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CANDOR HEALTH INTEL

The Weekly Reimbursement Brief
Issue 051326-01· May 13, 2026 · Plain-English billing intelligence for therapy practices

THIS WEEK’S TOP PAYER UPDATE

Commercial payers must now prove their behavioral health coverage is as accessible as their medical coverage

A key piece of the Mental Health Parity Act finally has teeth. As of January 1, 2026, commercial health plans are required to document that their rules for behavioral health, prior authorizations, visit limits, and coverage restrictions are no more restrictive than their rules for medical and surgical services. If a payer requires prior authorization for therapy but not for a comparable medical service, that is now a documented violation, not just an inconvenience.

This gives your practice real leverage on appeals. When you get a denial that feels inconsistent, write it down, note the date, note the payer, and reference MHPAEA in your appeal letter. A pattern of denials can support a formal complaint to your state insurance department or the Department of Labor.

Source: U.S. Department of Labor MHPAEA Final Rule: dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/fact-sheets/final-rules-under-the-mental-health-parity-and-addiction-equity-act-mhpaea

TELEHEALTH BILLING WATCH

Audio-only therapy under Medicare is permanent, but your documentation has to say the right thing

This one is settled. Audio-only behavioral health sessions are permanently covered under Medicare with no geographic restrictions. This is not a temporary extension, it is not expiring. Clinical psychologists, clinical social workers, marriage and family therapists, and mental health counselors are all covered distant site providers.

The catch: your note needs one sentence documenting that the patient could not use video or did not consent to it. That sentence is what protects your claim in an audit. Without it, the session is vulnerable. Also confirm you are using POS code 10 for sessions where the patient is at home, and POS code 02 everywhere else.

Source: CMS Telehealth Policy Updates: telehealth.hhs.gov/providers/telehealth-policy/telehealth-policy-updates

CODING CORNER

If your depression diagnosis codes still default to “unspecified”, that is costing you

The ICD-10 code set added more specific codes for major depressive disorder, obsessive-compulsive disorders, and several other behavioral health conditions effective October 1, 2025. More specificity is now available, and payers have noticed. Claims that default to unspecified codes like F32.9 when the clinical note clearly supports something more specific are getting denied or reduced more frequently.

Check your EHR templates and superbills. If they default to unspecified diagnosis codes, update them. Make sure your codes reflect what your notes already say.

Source: CMS ICD-10 Updates: cms.gov/medicare/coding-billing/icd-10-codes

ON THE RADAR

Upcoming items your practice should know are coming, not yet actionable, just awareness.

· UHC announcing 30% reduction in prior authorization requirements — watch for the therapy services list. UnitedHealthcare announced on May 5th that it will eliminate prior authorization requirements for 30% of remaining services by end of 2026, including “some outpatient therapies.” The full list of affected services has not been published yet. When it posts on UHCProvider.com we will cover it in detail, if behavioral health CPT codes are on that list, this is meaningful news for every practice billing UHC. We are watching it.

· CMS 2027 Physician Fee Schedule Proposed Rule drops in July. This sets proposed reimbursement rates for all behavioral health CPT codes effective January 1, 2027. We will cover it when it lands.

· Parity complaints now have a clearer path. If you are seeing a pattern of prior auth denials for therapy that are not required for comparable medical services, the Department of Labor’s Employee Benefits Security Administration is where formal complaints go. Start logging denials by payer now.

Sources: CMS.gov, UnitedHealthcare, Department of Labor EBSA.

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That is everything worth knowing this week.

The parity update is the one to act on now. Start logging denials. That record is your leverage when it matters most.

See you next Tuesday.

Gail, Candor Health Intel [email protected]

Candor Health Intel is an independent research and intelligence service. Nothing published constitutes legal, billing, or compliance advice. Always verify with a qualified professional before making billing decisions. Sources cited above.