Washington behavioral health billing for Apple Health, commercial plans and Medicare

Our behavioral health billing service is built for Washington outpatient clinics, private practices, IOP, PHP, MAT, residential and detox programs. We handle claims, authorizations, denials and payer follow up for commercial plans, Medicare and Apple Health managed care plans.

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What makes Washington billing different

The rules that decide whether a Washington claim pays the first time.

Apple Health pays through MCO networksMost Apple Health clients are enrolled in a managed care plan and must see providers in that plan's network unless care is prior authorized or urgent. Coordinated Care, CHPW, Molina and Wellpoint serve every region, and UnitedHealthcare Community Plan serves six western regions. ProviderOne enrollment with HCA does not put you in any MCO network.

Filing limits differ by payerAn Apple Health fee-for-service claim generally must receive a transaction control number within 365 days of service, and it cannot be resubmitted or adjusted after 24 months, under WAC 182-502-0150. MCO filing limits are set by contract and are often shorter. Check each plan's provider manual.

No prior authorization for residential SUD on state-regulated plansOn state-regulated commercial plans (not self-funded ERISA plans), RCW 48.43.761 bars prior authorization for withdrawal management and for inpatient or residential SUD treatment. Review cannot start until at least two business days into the stay, or three days into withdrawal management. Plans issued or renewed since January 1, 2025 must also give an initial authorization of at least 14 days.

H0015 does not pay in WashingtonWashington's Apple Health SUD fee-for-service billing guide, effective July 1, 2026, does not list H0015. The guide bills SUD IOP as itemized codes such as H0004 and 96164 to 96171 with the HF modifier. Mental health IOP is billed as S9480 with the HK modifier, only by behavioral health agencies under taxonomy 251S00000X.

Payers we bill in Washington

Public and commercial payers, and what matters for behavioral health claims with each.

Apple Health fee-for-service (HCA, ProviderOne)For clients without a managed care plan, such as American Indian or Alaska Native clients who choose fee-for-service. Claims generally need a transaction control number within 365 days of service.

Coordinated Care, CHPW, Molina and WellpointApple Health MCOs in every region. Each credentials and contracts separately, credentialing can take up to 90 days, and billing starts only after the contract is fully executed.

UnitedHealthcare Community PlanApple Health MCO in North Sound, King, Pierce, Thurston-Mason, Salish and Great Rivers only.

Behavioral health administrative services organizations (BH-ASOs)Administer crisis services separately from the MCOs.

Premera Blue CrossManages behavioral health in-house and requires prior authorization for PHP. From November 16, 2026, policy 3.01.521 adds evaluations at least every 7 to 10 days during PHP.

RegenceManages behavioral health in-house. PHP and IOP need prior authorization within 7 calendar days of the start, and practitioner credentialing has run through CAQH since June 15, 2026.

Providence Health Plan (southwest Washington)Will not offer new commercial plans in 2027, and provider contracts do not change in 2026.

PacificSourceIts commercial SUD policy requires notice within two business days of a residential admission and covers the first two business days at a Washington facility without medical necessity review. IOP needs prior authorization before care starts.

Kaiser Permanente WashingtonResidential SUD gets the first 2 days without prior authorization, then review. Mental health review moved to LOCUS and CALOCUS on January 1, 2026.

Kaiser Permanente Northwest (southwest Washington)Uses prior or concurrent authorization for inpatient and residential mental health and SUD care.

AetnaBehavioral health runs through Aetna Behavioral Health. Residential and PHP need precertification; IOP has not needed it since 2019.

Cigna (Evernorth)Behavioral health runs through Evernorth, which requires accreditation such as CARF or Joint Commission, or Medicare certification, before it contracts with a residential, PHP or IOP facility.

UnitedHealthcare (Optum)Behavioral health network and authorizations sit with Optum, so a UnitedHealthcare medical contract does not make you in network for behavioral health.

Medicare (Noridian)Noridian is the Medicare contractor. Claims are due within one calendar year of service, and IOP and PHP pay only in certain settings, such as hospital outpatient departments and CMHCs.

What we handle

Billing run by people who have operated treatment programs, inside the EHR you already use.

Eligibility and benefits checked at admission and at every level of care change, including which Apple Health plan covers the client
Authorization tracking for MCOs and commercial plans: approvals logged, end dates and review dates watched
Commercial, Medicare and Medicare Advantage, and Apple Health claims, scrubbed against payer rules before submission
Denials and appeals worked with the clinical record behind them
Payer follow up by phone and portal until paid or appealed
ERA and EOB posting, with underpayments measured against your contract
A monthly written report with aging by payer and level of care, plus a review call with your leadership
Work inside the EHR you already run, under a signed BAA with 42 CFR Part 2 terms

Washington billing questions

Payers, deadlines and how the service works.

Does Apple Health cover IOP and PHP for adults?

Not as a required benefit. Mental health IOP and PHP are mandatory only for clients under 21, and MCOs may choose to cover them for adults. Apple Health covers SUD IOP at ASAM level 2.1, but SUD PHP at ASAM level 2.5 is not currently covered.

Is ProviderOne enrollment the same as being in an MCO network?

No. ProviderOne enrollment with a Core Provider Agreement sets up your relationship with HCA. Clients in an MCO must be served through that MCO's contracted network, so you also need credentialing and a contract with each plan.

What changes for Premera PHP claims on November 16, 2026?

Premera already requires prior authorization for PHP. From November 16, 2026, medical policy 3.01.521 adds psychiatric, substance use or nutritional evaluations, depending on the program, at least every 7 to 10 days during treatment. PHP stays that start before the cutover and run past it are where gaps will appear first.

Do Washington commercial plans carve out behavioral health?

The regional plans do not. Regence, Premera, Providence and PacificSource manage behavioral health in-house, while UnitedHealthcare uses Optum and Cigna uses Evernorth. A program can hold a UnitedHealthcare medical contract and still be out of network for behavioral health.

Is MCO credentialing included in your billing rate?

No. Credentialing and payer enrollment are handled by our consulting division and quoted separately. HCA says MCO credentialing can take up to 90 days, and each licensed location is credentialed separately.

Guides for Washington programs

Our Journal articles on the payers and rules above.

Request your free billing audit

Send 90 days of claims data for a free written review of your denials, aging AR and missed authorizations, with dollar amounts attached, across commercial, Medicare and Apple Health claims. A BAA is signed before any data changes hands, findings arrive within 5 business days of complete data, and you keep them whether or not you hire us.

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