Insurance Billing Guidelines

The purpose of these Insurance Billing Procedures is to establish a consistent process for submitting, monitoring, and reconciling insurance claims in order to support accurate reimbursement, maintain compliance with payer requirements, and promote sound financial stewardship.

Insurance billing procedures are documented and followed to ensure accuracy, accountability, and timely revenue cycle management. The following processes apply to all insurance claims.

1. Claim Submission Workflow

  • Client insurance eligibility and benefits are verified prior to the first session and rechecked periodically throughout the course of treatment.
  • All required intake documents, consent forms, and financial agreements must be completed before claims are submitted.
  • The clinician documents each session in the electronic health record within the required timeframe.
  • Billing staff review documentation for completeness, accuracy, and appropriate coding, including CPT codes.
  • Claims are submitted electronically through the designated billing platform to the applicable insurance payer.
  • Submission reports are reviewed to confirm successful claim transmission.


2. Denial Management

  • Denied or rejected claims are reviewed within the normal billing cycle.
  • The reason for denial is identified, such as eligibility issues, coding errors, or missing authorization.
  • Billing staff correct and resubmit claims when appropriate.
  • When additional documentation is needed, the clinician is notified and asked to provide the required information promptly.


3. Appeals Process

  • When a claim remains denied after correction or reconsideration, an appeal may be initiated.
  • Billing staff compile all supporting documentation, which may include clinical notes, treatment plans, and authorization records.
  • A formal appeal letter and all required documentation are submitted within the payer’s appeal deadline.
  • Appeals are tracked until a final determination is received.


4. Explanation of Benefits Reconciliation

  • Explanations of Benefits and Electronic Remittance Advices are reviewed upon receipt.
  • Payments are posted to the client account in the billing system.
  • Contractual adjustments are applied in accordance with payer agreements.
  • Any remaining client responsibility, including copayments, coinsurance, or deductibles, is billed in accordance with the Center’s billing policy.
  • Any discrepancies between expected and received payment amounts are investigated and resolved.

These procedures support accurate claims processing, timely reimbursement, and compliance with applicable payer standards.