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The entire process happens under one workflow. We identify the need for authorization by conducting eligibility verification. We prepare the clinical packet, submit to the appropriate UM entity, and monitor the decision clock. We renew the authorization before your units or days expire. This is what we call behavioral health prior authorization services, with a specific focus on testing, TMS, ABA, and levels of care that are beyond the outpatient level.
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The CMS accelerated decision time frame for affected payers since 2026
The regular decision time frame, compared to 14 days before the new regulation
The denial that no authorization is needed because of this service
Optum, Carelon, Evernorth, Magellan, and Lucet process most of BH authorizations
Authorization of services involves obtaining payer approval before offering a particular service. This is especially the case in behavioral health where the authorized services include testing hours, TMS classes, ABA programs, and other higher levels of care. It includes services from submission to documentation of medical necessity, status check, peer to peer coordination, and renewal of services. All three terms refer to the same process.
These vary according to the payer, but the process remains the same. An authorization has a number and a unit/session number. There is also the date range and the specific CPT code range. The provider from the claim should correspond to the one from the authorization. Get even one wrong and a seemingly paid procedure ends up a denial. Here we are dealing with requests in this process. Checking whether there is an authorization is within insurance eligibility verification.
The behavioral health preauthorization process does not follow the same process as medical preauthorization. First, the request is directed to an independent company and not the plan listed on the card. Authorization is done in terms of units and treatment days and not open-ended. High levels of care must be reviewed during treatment.
Most for-profit plans will split off behavioral health into a separate benefits manager. The card will say Cigna, Anthem, or UnitedHealthcare. The authorization request will be sent to Evernorth, Carelon, or Optum. A perfectly constructed request sent to the medical plan will automatically be denied. We will confirm the carve-out and the portal before submitting anything.
Medical authorizations typically go through in one decision. Authorizations for behavioral health allow testing hours, ABA units, or a range of days. A therapist could receive 6-12 visits whereas a medical expert receives 6 months. Going over the allowed units without an extension leads to a CARC 198 denial. We count the units up until the ceiling.
IOP, PHP, or residential treatment is not granted only once and then forgotten. Payer performs a concurrent review based on ASAM criteria for substance abuse or LOCUS criteria for mental health conditions. Some residential stays are reviewed by Carelon every 3 to 7 days. A failure to perform a concurrent review is not usually appealable, thus making the day non-payable. We schedule every deadline of a concurrent review with an owner.
A plan may not authorize therapy in a stricter manner than it authorizes equivalent medical services. It is a non-quantitative treatment limitation under MHPAEA. It is represented in standard therapy subject to a review while a medical service will not undergo any such thing.
In the field of behavioral health, the most frequent error that leads to authorization failure is not documentation. This is incorrect routing of the request. The very first step dictates further actions.
These steps go through five phases, and at every step there is a risk of failure. From detection to eligibility, from eligibility to clinical packet preparation, from clinical packet to request routing to the right reviewer, from review request to its deadline monitoring, and from current authorization deadline to renewal request – we handle them all.
Eligibility verification checks whether the service will require authorization. The handoff triggers the process.
We prepare the clinical data on the diagnosis, severity score, failed trials record, and treatment plan as requested by the payer.
We submit the request to the correct UM entity by using portals, APIs, or faxes, but never by default to the plan listed on the card.
We monitor the decision deadline and escalate once the payer has passed it.
We calendar the renewal before the units or time frame have expired.
Insurance eligibility verification is responsible for detecting and marking the 270/271 transaction where the need for authorization is highlighted. All steps beyond detection take place from here onwards. The retrospective authorization route is an exception route and not a rule. In case services are availed prior to authorization, some payers permit a retrospective request in a limited time period. These periods are small and payer specific, which is why we submit as soon as this gap is detected.
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Your clinicians handle the clinical part. We do the rest in your existing portals.
Authorization for behavioral health depends on where the units and the money are. Testing gets authorized based on hours. TMS gets authorized as a course. ABA gets authorized based on a signed treatment plan. Level of care increases, more billing per block of days. Regular psychotherapy typically does not require authorization at all. Rules apply for each line below.
