Active Findings
3
3 open · 0 resolved
Recovery Opportunity
$8,861
Across all open findings
Denied Claims
29
UHC 90837-GT cluster
Denial Rate
14.4%
vs. 4.2% industry avg
Claims Evaluated
202
May – Jun 2026
| CPT | Modifier | POS | Payer | Type | DOS | Provider | Expected | Paid | Variance | Status |
|---|
FIND-BH-001
Carelon Behavioral Health
$1,279.20
Systematic underpayment of 97153-HN (RBT-level ABA treatment). Contracted rate $17.85/unit; consistently paid at $13.75/unit across 39 service dates. Likely fee schedule load error on Carelon's CY2026 update.
UNDERPAYMENT
ABA
HN
FIND-BH-002
Optum Behavioral (UHC carve-out)
$4,309.40
Blanket denials of 90837-GT (telehealth psychotherapy 53+ min) under reason code PR-4 (deductible). Pattern suggests eligibility file mismatch — members show active behavioral coverage but claims denied as patient responsibility. Appeal window open.
DENIAL
TEL
GT
FIND-BH-003
WellCare Behavioral Health (Centene)
$3,272.40
Rate swap on 90847 (family therapy with patient present). Contract rate $89.00; paid at $28.40 which matches the 90846 (family therapy without patient) rate. Systematic crosswalk error in WellCare's remittance mapping for CY2026 contract renewal.
RATE SWAP
OUT
Carelon Behavioral Health
Claims
58
Variance
$1,279
Denial Rate
0%
97153-HN underpayment$1,279.20
ABA services (AUT diagnosis)39 claims
Contract: CY2026 ABA ScheduleActive
Optum Behavioral (UHC carve-out)
Claims
44
At Risk
$4,309
Denial Rate
65.9%
90837-GT denial cluster (PR-4)$4,309.40
Telehealth psychotherapy29 denials
Contract: UHC BH 2026 ProActive
WellCare Behavioral Health (Centene)
Claims
71
Variance
$3,272
Denial Rate
1.4%
90847 rate swap (→ 90846 rate)$3,272.40
Outpatient family therapy54 claims
Contract: WellCare BH 2026Active
BCBS Commercial
Claims
29
Variance
$0
Denial Rate
0%
No findings this period—
Payment accuracy100%
Contract: BCBS BH 2026Active