Billing & Claims

Automated claim generation with AI-powered denial prevention

---

Overview

Turtle RCM's billing module provides:

• Automated claim generation from session documentation
• AI code suggestions with confidence scores
• Prior authorization via FHIR (Da Vinci PAS)
• Denial prediction before submission
• Appeals automation for denied claims
• Real-time tracking and reporting

---

Creating a Claim

From Session Documentation

Automatic flow:

1. Clinician documents session
2. AI suggests CPT/ICD codes
3. Biller reviews in Claims module
4. Click "Generate Claim"
5. Verify pre-filled data
6. Submit

Manual Claim Creation

1. Go to Claims Module

• Click "Claims" in sidebar

2. Click "Create New Claim"

3. Select Patient & Session

• Search patient
• Choose session date
• System loads session data

4. Review Pre-Filled Information

Patient Demographics:

• Auto-filled from patient record
• Name, DOB, address, gender

Insurance Information:

• Member ID
• Group number
• Policy holder details
• Auto-filled from patient insurance

Provider Information:

• Rendering provider (who saw patient)
• Clinic NPI
• Tax ID
• Auto-filled from user/clinic settings

Service Information:

• Session date
• CPT code (AI suggested or manual)
• ICD-10 diagnosis codes
• Modifiers (if applicable)
• Units (typically 1 for psychotherapy)

5. Review AI Suggestions

💊 AI Code Suggestions

Green badge = AI assisted

Click badge to see reasoning:

• "Based on 55-minute session"
• "GAD-7 score of 18 (severe anxiety)"
• "Interactive complexity documented (family member present)"
• "Diagnosis F41.1 (Generalized Anxiety Disorder) supports psychotherapy"

Confidence level:

• 🟢 High (>85%): AI is confident
• 🟡 Medium (60-85%): Review carefully
• 🔴 Low (<60%): Manual review recommended

Always review before submitting. Override if incorrect.

6. Check Denial Risk

🚨 AI Denial Prediction

Yellow/red warning = High denial risk

System analyzes:

• Payer history (has this payer denied this code before?)
• Provider patterns (coding consistency)
• Missing requirements (prior auth, modifiers)
• Diagnosis-procedure alignment
• Time of year (deductible reset)

Example warning:"⚠️ High denial risk (65%): This payer denies CPT 90837 for telehealth 40% of the time without modifier 95. Add modifier to reduce risk."Fix issues before submitting to avoid denial.

7. Submit or Save Draft

• Submit: Sends to payer electronically
• Save Draft: Save for later review
• Drafts auto-save every 30 seconds

---

CPT Codes Reference

Common Behavioral Health Codes

Diagnostic Evaluation:

• 90791 - Psychiatric diagnostic evaluation (no medical)
• 90792 - Psychiatric diagnostic evaluation (with medical services)

Individual Psychotherapy:

• 90832 - 16-37 minutes
• 90834 - 38-52 minutes
• 90837 - 53+ minutes

Add-On Codes:

• +90785 - Interactive complexity
• +96127 - Brief emotional/behavioral assessment (PHQ-9, GAD-7, etc.)

Crisis:

• 90839 - Crisis psychotherapy, first 60 minutes
• +90840 - Each additional 30 minutes

Group & Family:

• 90853 - Group psychotherapy
• 90847 - Family therapy with patient present
• 90849 - Multiple family group therapy

Medication Management:

• 90863 - Medication management

Testing:

• 96136 - Psychological/neuropsychological test administration and scoring (first 30 min)
• +96137 - Each additional 30 minutes

Modifiers Reference

Telehealth:

• 95 - Telehealth service (most common)
• GT - Telehealth via interactive audio/video (some payers)
• GQ - Asynchronous telehealth (rare in behavioral health)

Location:

• POS 02 - Telehealth
• POS 10 - Office (includes telehealth for some payers)
• POS 11 - Office
• POS 12 - Home

Other:

• 22 - Increased procedural services (unusually complex)
• 52 - Reduced services (session interrupted)
• 76 - Repeat procedure by same provider

📚 Automated Modifier Selection

Turtle RCM's Geo-Aware Rules Engine automatically determines required modifiers:

Based on:

• Patient state
• Provider state
• Payer policy
• Visit type (telehealth vs. office)
• Service date

Example: "For Blue Cross Texas, use modifier 95 with POS 10 for telehealth services as of 2025."Rules automatically updated when payer policies change (no manual tracking needed).

