Glossary

Behavioral-health denial and appeal terms, in plain English.

34 terms that come up when a payer denies behavioral-health care, from medical necessity and level of care to peer-to-peer review and external review. Definitions are general information, not legal or clinical advice. The denial notice and the member's plan control.

Updated October 31, 2026

Appeal deadline: The window you have to file an appeal, stated in the denial notice. Missing it can end the appeal, so it's worth tracking from day one. Not legal advice. Work out a deadline.
Appeal packet: What ClaimParrot sends back: an appeal letter built on the payer's stated reason, an evidence checklist and a deadline plan. Level-of-care packets add a criteria crosswalk and a peer-to-peer brief. Your clinician reviews, signs and submits it. See a sample packet.
ASAM Criteria: The American Society of Addiction Medicine's framework for matching addiction treatment to a level of care, using six dimensions of a person's needs. Payers often cite it in substance-use denials.
BAA: A HIPAA contract that's needed when a vendor handles protected health information for a provider. ClaimParrot accepts no PHI, so no BAA is needed. Not legal advice.
Clinical summary: A short, de-identified account of the case: symptoms, risks and progress written in relative days (day 1, day 6) instead of calendar dates.
Concurrent review: A review while treatment is still going, usually to decide whether more days or sessions will be covered.
Criteria crosswalk: A table that lines up each criterion the payer cited against the evidence in the record: met, partly met, or a gap to close. Level-of-care packets include one. Build a crosswalk.
De-identified: With names, ID numbers, calendar dates and other identifiers taken out, so the case can't reasonably point to a person. ClaimParrot only accepts de-identified cases, written in relative days.
Denial codes: Standard codes on a payment remittance. A CARC says why a claim line was adjusted or denied; a RARC adds detail. Look up a code.
Denial notice: The plan's written decision to deny or limit coverage. It should say why, which criteria it used and how to appeal, so it's the starting point for every appeal. Not legal advice. Check a denial notice.
ERISA: The federal law that governs most employer-sponsored health plans, including how they have to handle claims and appeals. Not legal advice.
Expedited appeal: A faster appeal track for when waiting could seriously harm the patient's health. Plans have to decide these on a much shorter clock. Not legal advice.
Explanation of benefits: The statement a plan sends showing what it paid, what it denied and what the patient may owe. It isn't a bill.
External review: A review by an independent organization outside the health plan, usually available after internal appeals. Who qualifies and the deadlines depend on the plan type and state. Not legal advice. Draft an external review request.
HIPAA: The US law that sets privacy and security rules for health information held by providers, health plans and the vendors who work with that information for them. Not legal advice. Our HIPAA page.
Internal appeal: Asking the health plan itself to reconsider its denial. It's usually the first step, and the denial notice states the deadline for it. Not legal advice.
InterQual and MCG: Commercial sets of medical-necessity criteria that many payers license and quote in their denials.
IOP: Intensive outpatient program: several hours of treatment a day, a few days a week, while the person keeps living at home.
Level of care: How intensive the treatment setting is: outpatient, then intensive outpatient (IOP), partial hospitalization (PHP), residential and inpatient. A level-of-care denial means the payer thinks a lower level would do. Try the crosswalk builder.
LOCUS: The Level of Care Utilization System scores mental-health needs to suggest a level of care. CALOCUS is the version for children and teenagers.
Medical director: The payer's physician who reviews coverage decisions and can change them.
Medical necessity: The payer's judgement of whether care is reasonable and needed for the patient's condition, measured against its own criteria. Many behavioral-health denials say care wasn't medically necessary at that level.
Mental health parity: The Mental Health Parity and Addiction Equity Act, a US law: in the plans it covers, mental-health and substance-use benefits can't be more restrictive than medical and surgical ones. Not legal advice. Run the parity checker.
Merchant of Record: Paddle sells and invoices on ClaimParrot's behalf, so it handles the payment, sales tax and receipts.
Peer-to-peer review: A phone call where the treating clinician talks directly with the payer's reviewing clinician about the denial. It's a chance to explain the case before or alongside a written appeal. Prep for a peer-to-peer.
PHI: Health information tied to an identifiable person, which HIPAA protects. ClaimParrot never asks for it: you send a de-identified case instead. How we handle privacy.
PHP: Partial hospitalization program: structured treatment for most of the day, most days of the week. The person goes home at night.
Prior authorization: Approval a plan requires before certain care starts. Without it, a claim can be denied even when the care was needed.
Residential treatment: Round-the-clock care in a structured, non-hospital setting, for people who need more support than a day program can give.
Retrospective review: A review after the care has already been given, looking back at the records.
Revenue cycle: Everything between giving care and getting paid for it: billing, claims, denials and appeals.
Timely filing: The payer's limit for submitting the claim itself, set by the contract or the plan. It is not the appeal deadline: a timely-filing denial is usually fixed with proof the claim went in on time. Not legal advice. CARC 29: filing limit passed.
Utilization review: The payer's process of checking care against its criteria: before it starts (prior authorization), while it's happening (concurrent review) or afterwards (retrospective review).
Withdrawal management: Medically supervised care to get safely through withdrawal from alcohol or drugs. It's often the first step before other treatment.