Behavioral Health & SUD
Behavioral health claims, checked before they deny.
Community behavioral health and SUD billing runs on Medicaid MCO rules, authorizations that run out, and denials that trace back to enrollment and coverage lapses. ClaimYours AI prices every line with the published Ohio Medicaid fee schedule you confirm and checks the Ohio behavioral health rules before the claim goes out. Each check names the rule it comes from.
How behavioral health billing works in Ohio
Community behavioral health and SUD services are paid by Ohio Medicaid, mostly through managed care plans, under the rules ODM publishes in its Behavioral Health Provider Manual.
Managed care plans
Most Ohio Medicaid members are enrolled in a managed care plan (MCO). Each plan pays its own claims under ODM’s rules, and each can have its own authorization steps and filing window.
OhioRISE
Youth with complex behavioral health needs may be enrolled in OhioRISE, a specialized plan for their behavioral health services.
Codes and modifiers
Services go out on the professional claim (837P) with CPT and HCPCS codes, modifiers for the practitioner and how the service was delivered, and a place of service.
The fee schedule
ODM publishes the behavioral health rates in OAC 5160-27-03. MCO contracts can pay those rates or rates you negotiated.
42 CFR Part 2
Federal rules limit what can be shared from SUD treatment records without the patient’s written consent, including in records sent to a payer.
Provider enrollment
Every rendering practitioner has to be enrolled with Ohio Medicaid and in good standing on the date of service.
Where the money goes missing
- Authorizations that run out partway through treatment
- Telehealth billed with the wrong modifier or place of service
- A practitioner whose enrollment lapsed before the visit
- Medicaid billed before the primary insurance has answered
- Lines paid below your MCO contract or the fee schedule
Where ClaimYours AI fits
ClaimYours AI checks every claim against the Ohio behavioral health rules before it goes out, compares each paid line with your contract or the ODM fee schedule, and holds SUD records for consent.
The claims engine works for behavioral health now
Upload or connect your claims, remittances and MCO contracts. Every line is compared, expected versus paid, and every fix waits for a person on your team.
Connect
Upload or connect your claims, remittances and payer contracts. Works from the files your clearinghouse and EHR already produce (837, 835, 999, 277CA); direct connections are set up and tested with each practice and vendor.
Compare
Every line checked: expected vs paid, against your contract or your payer’s real history.
Propose
We draft the fix, the appeal, or the records packet, with the reason and the source.
Approve
One inbox. One click. Tracked until the money lands.
Built for how you bill
Each item is marked as available now, in build, or coming next. We do not describe a feature as live until it is.
Paid below your contract
Each paid line is compared with your MCO contract rate, or with what that payer has really paid you, and the difference is traced to the claim line and the contract line.
Denials sorted by reason
Every denial is placed in one bucket from its reason code: underpaid, denied, timely filing, authorization missing, eligibility, bundled, duplicate or records requested.
Authorization tracking
Authorizations on file show units or visits authorized, used and remaining, with a view of the ones about to expire.
42 CFR Part 2 consent check
A substance use disorder record is held back from any records packet until a consent reference is recorded. Nothing goes out without it.
Appeals and records packets
Appeal letters and records packets are drafted with the reason and the source. A person approves each one before anything is sent.
Filing clock per payer
Set each MCO’s filing window once and see the days left on every claim.
Provider status on the date of service
Each claim’s rendering provider is checked against your roster. An NPI deactivated before the date of service, a confirmed exclusion or a payment suspension holds the claim; a possible match waits for a person.
Medicaid billed last
A claim that bills Medicaid as the secondary payer is held until the primary payer’s answer is on file.
Ohio Medicaid BH fee schedule
The published ODM rates (OAC 5160-27-03), with office and community rates and the half rate past 90 minutes a day. You pick the payers that pay it and confirm the rates before they are used.
Ohio behavioral health checks
Telehealth needs the GT modifier and never POS 02; SUD assessments twice a year without authorization; licensed SUD group minimum units; MCO authorization thresholds from July 2026.
OhioRISE rules
Youth services under OhioRISE, including IHBT and its authorization windows.
Coverage-lapse denials
Denials that trace to a member’s coverage lapse, caught before the claim goes out.