---

Prior Authorization

When is Prior Auth Needed?

Typically required for:

• Initial assessment (90791/90792)
• Ongoing therapy beyond 6-10 sessions
• Intensive outpatient program (IOP)
• Partial hospitalization (PHP)
• Psychological testing

Varies by:

• Payer (commercial vs. Medicaid vs. Medicare)
• Diagnosis
• Patient age
• Service intensity

CRD automatically checks when you schedule appointments.

Submitting Prior Authorization

Automated via PAS:

1. Start Authorization Request

• From appointment (if CRD flagged)
• From Claims → "Prior Auth" tab
• Click "New Authorization Request"

2. System Pre-Fills Data (DTR)

• Patient demographics
• Provider information
• Diagnosis codes
• Requested services
• Clinical justification (from session notes)
• Assessment scores

3. Review and Complete Form

• Payer-specific questionnaire
• Most fields auto-populated
• Add any missing clinical details
• Upload supporting documents if needed

4. Submit Electronically

• Sent via FHIR PAS to payer
• Real-time submission
• Confirmation receipt

5. Track Status

• Submitted: Request received by payer
• Pended: Additional information requested
• Approved: Authorization granted
• Denied: Request rejected

6. Get Decision

• Webhook notification when decided (no need to check repeatedly)
• Authorization number if approved
• Denial reason if rejected
• Can appeal if denied

Manual Prior Authorization

If payer doesn't support electronic:

1. Generate authorization request form
2. System fills out form
3. Print or download PDF
4. Fax to payer
5. Call to confirm receipt
6. Follow up for decision
7. Manually enter authorization number when approved

---

Claim Submission

Electronic Submission

FHIR-enabled payers:

• Submit directly via FHIR API
• Real-time response
• Immediate confirmation

Clearinghouse submission:

• System generates X12 837 file
• Sent to clearinghouse (e.g., Change Healthcare)
• Clearinghouse routes to payer
• Confirmation via 999/277CA

Paper Claims

If electronic not available:

1. Generate CMS-1500 form
2. Review for completeness
3. Print
4. Sign (if required by payer)
5. Mail to payer address

CMS-1500 auto-fill:

• All boxes pre-populated from system data
• Provider signature on file (electronic)
• Clean claim ready to submit

---

Claim Status Tracking

Status Meanings

Status	Description	Action Needed
Draft	Not yet submitted	Complete and submit
Submitted	Sent to payer	Wait for response
Accepted	Payer received	Wait for adjudication
Pended	Additional info requested	Respond within 14 days
Approved	Will be paid	Wait for remittance
Paid	Payment received	Post payment
Denied	Rejected	Review reason, appeal if appropriate

Checking Status

Real-time updates:

• Webhook notifications from payer (FHIR)
• Dashboard shows pending actions
• Email alerts for status changes (Phase 2)

Manual check:

• Go to Claims → Find claim
• Click "Check Status"
• System queries payer via 276/277
• Result displayed

Typical timeline:

• Submission to acknowledgment: Minutes to hours
• Acknowledgment to adjudication: 7-14 days
• Adjudication to payment: 7-30 days
• Total: 2-6 weeks (varies by payer)

---

Handling Denials

Common Denial Reasons

1. Missing Prior Authorization (Most common)

• Fix: Obtain authorization retroactively (if allowed)
• Prevent: Check prior auth requirements when scheduling

2. Medical Necessity Not Established

• Fix: Submit additional clinical notes
• Prevent: Better documentation, include assessment scores

3. Non-Covered Service

• Fix: Appeal with payer policy showing coverage
• Prevent: Verify benefits before providing service

4. Incorrect Coding

• Fix: Correct code and resubmit
• Prevent: Review code suggestions carefully, verify time matches code

5. Timely Filing Missed

• Fix: Appeal if special circumstances
• Prevent: Submit claims within 30 days of service

6. Patient Not Eligible

• Fix: Update insurance info, resubmit
• Prevent: Verify eligibility at each session

Denial Management & Appeals

🚧 Feature in Development

Advanced denial management and automated appeal generation are currently under development.

