/Behaviors: Note any persisting withdrawal symptoms, psychiatric symptoms, or substance use incidents. If the patient is still detoxing, list current withdrawal scale scores. If cravings or mood swings persist, detail them.

    • ASAM Dimensions Update: It’s critical to re-evaluate the ASAM dimensions during continued stay. Elevance’s concurrent review forms often explicitly ask for current ASAM dimension ratings  . For example, you may need to provide a current risk rating (Minimal, Moderate, Severe) for each dimension along with narrative. The form example shows fields for each Dimension (1 through 6) with risk ratings and a prompt for description  . Ensure you fill these out, as they directly tie to continued stay criteria. If Dimension 3 (emotional/behavioral) is still severe (e.g., patient has continued suicidal ideation), that strongly supports ongoing inpatient care. If Dimension 5 (relapse potential) remains high due to patient expressing cravings, document that clearly.

    • Treatment Plan/Goals: Indicate what the focus of treatment is for the next period. Highlight any adjustments in the plan (e.g., starting trauma therapy, adjusting medication). If a patient hasn’t progressed, mention any barriers and how you’re addressing them. Utilization reviewers want to see that continuing treatment will likely yield benefit (or is needed to prevent deterioration).

    • Discharge Planning: Ironically, part of proving ongoing need is showing that discharge isn’t safe or appropriate yet. Note what is needed before discharge can occur. For example, “Patient still lacks a safe housing option; working with case management to secure sober living by next week” or “Patient to step down to IOP but still experiencing daily panic attacks, needs stabilization before transition.” This signals to Elevance that while you are planning for discharge (as you should), certain criteria to safely discharge are not yet met.

Example: On a concurrent review for a residential rehab patient, you might report: “After 7 days in treatment, Mr. X has become medically stable (no withdrawal symptoms, Dimension 1 now minimal). However, in Dimension 3 (Emotional/Behavioral), he continues to have depression (Beck’s score 30) and occasional suicidal ideation with no plan. Dimension 5 (Relapse Potential) remains high – he reports strong cravings when thinking about returning home. In Dimension 6 (Recovery Environment), it’s still poor; family refuses to take him back unless he completes a full program. Progress: He is attending groups but struggles to open up. Plan: Continue residential care focusing on relapse prevention and psychiatric stabilization, initiate antidepressant medication. Not yet ready for lower level care.” This kind of detail maps to ASAM and justifies continued stay.

Elevance Health’s forms often have specific questions. For example, an Anthem concurrent review fax form asks whether a post-discharge appointment is scheduled and the expected length of continued stay ([PDF] Behavioral Health Concurrent Review Fax Form - Providers), and prompts for risk assessment (suicidal thoughts, etc. in last 24-48 hours) ([PDF] Behavioral health concurrent review (For inpatient, residential ...). Be thorough in responding to each item.

Utilization Review (UR) Process: During concurrent reviews, Elevance’s UR clinicians apply continued stay criteria. Generally, the rule is that continued treatment at the current level is only authorized if clinical evidence shows that stepping down would likely result in relapse or deterioration. They will deny continued stay if they determine the patient has achieved sufficient stability or could be safely treated at a lower level. Therefore, to get continued days authorized, emphasize any ongoing risks and why a step-down now would be premature.

Communication: Sometimes concurrent review is done via a phone call between your facility clinician and an Elevance utilization reviewer (nurse or doctor). Be prepared to present a concise but comprehensive update. It can be helpful to have the patient’s chart and most recent notes in front of you. Also, take note of any feedback from the reviewer—if they say, “We’ll authorize 3 more days, but we expect to see a discharge plan to IOP,” make sure to have that ready by next review.

If Continued Stay is Denied: If Elevance Health denies additional days (i.e., they say the patient no longer meets criteria and should step down), you have a couple of options:

  • Peer-to-Peer Review: Request an immediate peer-to-peer discussion with the Elevance medical director or psychiatrist who made the denial. This is your chance to verbally argue your case and provide any info that might have been missed. Many denials can be overturned in peer reviews if additional context is given.

  • Appeal (Expedited): For inpatient and residential cases, if a denial stands and you believe it’s not justified, you can file an expedited appeal on behalf of the patient. Given that the patient is still in treatment, expedited (fast track) appeals are warranted. Some states have specific protections – for example, in New York, if an insurer denies further inpatient SUD treatment, an external appeal can be requested that must be decided within 24 hours in certain cases (Plan Appeals). Understand your state’s rules. (We’ll cover appeals more later, but know that you shouldn’t just accept a denial if the patient clinically needs to stay – act quickly to appeal and avoid interrupting care.)

Documentation for Denied Days: If you do end up keeping a patient beyond authorized days (e.g., you’re contesting a denial), meticulously document the medical necessity each day. Even if initially denied, solid documentation can support a retrospective appeal or at least provide justification in case of audit.

Proactive Tip: Develop a schedule for your utilization review team to track all Elevance-authorized patients and their review dates. A simple spreadsheet or calendar with “Auth through [date]” and “Concurrent review due” can prevent accidental lapses. Missing a concurrent review deadline is a common reason for avoidable denials.

In summary, concurrent reviews are an ongoing part of working with Elevance Health for higher levels of care. By understanding what is required and keeping communication timely and thorough, you can continue treatment for as long as it’s medically necessary with coverage. Always demonstrate ongoing need with updated ASAM assessments and document, document, document !

In-Network Provider Contracting and Credentialing Requirements

Becoming an in-network provider with Elevance Health is highly beneficial for both patient access and your facility’s reimbursement. In-network (participating) providers are listed in Elevance’s directories and typically see faster authorizations and higher likelihood of patients choosing your facility (since their out-of-pocket costs are lower). This section outlines how addiction treatment providers and facilities can contract with Elevance Health and the credentialing steps involved.

Credentialing vs. Contracting: These are two linked but distinct processes:

  • Credentialing is the process by which Elevance Health verifies a provider’s or facility’s qualifications (licenses, certifications, background, etc.) and approves them to participate in the network.

  • Contracting (network contracting) is executing an agreement between your organization and Elevance Health, which includes the terms of reimbursement, obligations, and network participation.

Elevance Health has a standardized credentialing process which follows NCQA (National Committee for Quality Assurance) guidelines. According to Elevance’s provider resources, credentialing is required for licensed independent practitioners and facilities before joining the network (Join Our Network | Provider | Individual & Commercial Plans | Anthem).

Credentialing Requirements for Individual Clinicians: If you have doctors, counselors, or other licensed professionals billing under your group, each typically needs to be credentialed or linked to a credentialed group. Key steps:

  • CAQH Registration: Elevance uses the Council for Affordable Quality Healthcare (CAQH) ProView for collecting provider credentialing data  . Practitioners should create or update their CAQH profiles with all current information. Elevance instructs providers to authorize them to access the CAQH data (Join Our Network | Provider | Individual & Commercial Plans | Anthem). Make sure the CAQH application is in a complete status and attested within the last 90 days when you apply.