Universal authorization. The insurance company expects documented unsuccessful attempts at antidepressant therapy, generally 2 to 4 times. They expect standardized scoring of severity, for example, the PHQ-9 test. The authorization is based on course, with a defined number of sessions.
Authorization is done based on hours and not visits. The insurance company authorizes the block of hours, which gets billed as an initial hour and each additional hour after that. Overutilization without extending the authorization results in CARC 198 denial. The diagnosis should match the testing.
Authorization takes two parts. The assessment is the first authorization, using 97151. The second is the treatment plan, which has to be signed by a BCBA. Reauthorizations are usually done every six months. There is a unique unit limit for each code.
It must be given at a REMS-certified facility. Payers require treatment-resistant depression. The in-office observation time is covered as part of the service, not a separate visit. For Medicare, the medication and service are bundled together in their own codes, separate from commercial payers.
For most significant private payors, no preauthorization is required in parity for these. There are exceptions, such as Medicaid MCOs or EAP conversions. Authorization that is applied more restrictively to routine treatment compared to medical care is a parity violation.
An initial authorization starts the stay. Then, the concurrent review based on ASAM or LOCUS will keep it open. The days are authorized in groups rather than one lump sum. Any concurrent review that happens late means there will be non-paid days, and almost never reversed on appeal.
The CMS 2026 decision-making clock only starts on a complete submission. No incomplete submission starts the clock ever. An in-house team that spans intake and billing never gets a timeline. Outsourcing shifts the administration of the process to a specialized team. The clinical decision remains with your clinicians where it belongs.
Your clinicians make the decision about the treatment and provide justification for the medical necessity of the procedure. Your clinicians represent your practice in the peer-to-peer review. None of the information related to your treatment plan leaves your practice. We handle the paperwork according to your clinicians' decision, not instead of it.
We create and submit the packet, deliver it to the right reviewer and monitor the clock. We schedule peer-to-peer reviews and mark all renewals in the calendar. We work as a US-based team in your system, not an overseas queue.
Authorization coordinator is a full-time cost regardless of the volume. Per-authorization cost depends on the workload directly. The numbers look different when one failed renewal or routing of the authorization letter wastes a whole week of high-level treatments.
Our system works right where your existing EHR and payer portal systems are now. No new technology training and no data migrations. Front office maintains its process workflow and the authorization process is separated from it.
Starting from January 1, 2026, the CMS-0057-F rule imposes hard-decision deadlines. Impacted payers will have to render an expedited request decision within 72 hours and the standard request decision within seven calendar days. They need to provide a specific rationale for any denied request. The rule includes both Medicare Advantage and Medicaid, but has imposed the deadlines sooner. Complete and properly routed requests is how you can utilize it.
The CMS rule imposes requirements to Medicare Advantage, Medicaid and CHIP fee-for-service, and Medicaid and CHIP managed care plans. The decision-timeline requirement does not include QHP issuers on the federal exchanges. The drug authorization process is not impacted by the rule at all. Other commercial plans not included under this rule are regulated under the state authorization law.
Standard decisions moved from 14 days to seven calendar days. Expedited decisions are made in 72 hours. The catch is the clock itself. Clock runs once the submission is complete, so an incomplete submission will make the deadline meaningless. This is why completeness of the initial submission is crucial.
All denials now have a specific reason stated. That specific reason must come irrespective of the medium in which the decision was made – portal, fax or phone call. The specific reason ensures the resubmission is targeted. First public metrics of payer authorizations are due on March 31, 2026.
There are two denial codes related to authorization issues. One is CARC 197, which indicates that a service is charged without any authorization existing for the charge. The second one is CARC 198, which indicates a service being done beyond authorized units. Both denials are preventable prior to claim submission. We perform the prevention at submission, tracking and renewal stages.
Peer-to-peer review is the step before a denial becomes final. We coordinate this step and prepare our clinician with the medical record and payer criteria to present his/her clinical case. This conversation usually avoids denial of the claim before affecting any services. Once the denial is issued in the claim, denial management and appeals take care of the post-claim denial recovery.