Current capabilities:

• ✅ View denial reasons
• ✅ Track denial status
• ✅ Manual appeal submission
• 🔜 AI-assisted appeal letter generation
• 🔜 Denial pattern analytics
• 🔜 Predictive denial warnings

Coming soon in Phase 2. Contact your administrator for current denial workflows.

Current Appeal Process:

When to Appeal:

• ✅ You have additional documentation
• ✅ Payer policy supports your claim
• ✅ Error in payer's adjudication
• ✅ Claim value justifies the effort

Manual appeal steps:

1. Review denial reason carefully
2. Gather supporting clinical documentation
3. Draft appeal letter
4. Cite payer policy if applicable
5. Submit within payer's appeal deadline (typically 30-60 days)

Track appeals:

• Note appeal submission in claim record
• Follow up on status
• Document resolution

---

Payment Posting

Posting Remittance

Electronic Remittance Advice (ERA):

• Auto-imported from payer
• System matches payment to claims
• Auto-posts if exact match

Manual posting:

1. Go to claim
2. Click "Post Payment"
3. Enter:
   • Payment amount
   • Check number
   • Payment date
   • Adjustments (contractual, denials)
4. Calculate patient responsibility
5. Save

Patient Billing

After insurance pays:

• Calculate patient balance (copay + deductible + coinsurance)
• Generate patient statement
• Track payments received
• Can set up payment plans (admin feature)

---

Reports & Analytics

Available Reports

Claims Pipeline:

• Claims by status
• Aging report (claims > 30/60/90 days)
• Expected vs. actual reimbursement

Denial Analysis:

• Denial rate by provider
• Denial rate by payer
• Denial rate by CPT code
• Common denial reasons

Revenue:

• Revenue by payer
• Revenue by provider
• Revenue by service type
• Cash flow projection

Authorization:

• Active authorizations
• Expiring soon (< 3 sessions remaining)
• Utilization by patient

Interpreting Denial Reports

High denial rate (> 20%):

• Review documentation quality
• Check if codes appropriate
• Verify prior auth being obtained
• Consider payer policies

Specific payer high:

• May have unique requirements
• Check rules engine guidance
• Consider credentialing issues

Specific provider high:

• May need coding training
• Documentation improvement needed
• Review AI override patterns

Specific code high:

• May be payer-specific non-coverage
• Alternative codes available?
• Medical necessity documentation adequate?

---

Compliance Checks

Before Submission

System verifies:

• ✅ All required fields completed
• ✅ Diagnosis supports procedure
• ✅ Prior authorization on file (if required)
• ✅ Patient eligibility verified
• ✅ Timely filing deadline not passed
• ✅ Rendering provider credentialed with payer

Clean claim:

• No errors, complete information
• Higher chance of approval
• Faster processing

Audit Protection

What payers audit:

• Documentation supports code billed
• Time matches time-based code
• Medical necessity clear
• No pattern of over-coding
• Prior auth obtained when required

Turtle RCM helps:

• Links claim to session documentation
• Timestamps prove session duration
• Assessment scores justify medical necessity
• Coding trends monitored
• Prior auth tracked

If audited:

• Export complete documentation package
• Include session notes, assessments, treatment plan
• System generates audit response package
• All required elements included

---

Telehealth Billing

Telehealth Requirements

Documentation must include:

• Platform used (and that it's HIPAA-compliant)
• Patient location (state)
• Provider location (state)
• Quality of audio/video connection
• Any technical issues

Coding:

• Use appropriate POS code (varies by payer)
• Add modifier (95, GT, or GQ)
• Some payers require specific codes for telehealth

📡 State-Specific Telehealth Rules

Turtle RCM automatically applies correct rules for:Texas: POS 10 + Modifier 95California: POS 02 + Modifier 95New York: POS 10 + Modifier GTFlorida: Check payer policy (varies)System shows guidance during claim creation: "For [Payer] in [State], use POS [X] with modifier [Y]."Updated automatically when state laws or payer policies change.