  • Documentation Needed: Providers must have a current state license, DEA registration (if applicable), professional liability insurance, board certification or relevant training, an updated CV/work history, and no sanctions or adverse history. Elevance’s credentialing application checklist includes: signed application attestation, license in each practicing state, education/training info, hospital privileges or admitting arrangements, malpractice insurance, work history, and explanations for any gaps or issues  (Join Our Network | Provider | Individual & Commercial Plans | Anthem).

  • Timeline: The credentialing process typically takes around 45 days from the time Elevance has a complete application (Join Our Network | Provider | Individual & Commercial Plans | Anthem). In some cases it can take up to 90 days. Starting early is crucial if you anticipate taking Elevance patients.

Credentialing Requirements for Facilities/Programs: Elevance Health also credentials health delivery organizations, which include addiction treatment facilities (rehabs, clinics). Facilities usually must:

  • Have all required licenses (e.g., state license to provide SUD treatment, any required certifications for detox, etc.).

  • Accreditation: While not always mandatory, having accreditation (such as Joint Commission or CARF for a rehab facility) is often looked upon favorably and may expedite acceptance. Some networks do require accreditation for SUD facilities – check Elevance’s policy in your state.

  • Site Visit: The insurer may conduct a site survey or require an attestation of facility standards. Elevance’s process notes that applicants must allow a site review within 30 days of request, if applicable (Join Our Network | Provider | Individual & Commercial Plans | Anthem).

  • Staffing and Program Criteria: You might need to submit a roster of your clinicians, proof of 24-hour staffing for inpatient programs, and evidence of ability to provide required services (for example, if you offer medical detox, show you have medical doctors and nurses on staff).

  • Medicaid-specific enrollment: If you are joining an Elevance Medicaid network, you must first enroll with the state Medicaid program and obtain a Medicaid provider ID. For instance, “Providers interested in joining our network [Virginia Medicaid] should first complete enrollment with VA DMAS (Department of Medical Assistance Services)” (Join Our Network - Providers). Similarly, a Nevada Medicaid guidance states you must have an active state Medicaid ID before Anthem will contract (Join Our Network | Anthem Blue Cross and Blue Shield Healthcare Solutions).

Contracting Process:

  1. Application to Join Network: Start by reaching out to Elevance Health’s network management or using their online network participation request. On the Anthem provider site, there’s typically a “Join Our Network” section where you can express interest. They may have separate links for professional providers vs. facilities. For example, Anthem’s site has options for individual practitioners vs. ancillary providers (Join Our Network | Provider | Individual & Commercial Plans | Anthem). Fill out the required forms or online application with details about your facility (services, locations, TIN, NPIs, etc.).

  2. Credentialing Review: Elevance’s credentialing committee will review the submitted information. They’ll check that you meet their criteria for network providers. Elevance states: “We credential licensed healthcare professionals with whom the company intends to contract and market to our members” (Join Our Network | Provider | Individual & Commercial Plans | Anthem), and they have a Program Summary listing which provider types are credentialed. (Substance use treatment programs are typically included.) If anything is missing or if issues arise (e.g., a practitioner with a past license suspension), they may reach out for clarification or deny credentialing.

  3. Contract Offer: Once credentialing is approved, Elevance will send a contract (participating provider agreement). For facilities, this will outline reimbursement rates (per diem or DRG rates for inpatient, fee schedule for outpatient codes, etc.), authorization requirements, and administrative terms. Review this contract carefully, possibly negotiating rates if feasible. Elevance Health often has standard rates but some negotiation may be possible, especially if you offer a unique service or have leverage in your region.

  4. Execution and Effective Date: Sign the contract and submit any required supporting documents (like proof of insurance, W-9 for your Tax ID, etc.). Elevance will counter-sign and provide an effective start date for your network participation. You will receive a welcome letter or provider reference guide. Note: The effective date is often not retroactive to when you applied; it starts after credentialing approval and contract execution. As Anthem’s Nevada provider guide notes: “Upon completion of credentialing and full execution of contract documents, the provider will receive notice… with the effective date of participation. Services rendered prior to this effective date will be [out-of-network]” (Join Our Network | Anthem Blue Cross and Blue Shield Healthcare Solutions). So schedule your contract timeline with that in mind to avoid treating a bunch of patients before you’re effective (which could lead to OON claims).

  5. Panel Considerations: In some cases, a network might be “closed” for certain provider types if there are already sufficient providers. If that’s the case, you may be put on hold or denied network entry not due to your credentials but due to network need. You can often appeal or ask for re-consideration later, especially if you can demonstrate why inclusion of your facility is beneficial for members (e.g., maybe there’s long wait times at current in-network rehabs, etc.).

Recredentialing: Once in network, Elevance Health will require recredentialing every 3 years (standard) to update your info and ensure continued compliance. Keep your CAQH updated and respond to any recredentialing requests to maintain your status.

Tips to Smooth the Process:

  • Double-check that all your corporate documents (licenses, insurance, etc.) are current and will not expire during the credentialing process. A lapse in a license will halt your application.

  • Be honest and thorough. Disclose any prior issues (malpractice cases, disciplinary actions) with explanations – hiding them will cause denial if discovered, whereas explaining them upfront can often be acceptable to the committee.

  • Follow up if timelines stretch. If 60 days have passed without word, contact provider relations to check status. Persistence can sometimes expedite things.

  • Provider Referral: If you know a physician or entity already contracted with Anthem, ask if they can provide a recommendation or referral to the network team. Occasionally, networks consider such inputs.

In summary, joining Elevance Health’s network requires preparation and patience, but it is worth it. You’ll gain access to a large pool of patients and often better payment than out-of-network (since patients are more likely to use in-network providers). Make sure to fulfill credentialing requirements diligently (Join Our Network | Provider | Individual & Commercial Plans | Anthem) and your facility will be well on its way to in-network status.

(Internal note: For more on this topic, see our [Provider Contracting 101] article for strategies on negotiating with payers and understanding contract clauses.)

Utilization Review Policies, Denial Trends, and Compliance Requirements

Elevance Health, like all insurers, maintains Utilization Review (UR) policies to manage the cost and quality of care. For addiction treatment providers, this means your services will be subject to initial reviews (prior auth), concurrent reviews, and sometimes retrospective reviews to ensure that what was billed was medically necessary and properly documented. Being aware of Elevance’s UR expectations and common denial reasons will help your facility stay in compliance and avoid revenue loss. This section also covers the appeals process for adverse decisions and how to handle denials effectively.

Utilization Review and Compliance:
 Elevance Health’s UR process is guided by their medical policies and clinical guidelines. As noted, for substance use disorder treatment they largely defer to ASAM criteria for medical necessity . The company’s internal policies will mirror these criteria. Compliance for providers essentially means:

  • Adhering to the authorization requirements (as discussed earlier). Not obtaining required preauthorization is a breach of your provider agreement and typically results in denial of payment. The provider manual explicitly states providers must ensure the UM department has conducted pre-service reviews for non-emergency services . This is both a compliance and contract requirement.

  • Following continued stay criteria and not keeping patients in a higher level of care without clinical justification. UR programs look for outliers – e.g., if a patient stayed 60 days in residential when most similar patients discharge in 30, they may flag for review. Ensure your clinical rationale is sound and documented for extended stays.

