Implementation 13 min read

RCM Denial Prevention Playbook: Behavioral Health and Primary Care

Denials are mostly process failures that show up as payer responses. This playbook organizes interventions across scheduling, documentation, coding, and claims submission for two high-volume segments: behavioral health and primary care.

Core Denial Categories to Track Weekly

  • Eligibility and coverage failures
  • Authorization and referral defects
  • Coding mismatch and modifier errors
  • Documentation insufficiency
  • Timely filing misses

Behavioral Health Workflow Controls

  • Pre-visit authorization queue with level-of-care and service-limit checks.
  • Structured session-note templates aligned to payer medical-necessity criteria.
  • Group therapy attendance and rendering-provider validation before claim release.
  • 42 CFR Part 2 consent status checks embedded into documentation and release workflows.

Primary Care Workflow Controls

  • Real-time eligibility and PCP attribution verification at scheduling and check-in.
  • Automated preventive-service coding prompts by payer and plan rules.
  • Lab and imaging order documentation completeness checks before claim finalization.
  • Claim scrubber rules for modifier and diagnosis-pointer consistency.

Denial Analytics Operating Rhythm

  1. Daily: work denied-claim queue by financial impact and filing deadline.
  2. Weekly: publish denial reason trends by payer, CPT, provider, and location.
  3. Monthly: update front-end scripting and templates based on top preventable reasons.

90-Day Reduction Plan

  1. Month 1: baseline denial rate and top five root causes by specialty.
  2. Month 2: deploy workflow edits in one BH and one primary-care pilot team.
  3. Month 3: scale changes and tie dashboard goals to manager accountability.

For broader financial planning, pair this with the EHR cost guide and implementation checklist.

Frequently Asked Questions

Which denial categories should be tracked weekly?

Track eligibility, authorization/referral, coding/modifier mismatch, documentation insufficiency, and timely filing misses at minimum.

How does denial prevention differ for behavioral health?

Behavioral health workflows require stronger level-of-care, authorization, and note-structure controls tied to payer medical-necessity rules.

What is the fastest way to reduce avoidable denials?

Run weekly root-cause analytics and immediately feed top findings into front-office scripts, template rules, and claim-scrubber updates.

Editorial Standards

Last reviewed:

Methodology

  • Mapped denial root-cause categories to front-office, clinical, and billing workflow controls.
  • Separated behavioral health and primary-care interventions where payer rules diverge.
  • Prioritized controls that can be measured through EHR and claims-system data outputs.

Primary Sources