How a behavioral health claim moves
Five steps. The last decision is always a person’s.
Step 1: Upload
Claims, 835 remittances and MCO contracts land in your workspace.
Step 2: Compare
Expected versus paid on every line, with the source.
Step 3: Hold for consent
SUD records wait for a Part 2 consent reference before any packet.
Step 4: Propose
The fix, the appeal or the records packet is drafted for you.
Step 5: Approve
A person approves. Paid lines reconcile against the next remittance.
Honest status
Available today
- Expected-versus-paid against your contracts or payer history
- Denial sorting by reason code
- Authorization tracking with expiring view
- 42 CFR Part 2 consent check on records packets
- Appeal letters and records packets for approval
- Per-payer filing clock
- Provider status on the date of service
- Medicaid billed after the primary payer
- The Ohio Medicaid BH fee schedule, confirmed by you
- Telehealth, assessment, group-minimum and MCO threshold checks
Still to come
- OhioRISE youth services rules
- Detection of denials that treat behavioral health differently from physical health
- Member coverage-lapse checks before submission
Everything marked Available works today, and every check cites the Ohio rule or ODM manual page it comes from. Rates whose amount depends on who rendered the service in a way the claim cannot show are left out rather than guessed. The items still to come are not built yet, and we will not describe them as live until they are.
Built for Ohio community behavioral health
Community mental health agencies
Agencies billing Ohio Medicaid MCOs for counseling, CPST and psychiatric services, with authorizations to keep straight.
SUD and recovery providers
Programs where 42 CFR Part 2 consent has to be right before a single record leaves the building.
Billing teams for BH practices
Billers who need every denial sorted by reason and every appeal drafted with its source.
Questions behavioral health providers ask.
Can we use it for behavioral health today?
Yes. Upload your claims and remittances, confirm the ODM fee schedule for the plans that pay it, and every claim is checked against the Ohio behavioral health rules before it goes out.
How do you handle 42 CFR Part 2?
A substance use disorder record is held back from any records packet until a consent reference is recorded. Nothing is sent without a person approving it.
Can I try it with behavioral health claims?
Yes. The behavioral health sandbox loads synthetic claims and remittances, runs them through the engine and gives you sample 837P and 835 files to upload. No real patient information.
Do you submit claims for us?
No. Everything is staged for a person on your team to approve and submit through your own route.
Where do the rules come from?
The ODM Behavioral Health Provider Manual, the Ohio Administrative Code and ODM’s published guidance. Each check names its source, and for a new practice each one waits in the Work Inbox until you confirm it.
Tell us what your MCOs deny most.
Behavioral health providers on the early list get a walkthrough of what works today and first access as each Ohio rule set is released.
Three problems every billing office knows
Claims sit denied for weeks
A denial shows up days after you submit, then waits in a queue until someone has time to work out why.
Nobody knows which rule failed
A denial code tells you something is wrong. It rarely tells you which rule, or what to change.
Adjustments never get filed
Short pays and underbilling are easy to miss, and easy to put off until the window closes.
Made around the systems behavioral health providers actually use
Community behavioral health and SUD billing runs on ODM rules and Medicaid MCOs. Every check names the Ohio rule or ODM manual page it comes from.
ODM
The ODM Behavioral Health Provider Manual, the Ohio Administrative Code and ODM’s published guidance.
BH fee schedule
The published ODM rates (OAC 5160-27-03), with office and community rates. You confirm them before they are used.
Medicaid MCOs
MCO authorization thresholds, each plan’s filing window, and every paid line against your MCO contract rate.
42 CFR Part 2
A substance use disorder record is held back from any records packet until a consent reference is recorded.
Provider roster
Each rendering provider checked on the date of service: a deactivated NPI, an exclusion or a payment suspension holds the claim.
837P and 835
Claims and remittances in the standard formats, compared line by line, expected versus paid.
Patient data stays inside the platform
From sign-up to your first checked claim
Sign up
Create an account, or start with the demo to see the platform first.
Approved
A person at ClaimYours AI reviews and approves your account.
BAA accepted
Your practice accepts the Business Associate Agreement inside the platform.
Upload & check
Upload claims inside your account and see every result with its source.
See how every claim gets checked.
Try the demo yourself, or ask for a walkthrough. No patient information needed.