  • Cooperating with post-payment reviews or audits. Elevance might conduct random or focused audits on SUD treatment claims. They could request medical records to verify that services billed were provided and appropriate. Providers are required to comply by furnishing records (NYBCBS-CD-PM-068223-24 NY Medicaid Prov Manual Annual Review_DASH.docx). Non-compliance (like failing to send records) can result in recoupment of payments and even network termination if egregious.

Common Denial Trends for Addiction Treatment:
 Understanding why claims or auths get denied can help you proactively address issues. Here are some frequent denial reasons (and ways to preempt them):

  • Lack of Medical Necessity: This is the number one reason for denial of SUD treatment days. Elevance may issue a denial stating “criteria not met for requested level of care.” This often happens if the documentation did not convincingly show severe enough issues, or if the patient’s condition improved. For example, a concurrent review might be denied because the patient is now sober for 10 days with no withdrawal symptoms and has a stable home – meaning they likely only meet criteria for a lower level (IOP). To avoid unjust denials, always align documentation with the medical necessity criteria as discussed. If denied, gather additional evidence (progress notes, physician letters) and appeal, arguing how the patient did meet criteria. According to one insurance guide, “The requested service or treatment is ‘not medically necessary’” is among the most common denial reasons (How to Appeal an Insurance Denial for Rehab & Addiction Treatment) – so focusing your appeal on medical necessity justification is critical.

  • No Authorization/Precertification: Failing to get a required prior authorization will lead to administrative denials. These are often termed “authorization not on file” or “no prior auth.” They can sometimes be overturned if you can prove it was truly an emergency or if you appeal and Elevance grants a retroactive auth as a courtesy (rare). The best strategy is prevention: have robust front-end processes to capture all cases needing auth. If a slip-up occurs (e.g., staff missed that a certain service needed PA), you can attempt a retro auth request within a short window (some plans allow within 72 hours of service for urgent scenarios). Otherwise, you may be stuck with a denial.

  • Excluded or Non-Covered Service: Some denials state the service isn’t covered under the member’s plan. This could happen if the plan doesn’t cover a certain level (e.g., no residential benefit on some insurance policies) or if the patient has maxed out a benefit. With parity laws, most plans now cover all levels of SUD care, but limitations can exist. For example, a plan might cover residential rehab but not “sober living” or not unlicensed recovery homes. If you submit a claim for a service the plan doesn’t cover, it’ll deny as “not a covered benefit.” According to the Washington State OIC, a common denial reason is “The benefit isn’t offered under your health plan” (How to Appeal an Insurance Denial for Rehab & Addiction Treatment). Prevent these by verifying benefits upfront and not billing for services outside what was authorized. If you believe a service should be covered (parity argument), you can appeal on that basis, but that can be an uphill battle unless regulations support you.

  • Treatment Beyond Guidelines (Length of Stay Denials): Insurers track typical lengths of stay. If your patient stays significantly longer than average without clear need, expect scrutiny. Denials might say “continued stay not medically necessary after X date.” The remedy is again to appeal with strong evidence of why the extended care was necessary (e.g., patient had a medical setback or co-occurring issue that prolonged treatment). It helps to reference ASAM criteria for continued stay or any extenuating circumstances. Also, ensure discharge planning is documented; if a longer stay was due to lack of step-down options (e.g., waiting for an IOP slot to open), mention your efforts to find alternatives – it shows you weren’t just keeping the patient for convenience.

  • Incomplete Documentation / Coding Errors: Sometimes claims are denied not because care wasn’t needed, but because of technical issues. For instance, if documentation signatures are missing or notes don’t support the codes billed, a claim might deny on audit. Or if required modifiers (like a modifier for telehealth if service was remote) were omitted, claims can deny. Always double-check billing submissions (more on this in coding section). Keep documentation complete to back up every claim (progress notes for each date of service, physician orders for medications, etc.).

Appeal Processes:
 Despite best efforts, denials will happen. It’s important to know how to appeal decisions with Elevance Health effectively. Here’s a rundown:

  • Internal Appeals (Provider Disputes): For denial of payment on a claim, providers typically file a claim dispute or appeal through the provider portal or by mail. Elevance often allows 90 to 180 days from the denial/EOB date to file an appeal (exact timeframe varies by plan; many commercial plans give 180 days (Individual & Family: Complaints, Grievances, And Appeals)). In your appeal, include the claim information, denial reason, and a clear explanation with supporting documentation on why it should be overturned. For medical necessity issues, attach clinical records and perhaps a letter of medical necessity from the treating physician. Anthem’s guidelines state that you should submit any additional info you want considered, such as provider letters (How to Appeal an Insurance Denial for Rehab & Addiction Treatment) (How to Appeal an Insurance Denial for Rehab & Addiction Treatment).

  • Member (Patient) Appeals: For authorization or treatment denial (as opposed to a claim after service), often the appeal rights lie with the patient (member). However, as providers, you can assist the patient in filing an appeal or be their representative. For urgent concurrent denials, you would do an expedited appeal on the patient’s behalf. Always inform the patient or their family of any denial and coordinate on appeals – two appeals (one from provider, one from patient) isn’t needed; one well-crafted appeal is enough, but ensure it’s clear it’s on behalf of the patient. Members generally have up to 180 days from denial to file an appeal as well (Individual & Family: Complaints, Grievances, And Appeals).

  • Expedited (Fast) Appeals: If the denial could seriously jeopardize the patient’s health (e.g., a denial of continued inpatient care or a medication), request an expedited appeal. Elevance must review expedited appeals quickly (within 72 hours typically, or faster depending on state law) (How to Appeal an Insurance Denial for Rehab & Addiction Treatment). Indicate clearly “Urgent – Expedited Appeal” in your request and explain why it’s urgent (e.g., “Patient is at high risk of relapse or harm if residential treatment is terminated early.”). Some states have special rules for SUD. For example, New York requires an external review decision within 24 hours for certain SUD treatment appeals if filed timely (Plan Appeals).

  • External Appeals: If the internal appeal is denied, patients (or providers with patient consent) can often seek an independent external review by a third-party reviewer. This is usually coordinated through the state or an independent review organization. External appeals are typically for medical necessity or experimental treatment disputes. For medical necessity denials in behavioral health, external reviewers will also use generally accepted criteria (like ASAM) and parity standards. It can be worthwhile to pursue external review if you strongly believe the denial was wrong – success rates can be decent if there’s solid evidence. The external appeal must be filed within a certain time after the internal denial, often 4 months. Anthem materials say you have other appeal rights for not medically necessary decisions via your state’s external appeal process (Plan Appeals).

Crafting Effective Appeals:
 When writing appeal letters, be concise but thorough. Reference the member name, ID, dates of service, and denial reference number. Then clearly state why you disagree with the denial and provide evidence. Some best practices:

  • Address the specific denial reason: If they said “not medically necessary,” directly counter that with clinical facts and refer to medical necessity criteria. E.g., “Your denial letter stated inpatient rehab was not medically necessary because patient was allegedly stable. However, we wish to point out that at the time of denial, the patient was experiencing nightly cravings and had no sober support (ASAM Dimension 5 and 6 still high severity), indicating continued need for 24-hour care. We are including progress notes from those dates showing ongoing symptoms and the treatment team’s assessment that stepping down would likely result in relapse.” By pinpointing the criteria, you strengthen your case.