We process behavioral health authorizations for all 50 states. The federal authorization deadlines apply nationwide. But the authorization process is not the same everywhere. Each state has authorization requirements for commercial insurance aside from CMS regulations. And Medicaid authorizations vary state to state. Here, each of the states listed has its own unique authorization process.
| State | Prior Authorization Services |
|---|---|
|
California |
Medi-Cal processes behavioral health authorizations through different county plans, each one with its own portal. State law determines turn-around time for commercial plans. |
|
Texas |
HB 3459 gold cards providers that receive 90% authorization success rate. STAR MCOs have their own review process. |
|
New York |
Behavioral authorizations fall under Medicaid managed care and HARP plans in New York. The authorization assistance search demand is reflected here. |
|
Florida |
MMA Medicaid plan performs authorization along with a large Medicare Advantage population based on CMS timeline requirements. |
|
Georgia |
Each Georgia Families CMO has its own authorization process. Carve out process determines who processes the authorization request. |
|
Tennessee |
TennCare operates on managed care only and therefore all authorizations go to an MCO. Authorizations portals vary from one plan to another. |
|
Arizona |
Behavioral health services in Arizona get provided by AHCCCS through its RBHA structure. Authorization gets directed to the respective regional plan. |
|
New Hampshire |
Behavioral authorization rules are defined by Medicaid managed care. |
|
Mississippi |
Medicaid coordinated care organizations handle behavioral authorization. Each behavioral request is routed according to carve-out routing. |
|
Washington |
The Apple Health Integrated Managed Care handles behavioral authorization. Commercial turnaround is regulated by state statute. |
|
New Jersey |
NJ FamilyCare MCOs conduct behavioral authorization. Decision window for commercial plans outside CMS jurisdiction is determined by state statute. |
|
Illinois |
HealthChoice Illinois MCOs handle the Medicaid authorizations. Carve-outs have different routes depending on the plans covering the member. |
|
Pennsylvania |
Each HealthChoices regional behavioral MCO conducts behavioral authorization. The carve-out zone is responsible for identifying the entity to review. |
|
Massachusetts |
The MassHealth plans conduct behavioral authorization. Strong parity enforcement underlies session limits challenge. |
|
Virginia |
Cardinal Care MCOs handle Medicaid authorization according to the CMS deadlines that were effective from 2026. |
|
Colorado |
Regional Accountable Entities handle behavioral authorizations. The commercial turnaround is governed by state law outside of CMS rule. |
|
North Carolina |
North Carolina Medicaid carved out behavioral health into Tailored Plans. Authorization goes to the plan covering the member. |
Prior Authorization is centered around the more costly treatments. TMS, psychological and neuropsychological testing, ABA, Spravato, and all levels of care above outpatient typically require it. Outpatient psychotherapy does not, usually post-parity for commercial payers. There are a few exceptions among Medicaid MCOs and EAP plans that we check by payer.
As of January 1, 2026, impacted payers have to make a decision on expedited requests within 72 hours and a standard request within seven days. The clock does not start until there is a complete application. The plans not subject to the CMS requirement follow their state turnaround times, which differ by state.
Other payers have a policy for a retro authorization during a time frame after service. The time frames are very brief and payer specific. There is never any guarantee of an approval. The retro authorization process is just a secondary route, but it's not meant as a replacement for getting authorization ahead of time. We submit the retro authorization once we find out there is an issue.
The peer-to-peer review is a discussion between the clinician working with us and the payer's reviewer discussing the medical necessity. We arrange this discussion and brief the clinician with documentation and payer criteria. This usually changes the decision of denying the service.
Absolutely. We process claims within the TherapyNotes, SimplePractice, Valant, and other platforms used by behavioral health practices. We file and monitor through your payers' portals. There is no need for migration or an additional portal for your team to learn.
Doing in-house authorizations is a flat salary rate for a coordinator versus a number of authorizations that fluctuates. Outsourcing authorization involves payment per each authorization done, so the pricing matches the actual effort. It changes the comparison even more because one incorrectly routed or unsubmitted request may nullify a whole week of expensive consultations.
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The authorization process is one part of the revenue cycle. Please send us your current authorization queue and payer mix, and we will show you where your requests are going awry or getting hung up
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