CurrentOptumPolicy N/A

Facility-based behavioral health per diem reimbursement

Governs Optum reimbursement for facility-based behavioral health services billed on UB-04/837I (per diem payment), affecting facilities and providers submitting claims under behavioral health benefits administered by Optum (including UnitedHealthcare).

Policy Summary

PayerOptum

PolicyFacility-based behavioral health per diem reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateDec 1, 2025

Key ActionSubmit accurate claims on UB-04 (or 837I/electronic portal); policy applies to Medicare products and network/non-network providers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

single day ratepayment method for facility-based behavioral health services

90791 not reimbursedpsychiatric diagnostic evaluation without medical services

90792 billed separatelyattending professional charges excluded from per diem

UB-04/837Iclaim forms/electronic equivalents covered

Per Diem Coverage Criteria

Per diem coverage criteria

Optum will reimburse facility-based behavioral health services using a single per diem rate when services meet CMS/Optum criteria for active treatment:

Services are supervised and evaluated by the attending/rendering provider.

Services are provided under an individualized treatment plan focused on addressing the factors that precipitated admission and make use of clinical best practices.

Services are reasonably expected to improve the member's presenting problems within a reasonable period of time.

Treatment consists of clinically recognized therapeutic interventions such as group, individual, and family psychotherapies; medical and psychiatric diagnostic evaluation; and medication management; programs treating co-morbid Substance-Related Disorders must be prepared to appropriately treat the co-morbid condition.

Describes scope of active treatment interventions.

Policy Summary

PayerOptum

PolicyFacility-based behavioral health per diem reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateDec 1, 2025

Key ActionSubmit accurate claims on UB-04 (or 837I/electronic portal); policy applies to Medicare products and network/non-network providers.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Relevant Codes and What's Included

Behavioral health diagnostic evaluation codesCPTCovered

90791	Psychiatric diagnostic evaluation without medical services — not reimbursed separately (included in per diem)
90792	Psychiatric diagnostic evaluation with medical services — attending professional charges excluded from per diem (may be billed separately)

Per diem inclusion

Included in per diemSingle day rate incorporates payment for all dependent, ancillary, supportive, and therapeutic services; separate payment is not made for ancillary services billed with the primary program.

Attending professional chargesAttending professional charges billed with CPT 90792 or a single daily E&M code are not included in the per diem and may be billed separately.

Psychiatric diagnostic evaluation (90791)CPT 90791 is not separately reimbursable — psychiatric diagnostic evaluation without medical services is included in the daily per diem.

Key Definitions

Active treatment

PurposeDetermines eligibility for per diem reimbursement for facility-based behavioral health services when criteria are met.

Reference standardsOptum applies CMS criteria and internal criteria (42 CFR 422.101(b)(6)) and adopts external clinical criteria to assess appropriateness.

Integral program services

Integral services includedAll supplies, ancillary services, psychological and neuropsychological testing, clinical diagnostic laboratory tests (including drug testing), and treatment planning are included in the per diem.

Therapies includedIndividual therapy, group therapy, family therapy, and crisis intervention are considered integral and are reimbursed under the single day rate.

Diagnostic and medication managementMedical and psychiatric diagnostic evaluation and medication management are integral to treatment and incorporated into the per diem (note: CPT 90791 specifically is not reimbursed separately).

OpenPayer

Facility-based behavioral health per diem reimbursement

Per Diem Coverage Criteria

Relevant Codes and What's Included

Claims Submission and Applicability

Key Definitions