  • Use templates and evidence-based support: The NAIC (National Association of Insurance Commissioners) and some state insurance departments provide appeal letter templates (How to Appeal an Insurance Denial for Rehab & Addiction Treatment). These templates help ensure you include all key elements. Washington’s Office of Insurance Commissioner, for instance, provides examples of appeal letters for various scenarios (Common reasons for a denial and examples of appeal letters). You can adapt these to your case. Include references to parity law if relevant: e.g., if the criteria applied seem more stringent than what is used for analogous medical/surgical conditions, point that out (Parity Act requires comparable level of scrutiny). Also, attach relevant literature or guidelines if you have them – for example, a letter from the patient’s psychiatrist or primary doctor supporting the necessity of continued rehab can be persuasive.

  • Keep Records: Document every phone call and correspondence during the appeal. Note dates, names of people you speak to, and what was said (How to Appeal an Insurance Denial for Rehab & Addiction Treatment). If you fax an appeal, keep the confirmation. If mailing, send it certified with return receipt (How to Appeal an Insurance Denial for Rehab & Addiction Treatment). This not only ensures they received it but also creates a paper trail in case of any dispute about timely filing.

  • Follow Timelines Strictly: Appeals have deadlines. Missing them can forfeit the chance to overturn a denial. Set internal reminders for appeal due dates (for both first-level and any second-level or external appeals).

Denial Management Strategies:
 Proactively, your facility should analyze any patterns in denials from Elevance Health:

  • Conduct periodic utilization review meetings to review cases that were denied or partially approved. What was common? For example, if you notice multiple denials for “no clinical information received,” perhaps your team missed sending documentation – fix that process. If denials often say “failed to meet ASAM 3.7 criteria,” maybe admission assessments need to be more detailed or maybe borderline cases should be considered for a lower level to avoid denial.

  • Train your team on how to handle peer-to-peer discussions. Sometimes, appealing doesn’t have to be a formal letter; a quick peer call within the appeal period can result in overturn. Ensure your medical director or clinicians are comfortable presenting cases to insurance medical directors.

  • If you frequently encounter one particular medical director or reviewer, learn their style. Some might focus on certain dimensions more; tailor future reviews to preempt their concerns.

  • Develop appeal letter templates internally for common denial reasons (medical necessity, no auth, etc.), so that your staff isn’t writing from scratch each time. The template can have placeholders for patient specifics, but the general structure and key points to hit will be pre-drafted. This also ensures consistency and that nothing is omitted.

Case Study Example: Facility ABC had a denial for a 14-day residential treatment claim, where Elevance only authorized 7 days and denied the rest as not medically necessary. Instead of writing it off, the facility appealed. They gathered daily clinical notes, which showed the patient had ongoing cravings and that discharge was delayed because an outpatient psychiatrist appointment wasn’t available for 10 days (a factor outside patient’s control). The facility wrote an appeal letter highlighting these facts, noting that had the patient been discharged earlier with no psychiatric follow-up, it would have been a setup for relapse – thus continued stay was justified. They cited ASAM criteria about relapse potential (Dimension 5) and even included a letter from the outpatient psychiatrist that they could not see the patient sooner. As a result, upon appeal review, Elevance overturned the denial and paid for the full 14 days. This illustrates that thoughtful appeals with supporting evidence can succeed.

In case your appeal is ultimately unsuccessful, and the patient is left with a bill, work with the patient – often they can request an external review or involve the state insurance department or an ombudsman. Some states have grievance procedures beyond the insurer’s process.

Lastly, compliance is not just about avoiding denials but also about staying out of trouble. Ensure your facility is also following any additional Elevance requirements like utilization data reporting or quality measures if in network. For example, some contracts require providers to submit outcomes data or adhere to certain protocols. Staying compliant in these areas keeps your relationship with Elevance positive and can indirectly help during any disputes.

(Internal link suggestion: See our [Denial Management and Appeals Toolkit] for sample appeal letters and a checklist to streamline the process of challenging denials.)

Provider Enrollment and Payer Registration for New Facilities

If you are a new addiction treatment facility starting up (or new to taking insurance), there are important steps to get set up with payers like Elevance Health beyond just contracting. Provider enrollment and administrative registration ensure that Elevance’s systems recognize your facility and can process claims correctly. This section addresses what new facilities need to do to be properly enrolled with Elevance Health, especially focusing on those initial logistics.

Obtain Necessary Identifiers:
 Before engaging with any payer, make sure your facility has the foundational identifiers:

  • National Provider Identifier (NPI): If you are a new organization, obtain an NPI for the facility (Type 2 NPI for organizations). Many addiction treatment centers will have one NPI for the facility and possibly additional NPIs for subparts (if operating multiple levels of care under one roof, though usually one is fine). Individual clinicians also have Type 1 NPIs.

  • Tax ID and Business Registration: Ensure your Tax Identification Number (TIN or EIN) is set up for the entity that will be billing. Elevance will use this to set you up in their payment system.

  • State Provider ID (for Medicaid): As noted, if you plan to serve Medicaid members via Elevance (which operates Medicaid plans in several states), you must enroll with the state Medicaid program first. For example, to bill Anthem HealthKeepers Plus in Virginia, you need a Virginia Medicaid provider ID. Similarly in other states like California or New York – enroll through state portals or Medicare (for Medicare Advantage plans) if relevant. Once you have those, you can register with the Elevance Medicaid plan.

Payer Registration (If Out-of-Network Initially):
 Even if you aren’t immediately in-network, you should still register as a non-participating provider once you start seeing Elevance-covered patients. This means providing Elevance with your facility’s details so they can create a provider profile in their claims system. This helps avoid claim rejections that say “provider not found”. Typically, you’d do this by submitting a W-9 form and perhaps a simple enrollment form to the payer. Some payers also let you do this via the provider portal (Availity). Check with Elevance’s provider relations — ask “What do I need to do so that our new facility is set up in your system for claims?” They may direct you to complete a provider data form.

  • Note: If you’re in the process of credentialing to become in-network, a lot of this will be done as part of that. But if you’re starting out of network, definitely handle this administrative step.

Digital Tools and Portal Access:
 Register your facility for the Availity multi-payer portal and specifically link to Elevance Health’s payer space. Having an Availity account is crucial for verifying eligibility, submitting auths, and checking claims with Elevance (Join Our Network | Anthem Blue Cross and Blue Shield Healthcare Solutions). Availity registration is free; you’ll designate an administrator to manage access for your staff. Once in Availity, add Elevance Health (Anthem) as one of your payers under “My Providers” using your TIN/NPI. This will allow you to use tools like the Interactive Care Reviewer and claims status inquiry from day one.