---

Group Therapy Billing

CPT 90853 - Group Psychotherapy

Requirements:

• 2+ patients present
• Interactive group process
• Led by qualified provider
• 90 minutes typical

Documentation:

• Number of patients in group
• Group process notes
• Individual patient participation
• Therapeutic interventions used

Billing:

• Separate claim for each patient
• All receive same CPT 90853
• Duration should match across all claims
• Can bill with individual therapy (different dates)

Common denial reasons:

• Only 1 patient present (not a group)
• No documentation of group process
• Billed same day as individual therapy (usually not covered)

---

Coordination of Benefits (COB)

Primary vs. Secondary

When patient has 2+ insurances:

1. Bill primary insurance first
2. Wait for primary payment/EOB
3. Bill secondary insurance
4. Include primary's EOB with secondary claim
5. Secondary pays remaining covered amount
6. Patient responsible for rest

Birthday rule:

• For dependent children with both parents' insurance
• Parent with earlier birthday in year = primary
• Example: Mom's birthday 3/15, Dad's 7/22 → Mom's insurance is primary

Medicare + Secondary:

• Medicare always primary (except working aged, ESRD, or auto accident)
• Secondary insurance or Medigap pays after Medicare
• Include Medicare's EOMB with secondary claim

---

Timely Filing

Deadlines by Payer Type

Commercial insurance: 30-90 days (varies by payer) Medicaid: 90-365 days (varies by state) Medicare: 1 year from service date

Check specific payer:

• Listed in claim creation
• System warns if deadline approaching
• Tracks submission date vs. service date

If deadline missed:

• Appeal for special circumstances (payer delay, patient hospitalization, etc.)
• May be denied as untimely
• Learn lesson: submit promptly!

---

Best Practices

For Clean Claims

✅ DO:

• Submit within 30 days of service
• Verify insurance before every session
• Obtain prior auth before starting treatment
• Document thoroughly
• Use appropriate modifiers
• Double-check patient demographics

❌ DON'T:

• Wait until month-end to submit
• Assume insurance hasn't changed
• Skip prior auth checks
• Use vague documentation
• Forget modifiers for telehealth
• Ignore AI denial warnings

For Denial Prevention

✅ DO:

• Review denial risk warnings
• Fix issues before submitting
• Track authorization usage
• Renew auths early
• Appeal high-value denials
• Learn from denial patterns

❌ DON'T:

• Ignore red/yellow warnings
• Submit without prior auth
• Let authorizations expire
• Miss timely filing deadlines
• Give up on first denial
• Keep making same mistakes

For Faster Payment

✅ DO:

• Submit electronically
• Include all required information
• Respond quickly to pended requests
• Follow up on unpaid claims > 30 days
• Post payments promptly

❌ DON'T:

• Submit paper claims (slower)
• Ignore requests for information
• Let claims age unnecessarily
• Forget to post payments
• Miss EOB review

---

FAQ

Q: How long until claim is paid?
A: 2-6 weeks typically. Electronic faster than paper. Medicare usually 14 days.

Q: What if payer asks for medical records?
A: Respond within 14 days. Export session documentation from Turtle RCM. Remove non-essential PHI. Fax or secure email.

Q: Can I bill two CPT codes same day?
A: Generally no for psychotherapy codes. Can bill therapy + assessment (96127). Check payer policy.

Q: What if I billed wrong code?
A: Void/cancel original claim. Resubmit with correct code. Or submit corrected claim (claim frequency "7").

Q: Do I need separate claim for each diagnosis?
A: No. One claim can have multiple diagnosis codes. Primary diagnosis in Box 21A, additional in B-L.

Q: What's the difference between claim and encounter?
A: Encounter = clinical session. Claim = bill for that session. One encounter = one claim (usually).

---

Next Steps

• Learn about AI features: AI Features
• Understand compliance: Security & Compliance
• Get more help: FAQ

---

Last updated: November 2025