Medicaid, Medicare, and Payer Compliance
Billing government and commercial payers correctly in behavioral health: medical necessity and covered services, prior authorization, scope of practice and provider qualifications, enrollment and credentialing, documentation that supports claims, claims accuracy, audits, and refunding overpayments.
Online, self-paced · about 40 minutes · graded exam and certificate
Who should take it
Billing and revenue cycle staff, clinicians, supervisors, practice managers and anyone who schedules, authorizes, documents or submits claims.
National course on general payer compliance principles. Each state Medicaid program, Medicare contractor and commercial plan has detailed rules on coverage, authorization, provider types, supervision, coding and telehealth that this course doesn't cover. Follow your billing team's guidance and payer manuals.
What employees will learn
- ✓Explain how medical necessity and coverage determine whether a service is payable.
- ✓Follow prior authorization requirements and track authorization limits.
- ✓Match services to provider qualifications, scope of practice, supervision and enrollment.
- ✓Submit accurate claims with correct codes, units, dates, places of service and providers.
- ✓Respond to audits and records requests appropriately.
- ✓Identify and refund overpayments on time.
Topics covered
- •Medical necessity
- •Covered services
- •Prior authorizations
- •Scope of practice
- •Provider qualifications
- •Documentation
- •Claims accuracy
- •Audit readiness
- •Refunds and overpayments
- •General federal program integrity principles
Sources this course is based on
- Medicare: reasonable and necessary (42 U.S.C. 1395y(a)(1)(A)) · Other
- Medicare coverage of marriage and family therapist and mental health counselor services (42 CFR 410.53, 410.54) · eCFR
- CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) · CMS
- Reporting and returning of overpayments (42 U.S.C. 1320a-7k(d)) · Other
- Medicare Advantage compliance program: training and education (42 CFR 422.503(b)(4)(vi)(C)) · eCFR
- General Compliance Program Guidance · OIG
- Mental Health Parity and Addiction Equity Act (29 U.S.C. 1185a; 42 U.S.C. 300gg-26) · Other
This course is not accredited for continuing education credit and is not approved by a government agency. Training supports, but does not guarantee, your organization's compliance. Course content explains federal rules and accepted practice; state requirements may differ.