EDI (Electronic Data Interchange) Setup:
 If you use a billing software or clearinghouse, ensure it’s configured to send claims electronically to Elevance Health. Elevance’s payer ID is typically the local Blue Cross Blue Shield payer ID (for example, Anthem California might use Blue Cross CA’s Payer ID, etc.). Availity can also act as a clearinghouse. Electronic claim submission will speed up payment. Similarly, set up Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) with Elevance if possible, so payments and remits come faster. Many states require insurers to offer EFT. Anthem/Elevance often has an EFT enrollment form on their provider site or through the Availity EFT/ERA enrollment utility.

Enrollment for Specific Services:
 Some services require additional enrollment or certification:

  • Laboratory Services (including drug testing): If your facility will bill for on-site lab tests (like urine drug screens), you might need to get a CLIA certificate and let Elevance know your CLIA number. Claims for lab services must have the CLIA on file to be paid. Include that in your enrollment info.

  • Prescribers for MAT: If you have prescribers writing buprenorphine prescriptions, they should have their DATA 2000 waiver (the X-license, though note as of 2023 the DATA waiver requirement was eliminated in the U.S., but still ensure prescribers are legally able to prescribe MAT).

  • Peer Providers: For Medicaid, if billing peer support, some payers require the peers be listed or their certifications on file. Check if you need to submit a list of your certified peer specialists to Elevance.

  • Specialty Codes: Some Medicaid plans use taxonomy or specialty codes to identify provider type. For example, a provider type code for “Substance Abuse Facility” might need to be on claims or in your enrollment. Anthem’s systems often use the taxonomy code submitted on claims to match to your provider record. Make sure your billing staff uses the correct taxonomy code (e.g., 3245S0500X for Substance Abuse Rehab Facility) on electronic claims; but also ensure that taxonomy is part of your provider profile with Anthem.

New Facility Checklist with Elevance:

  • Provide Service Address(es) and ensure they’re loaded correctly (so patients can find you in directories, and so claims process to the right region).

  • Provide Contact info for referrals/authorizations – some plans ask for a facility contact.

  • If your facility has multiple programs (detox, residential, IOP under same roof), clarify how you’ll be billing (usually same TIN/NPI but different revenue codes or CPT codes distinguish services).

  • Utilization Management Coordination: As a new facility, introduce yourself to the Elevance Health care management team in your area. Sometimes, having a brief call with the Anthem behavioral health medical director or network rep to explain your program can put you on their radar (in a good way). It establishes lines of communication, so if any question arises on an auth, they know who you are.

Enrollment Verification: Once you think you’re set up, do a test run. Perhaps submit an eligibility inquiry or a test claim (some payers allow test submissions) to see if it goes through. Or call and verify that your NPI/TIN is recognized. It’s better to catch any glitches (like your name spelling or address wrong in their system) early on.

Medicare Advantage Consideration: Elevance Health also offers Medicare Advantage plans (under brands like Anthem, Amerigroup in some states, etc.). If you plan to treat those, you’d need to be enrolled in Medicare and then contracted or at least registered with the MA plan. Check with Elevance if any additional steps are needed.

Keep Information Updated: After initial enrollment, always update Elevance if anything changes: address, ownership, adding a new location, etc. Use their provider maintenance forms or update via Availity. Outdated info can lead to issues like checks sent to wrong address or even network termination if mail bounces.

Summary: For new addiction treatment facilities, getting properly enrolled with Elevance Health involves securing all necessary IDs, registering with the payer (especially through the Availity portal), and ensuring compliance with any specific program enrollment. Take advantage of the resources Elevance provides – many have Provider Welcome Kits or orientation webinars. By completing these administrative steps early, you set a solid foundation for smooth billing and reimbursement once you start accepting patients with Elevance Health insurance.

(Internal resource: New to insurance billing? Check out our [Startup Guide for Behavioral Health Facilities] for a step-by-step walkthrough of enrollment with major payers and how to set up your revenue cycle systems.)

Coding and Claims Submission Best Practices

Accurate coding and billing are crucial for getting paid for the services you deliver. Addiction treatment comes with a variety of billing codes – including HCPCS “H” codes for many services – and using them correctly is important to meet Elevance Health’s billing guidelines. In this section, we will cover common CPT/HCPCS codes for substance use treatment, relevant modifiers, documentation requirements to support coding, and pitfalls that often lead to claim denials.

Common Codes for Addiction Treatment Services:
 Elevance Health, like other payers, recognizes standard billing codes for different levels of care. Here’s a summary table of frequently used codes and their descriptions:

Inpatient Hospital Detox (ASAM 4.0)

Residential Detox (ASAM 3.7)

Residential Treatment – Short Term (ASAM 3.5)

Residential Treatment – Long Term (ASAM 3.1)

Partial Hospitalization Program (PHP) (ASAM 2.5)

  • Common Code(s): H0035 or S0201

  • Description:

    • H0035 – Mental health partial hospitalization, treatment, less than 24 hours, per diem (2025 HCPCS 'H' Codes - HCPCSData.com) (often used for SUD PHP as well).

    • S0201 – Alcohol/drug partial hospitalization, per diem (some Anthem plans use this code as noted in reimbursement exemptions (REIMBURSEMENT POLICY MEDICAL DEPARTMENT)). Verify which code Elevance prefers in your region.

Intensive Outpatient Program (IOP) (ASAM 2.1)

Outpatient Therapy/Counseling (ASAM 1.0)

  • Common Code(s): H0004, 90834, 90837 (individual therapy); 90853 (group therapy)

  • Description: Traditional therapy codes.

Medication Management Visit

  • Common Code(s): 99213, 99214, etc. (E/M codes)

  • Description: If an MD/NP is seeing a patient for medication management (e.g., Suboxone follow-up), use standard Evaluation & Management office visit codes. Typically, no H-code is used; bill as psychiatric med check or general med check depending on the clinician.

Medication-Assisted Treatment (MAT) – Methadone

MAT – Naltrexone (Vivitrol)

  • Common Code(s): J2315 + 96372

  • Description:

Screening & Assessment

Group Counseling (SUD specific)

Peer Support Services

  • Common Code(s): H0038 (individual, per 15 minutes) and H0025 (group, per session)

  • Description:

Recovery Support (non-clinical)

Urine Drug Testing

  • Common Code(s): G0480-G0483, G0431/G0434 (older), H0048

  • Description: Definitive or presumptive drug testing codes. The G0480 series are Medicare’s definitive test codes by number of drug classes. H0048 – alcohol/drug testing by kit (used in some Medicaid plans). Ensure to follow Elevance’s lab coding policy.


Note: This is not exhaustive. There are many other codes (H0037 for residential aftercare, S9475 as mentioned for peer in some states, etc.), but these are among the most common in addiction treatment billing.

Use of Modifiers:
 Modifiers are additional code qualifiers that provide extra info. Some important modifiers in SUD billing:

  • Modifier HF – Often denotes Substance Abuse Program (in Medicaid contexts). For example, Horizon NJ Health advises using H0038 with modifier HF for peer support (Self-Help/Peer Support Billing Guidelines - Horizon NJ Health). Check if Elevance requires HF on certain H-codes to distinguish SUD services from mental health. If your claim is missing a required modifier, it might be denied or paid incorrectly.

