Built for Behavioral Health
Eligibility, payer rules, and MCO changes — finally working in your favor.
Coveragence is the eligibility and payer-management platform purpose-built for behavioral health and SUD providers. Stop chasing portals, untangling carve-outs, or re-keying patient coverage every time an MCO assignment shifts.
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THE BEHAVIORAL HEALTH CHALLENGE
Behavioral health revenue cycles are uniquely complicated.
Eligibility errors and payer-rule gaps drive the majority of behavioral health denials. Your team is left juggling Medicaid plans, MCOs, and carve-outs that change without warning.
Eligibility chaos
Coverage flips between commercial, Medicaid, and Medicare Advantage plans mid-treatment — often without the patient knowing.
Carve-out confusion
Behavioral health is carved out to a different payer than the medical plan in dozens of states — and the rules aren't documented anywhere consistent.
MCO re-assignments
Patients get re-assigned to new managed care orgs every renewal cycle, breaking authorizations your team already secured.
Single Case Agreements
Out-of-network admissions need SCAs, LOAs, and authorization workflows that don't fit a typical EHR or RCM tool.
Payer rule sprawl
Each payer has its own LOC criteria, frequency limits, and modifier requirements — buried in PDFs and provider manuals.
Denial whack-a-mole
Your billers spend hours fixing eligibility-driven denials that could have been caught at admission.
HOW COVERAGENCE HELPS
Purpose-built for the way behavioral health actually gets paid.
Coveragence combines an eligibility engine, a payer rules database, and a clearinghouse — tuned for the carve-outs, MCOs, and authorization workflows behavioral health teams deal with every day.
Real-time eligibility, every visit
Run 270/271 checks across 1,800+ payers in seconds — including Medicaid MCO assignments and behavioral health carve-outs that other tools miss. Detect plan changes before the patient walks in the door.
→ Eligibility Engine
Carve-out aware payer database
Track who actually pays for behavioral health in every state, plan, and product — Magellan, Carelon, Optum BH, state MCOs — so your team always bills the right entity the first time.
→ Payer Database
MCO change detection
Daily monitoring on every active patient flags MCO re-assignments, plan terminations, and benefit resets the moment they happen — so your auth team can re-secure coverage without service disruption.
→ Coverage monitoring
Rules engine for LOC and prior auth
Codify each payer's medical-necessity criteria, level-of-care guidelines, and prior-auth rules. Coveragence flags missing requirements before claims go out — not after they're denied.
→ Rules Engine
The outcomes our behavioral health customers see.
62%
Reduction in eligibility-related denials.
9 days
Faster average days-to-cash.
3.2x
More MCO changes caught before billing.