  • Modifier TG/TF – Some Medicaid plans use TG (complex/high level) or TF (intermediate level) to indicate intensity. For instance, intensive outpatient might require TF or TG to indicate level of care. Elevance’s guidelines don’t universally mandate these, but state Medicaid plans might. Verify any state-specific coding requirements.

  • Modifier GT or 95 – If you deliver services via telehealth (like tele-IOP groups), use the appropriate telehealth modifier (95 or GT) and ensure the place of service code is telehealth (02 or 10). During COVID, many payers expanded telehealth for SUD treatment, but correct coding is needed to get paid.

  • Modifier 25 – If a patient receives two services in one day by the same provider (e.g., a psychiatric visit and a therapy session), append modifier 25 to the E/M code to indicate a separate significant service. Otherwise, one service may be bundled.

  • UA, UB, U1, etc. – Sometimes used in state programs to differentiate levels (e.g., UB might indicate adult program, UA adolescent, etc.). Check if applicable.

  • Modifiers for MAT: There are some situations where modifiers are used for MAT services (for instance, Medicare uses modifier “HF” or “HG” for opioid treatment program services). Anthem’s policy excerpt suggests that in some markets, S9475 is used for peer support in opioid treatment – possibly requiring a modifier or special contract indicator (REIMBURSEMENT POLICY MEDICAL DEPARTMENT).

Documentation to Support Coding:
 Accurate coding must be backed by documentation in the medical record:

  • Start/Stop Times: For time-based codes (like H0004 counseling per 15 min, or group therapy of certain length), document the time spent. If you bill 4 units of H0004, your note should show something like “Counseling from 2:00 pm to 2:60 pm (60 minutes)” or list duration. Insurers may audit and recoup if time isn’t documented.

  • Detailed Group Notes: For group therapy or education billed under H-code or 90853, maintain sign-in sheets (if required by state) and group notes that include the topic and each patient’s participation or response. Avoid cloning identical notes – it raises flags.

  • Treatment Plans and Progress: Especially for per diem codes (H0015, H0018, etc.), ensure there is a master treatment plan and regular progress notes for each day. A payer could ask for a particular date of service documentation. If, say, you bill H0018 for a certain date, that day’s progress note should reflect active treatment (group attended, individual session, etc.). If a patient skipped all activities that day and you still billed, that could be a problem if revealed.

  • Corresponding Auth: Only bill for days/services that were authorized (if auth required) and make sure your codes align with the authorized level. For instance, if authorization was for “IOP 3 days/week,” don’t accidentally bill PHP code for those days.

  • Avoid Upcoding: Bill the code that reflects the service. If a patient is in outpatient therapy but you bill IOP, that’s fraudulent. Similarly, if doing a simple drug screen dipstick, don’t bill a high-level definitive test code. Insurers analyze claims data and outliers can trigger audits.

Common Coding Pitfalls:

  • Unbundling: Anthem has guidelines to prevent “per diem double billing.” For example, they do not expect to see an IOP per diem (H0015) on the same day as a bunch of individual therapy codes – that would be double billing for the same services (Behavioral Health H-Codes Per Diem Double Billing guideline change). Indeed, Anthem issued a guideline listing that they will prevent double billing of H0015 with other codes on the same day (Behavioral Health H-Codes Per Diem Double Billing guideline change). So if you’re billing a per diem code, do not also bill the component codes separately. Choose one approach based on contracting – if you have per diem contract, use per diem only.

  • Incorrect Place of Service (POS): Make sure the place of service code on the claim matches the setting. For facility claims (UB-04 form), use correct revenue codes. For professional claims (1500 form), the POS code (e.g., 10 for telehealth home, 11 office, 52 for psych facility, 57 for non-residential substance abuse facility, etc.) should be accurate. Wrong POS can lead to denials or reduced payment.

  • Billing Under Wrong Provider: Behavioral health claims often require the correct provider NPI. If a service was by a therapist, you usually bill under that therapist’s NPI (or incident-to rules might apply in some cases). Some plans allow using facility NPI for bundled services, others require rendering provider NPIs for certain codes. Check Anthem’s billing manual specifics for your contract – e.g., an Anthem guide notes that “behavioral health services by mid-level practitioners must be billed under the supervising MD’s NPI” in some networks ([PDF] Behavioral Health Reference Guide - Providers). Ensure you follow those rules to avoid claim rejection.

  • Global or Inappropriate Codes: Anthem doesn’t accept certain “global” codes or miscoding. For instance, avoid using a generic code like 99199 or 90899 unless instructed; Anthem lists what exceptions they allow (like they listed some S-codes allowed per state (REIMBURSEMENT POLICY MEDICAL DEPARTMENT) (REIMBURSEMENT POLICY MEDICAL DEPARTMENT) and even 90899 allowed in NH (REIMBURSEMENT POLICY MEDICAL DEPARTMENT) for specific use). Using undefined codes without prior arrangement can delay processing.

  • Modifiers for Denied Services: Sometimes adding a modifier can bypass a denial for inclusive services. E.g., if therapy and E/M on same day, adding -25 on the E/M typically ensures both pay. Without it, one may deny as duplicate. So know when to apply them properly.

Billing for Peer and Non-Traditional Services: When billing peer support (H0038) or other new services, be aware payers often manually review these initially. Ensure documentation is solid – e.g., note that “Peer Specialist provided 30 minutes of recovery coaching (bill 2 units H0038)” and have the peer co-sign or sign their notes, and a licensed supervisor review if required by state. Improper billing of peer services can be a target for denial if not documented as per guidelines.

Example – Coding a Typical Patient Stay: Suppose a patient goes through detox, residential, then outpatient:

  • Detox (3 days in residential detox unit): You’d bill H0010 or H0011 for each day (depending on how contracted, say H0010 per diem). Make sure you have auth for 3 days detox and bill exactly 3 units for the 3 days.

  • Then Residential Rehab (14 days): Bill H0018 per day for days 1-14 (assuming short-term code). If patient stepped down to a lower intensity after day 10 (say moved from 3.7 to 3.1 in same facility), check if coding needs to change (H0019 might apply for extended stay if contract differentiates). Often, payers may allow continuous billing on H0018 if not specified, but best practice is to align with level intensity.

  • IOP after discharge (3 days a week for 4 weeks): Bill H0015 for each day attended. That’s 3 units per week, for 4 weeks = 12 units total (make sure within auth limits).

  • Psychiatrist med check during IOP: If a patient sees the staff psychiatrist once a week during IOP, that service might be included in facility billing or billed separately. If separate, bill 99213 with modifier 25 (since patient also had H0015 that day under facility claim, if insurer sees both, the 25 tells them it’s separate provider).

  • Drug tests: If you do weekly drug screens in-house, bill appropriate codes (e.g., presumptive test G0434 or definitive G0480) with modifier if needed (like QS for monitoring, etc. depending on contract). Ensure not to overdo frequency beyond what’s allowed (Anthem often follows Medicare limits on drug testing frequency).

All claims should be submitted timely (within filing limit, e.g., 90 or 180 days from service).

Leveraging Internal Audits: Consider doing internal audits of a few charts vs. claims each quarter to ensure what was documented supports what was billed. This can catch issues before an external audit does.

Stay Updated: Coding rules can change. For example, ASAM criteria updates might lead to coding changes, or CMS might introduce new HCPCS codes (like how G2078-G2080 were introduced for MAT in OTPs for Medicare). Keep an eye on Elevance Health provider bulletins – they often announce coding updates or policy changes. In fact, Anthem Provider News and policies will list new code additions or billing guideline changes (like the one we saw about no double billing for H-codes (Behavioral Health H-Codes Per Diem Double Billing guideline change)). By staying current, you can adjust quickly (and also seize opportunities to bill new codes that become reimbursable, such as telehealth codes, etc.).

In summary, accurate coding and meticulous billing practices are as important as providing quality care. They ensure you get paid and stay compliant. When in doubt about a code or billing procedure for Elevance, reach out to their provider claims support or refer to their published reimbursement policies. It’s better to clarify upfront than fight a denial later.

(For more detailed coding guidance, see our [Billing Code Cheat Sheet for SUD Treatment] and [Medical Billing Documentation Guidelines] – include reference to internal materials if available.)

Strategies for Overcoming Denials and Successful Appeals

Despite best practices, you may still face denials from Elevance Health for certain claims or authorization requests. How you respond can make the difference between recovering payment or losing revenue. In this final section, we focus on actionable strategies to overturn denials, including crafting effective appeals, utilizing templates, and learning from case studies of successful advocacy.

1. Act Quickly and Don’t Give Up:
 When you receive a denial (whether an authorization denial or a claim denial), note the appeal deadline and initiate the process promptly. Elevance Health usually gives the denial reason in writing (e.g., in the Explanation of Benefits or a denial letter). By law, they must also provide instructions for how to appeal. Mark the calendar for the appeal due date – internal appeals often must be filed within 60 or 180 days of the denial (How to Appeal an Insurance Denial for Rehab & Addiction Treatment), and if you need a faster turn-around (for ongoing treatment), file an expedited appeal immediately. Quick action shows urgency and also prevents missing the window.

Do not assume a denial is final. Many denials get overturned on appeal. In fact, insurance regulators encourage consumers and providers to appeal because a significant percentage of denials are reversed upon further review. For example, data has shown that external appeals can overturn insurer decisions a good portion of the time, especially for behavioral health treatment where parity laws apply. Persistence is key: if your first appeal is denied, escalate to the next level (or external review if available).

2. Gather Additional Supporting Evidence:
 A strong appeal often requires more than what was initially submitted. Think about what might sway the reviewer:

  • Physician’s Letter of Medical Necessity: Have the treating physician or clinical director write a focused letter explaining why the treatment was necessary. For instance, if a residential stay was denied as not needed, the doctor’s letter can emphasize specific risks (e.g., “In my medical opinion, discharging John Doe at that time would likely have led to life-threatening relapse given his condition. Thus, the continued residential care was medically necessary to stabilize his sobriety.”). Attach this to the appeal (How to Appeal an Insurance Denial for Rehab & Addiction Treatment).

  • Patient’s Progress and Current Status: If applicable, include a brief summary of how the patient benefited from the service. E.g., “After the additional 7 days of treatment in question, patient’s withdrawal symptoms resolved and he developed a solid aftercare plan – outcomes that likely prevented a hospitalization.” This can show that the treatment was effective and thus worth covering.

  • Reference Clinical Guidelines: It can help to cite ASAM criteria or other guidelines directly, especially if you believe the reviewer misapplied them. For example, quote the ASAM Criteria book about the needed duration of treatment or the criteria point the patient met. If you have access to Elevance’s own medical policy (some are published online), reference that. If the denial contradicts their published policy, call it out.

  • Include Denial Letter and Relevant Records: Always attach the denial notice (so the appeal reviewer can see the reason) (How to Appeal an Insurance Denial for Rehab & Addiction Treatment) and any clinical records that counter the denial rationale. If they said “no evidence of withdrawal symptoms after Day 3,” include your nursing notes from Day 4-5 showing mild withdrawal signs persisted.

3. Use Appeal Templates and Checklists:
 Writing an appeal from scratch every time is inefficient. Develop an internal template for appeal letters, or use those provided by consumer assistance programs. The NAIC template mentioned in rehab.com’s guide is a good framework (How to Appeal an Insurance Denial for Rehab & Addiction Treatment). It will have sections for the who/what/when of the denial, a spot to explain why the decision is wrong, and a closing statement with requested action (approval/payment). Make sure to personalize it with patient specifics and remove any template placeholders.

Check that your appeal letter contains all key elements:

  • Member info (name, ID, DOB), claim or auth number, dates of service.

  • Statement that you are appealing and whether this is first level, second level, etc.

  • Reason for denial (quote from denial letter).

  • Clear rebuttal: “We believe this decision should be overturned because…”

  • Supporting points (as bullet or numbered list ideally, each with evidence).

  • Reference to attachments: “Attached you will find: Dr. Smith’s letter, Progress notes from 10/1-10/5, ASAM criteria excerpt…”

  • A polite but firm closing: request that they reconsider and approve coverage for the service, and provide contact info for any questions.

  • If patient is appealing, ensure the letter is signed by patient or their representative (or include a designation of representation if you, the provider, are filing on patient’s behalf – some insurers require a simple form for that).

4. Highlight Parity and Legal Rights if Relevant:
 If the service denied is a mental health/substance use service, remind Elevance of their obligations under the Mental Health Parity and Addiction Equity Act. Without being adversarial, you can state: “Under federal parity law, coverage limitations for substance use disorder must be comparable to those for medical/surgical care. The level of review being applied to this case appears more stringent than what is applied to analogous medical hospitalizations, and we urge you to consider the parity implications in this denial.” This signals that you’re aware of the law. If a state law (like New York’s law requiring coverage of medically necessary SUD treatment and rapid external appeals (Plan Appeals)) applies, mention that too. Sometimes just referencing these can make the insurer more cautious in upholding a denial.

5. Escalate through Right Channels:
 For complicated or urgent cases, use any available escalation path:

  • Peer-to-Peer Discussions: As noted, if an auth is denied, schedule a peer-to-peer with the medical director. Prepare talking points for the call – often you get 15-30 minutes to make your case. Be respectful of the reviewer’s perspective (they may have guidelines to follow), but emphasize unique factors of the case.

  • Provider Relations: If you keep hitting a wall, sometimes involving your provider relations representative can help. They might not overturn a clinical denial, but they can ensure that your appeal is being handled properly or get clarification on what info is needed.

  • State Consumer Assistance/Regulators: If an appeal is going poorly, the patient or you (with patient’s consent) can contact your state’s Department of Insurance or any Consumer Assistance Program. Some states will actually call the insurer on your behalf or guide you in the process. Washington OIC’s site (as an example) provides help to consumers for appeals (Common reasons for a denial and examples of appeal letters). Knowing this backstop exists can sometimes prompt insurers to be more reasonable internally.

6. Learn from Case Studies:
 Look at scenarios where appeals were successful to model your approach:

  • Case Study A – Peer Support Denial: A Medicaid plan denied payment for peer support services saying “not covered service.” The provider appealed, citing the state Medicaid manual where peer support was a covered benefit and noting that Anthem’s own policy allowed S9475 for peer support in opioid treatment in that region (REIMBURSEMENT POLICY MEDICAL DEPARTMENT). They included documentation of the peer support sessions and how it contributed to the patient’s engagement. The plan reversed the denial, acknowledging a processing error.

  • Case Study B – Continued Residential Days: As mentioned before, a facility got additional days approved on appeal by demonstrating that the patient’s condition still met inpatient criteria. Key in their appeal was providing daily progress notes and a letter from the clinical director explaining what could have gone wrong if the patient was discharged early. This realigned the insurer’s view and led to an overturned denial.

  • Case Study C – Coding Denial (Technical): A claim for IOP was denied because it was billed on a UB-04 with no revenue code. The billing team realized the error, corrected the claim with the appropriate revenue code (0906 for IOP (Attachment E_Substance Abuse Encounter Rpting_HCPCS and Revenue Codes Chart FY09.xls)) and resubmitted within the corrected claims/appeal timeframe, including a brief note explaining the correction. Payment was then issued. Lesson: some “denials” are really coding mistakes – fix and resubmit with explanation.

7. Use Data in Appeals (if available): If your facility tracks outcomes or patient satisfaction, you might include that in an appeal for a denial that claims “treatment not necessary.” For example, “We have treated 50 patients with similar profiles in the past year and find that those completing 4 weeks of residential care have a 80% sobriety rate at 60 days versus 50% for those who left after 2 weeks. This patient was given the full course of treatment to maximize success, and cutting it short would likely have put them in the poorer outcome group. Thus, it was in the best interest of the patient’s health (and cost-effective in the long run) to cover the additional treatment.” – This kind of argument, with data, can appeal to the medical and financial logic of the insurer.

8. Template for Appeal Letter (general outline):

[Your Organization’s Letterhead]
 Date:
 To: Elevance Health/Anthem Appeals Department (include address/fax or portal submission details)
Re: Appeal of Denial for [Service] for [Patient Name, ID]
Denial Reference: [Authorization/Claim number, date of denial letter]

Dear Appeals Reviewer,
 I am writing on behalf of [Patient Name, ID#, DOB] and [Provider/Facility Name, TIN/NPI] to appeal the denial of coverage for [specific service and dates]. The denial was issued on [date] with the reason “[quote the denial reason].” We respectfully request a reconsideration of this decision.

Patient Background: [Brief one-liner: e.g., Patient is a 32-year-old with severe alcohol use disorder and depression, who was admitted for inpatient treatment from X to Y.]

Medical Necessity and Rationale for Coverage:

  1. Meets Criteria: The patient met the ASAM Criteria for this level of care. Specifically, [explain which dimensions were pertinent – e.g., Dimension 1 withdrawal risk was high as patient had prior seizures; Dimension 3 emotional state was poor with suicidal ideation]. According to ASAM guidelines (see attached excerpt/page), this justified inpatient care.

  2. Improvement noted but continued care required: At the time of denial (or for the dates denied), the patient still needed ongoing treatment. [Detail evidence – e.g., “On Day 7, patient still had cravings rated 8/10 and no stable housing, indicating continued high relapse potential (Dimension 5 & 6).”] Discharging at that point would have been against medical advice of treatment team and likely led to relapse or harm.

  3. Outcomes/Benefit: Because the patient received the full course, [he/she] was able to achieve [outcome]. This demonstrates the medical necessity and effectiveness of the care that was provided.

  4. Parity Consideration: This treatment is consistent with nationally accepted standards for SUD care and should be covered comparably to analogous medical treatments. (For example, detox and rehab for substance use is analogous to a step-down ICU to acute care for a medical condition – both require gradual step-down as medically indicated). It would be a parity violation to limit coverage when criteria are met for continued care.

Attachments: We have included the following documentation in support of this appeal:

  • Letter from Dr. [Name] (Attending Physician) detailing the medical necessity of the treatment.

  • Treatment plan and daily progress notes from [dates] showing patient’s condition and response.

  • ASAM Criteria reference highlighting the patient’s needs at that level.

  • Copy of denial letter.

We believe this information clearly demonstrates that [the service] was medically necessary and appropriate. We urge you to overturn the denial and approve coverage for [service] so that [Patient Name]’s treatment is fully covered as per their policy.

Please contact us at [phone] or [email] if you require any further information. We appreciate your prompt attention to this appeal and are available for a peer-to-peer discussion if needed.

Sincerely,
 [Name and Title]
[Provider/Facility Name]
[Contact Information]

(Enclosures)

Using a structured letter like this hits all the points. Adjust tone and content for expedited vs routine appeals (expedited should emphasize urgency and risk of harm if not resolved quickly).

9. Follow Through: After submitting an appeal, follow up if you don’t get a confirmation or response within the expected timeframe. Elevance must adhere to regulated timeframes (30 days for pre-service appeals, 60 for post-service, etc., unless extended with notice) (How to Appeal an Insurance Denial for Rehab & Addiction Treatment). If those lapse, escalate or consider filing a complaint with regulators. Documenting each step protects the patient’s rights and your financial interest.

10. Continuous Improvement: Win or lose, gather your team after major appeals to debrief. If you lost, what could be done differently next time? If you won, celebrate and share that knowledge (perhaps anonymized) with staff to reinforce the importance of good documentation and persistence. Over time, you’ll refine an arsenal of strategies that work best with Elevance Health.

By mastering the art of appeals and denial management, your facility can significantly improve its reimbursement outcomes. Appeals are a normal part of the revenue cycle in behavioral health – do not be discouraged by them. Instead, see them as an opportunity to advocate for your patients and ensure they receive the coverage they are entitled to under their plan. With thorough preparation and leveraging the strategies outlined above, you can turn many “no”s into “yes”s, maintaining financial stability for your program and uninterrupted care for your clients.

Conclusion:
 Handling Elevance Health’s addiction treatment coverage requirements may seem daunting, but with knowledge and preparation, providers can navigate it successfully. From the first phone call to verify benefits, through meticulous documentation for authorizations, to the final claims submission and any necessary appeals – each step is an opportunity to secure the coverage your patients need and the reimbursement your facility deserves. By implementing the best practices detailed in this guide – aligning with ASAM criteria, adhering to authorization protocols, ensuring clean claims coding, and tenaciously following up on denials – treatment centers can build a robust insurance workflow. This not only improves financial outcomes but also strengthens relationships with payers like Elevance Health. Ultimately, the goal is shared: enabling individuals to access effective addiction treatment. With fewer administrative hurdles and clearer understanding of Elevance’s processes, you and your team can focus more on patient care and less on paperwork, knowing that the coverage side is under control.

For further reading and resources, providers are encouraged to consult Elevance Health’s provider manuals and policy updates (always reference the latest versions for any changes in procedures  ). Additionally, internal training modules on utilization review and billing can reinforce these concepts for new staff. By staying informed and proactive, your facility can excel in delivering quality care within the framework of Elevance Health’s coverage policies.