In behavioral health, missing eligibility data does more than slow down billing. It can block care.
Behavioral health patients tend to be cost-sensitive. If coverage or costs are unclear, they may not book an appointment. And an unexpected bill can mean skipping follow-ups or dropping treatment entirely.
Eligibility responses for behavioral health services also come with extra complexity. Uneven payer support, visit limits, and benefit carveouts make results harder to interpret. It can take some digging to figure out what the response really means.
This guide shares practical tips for getting eligibility checks for behavioral health right. They’re based on what we’ve learned from helping teams in the space build their eligibility workflows. Examples use Stedi’s JSON Eligibility API.
1. Test each payer’s support for behavioral health STCs
In an eligibility request, a Service Type Code (STC) tells the payer what kind of benefits you’re asking about. But not every payer supports the same STCs.
Testing is the best way to find out which STCs work for each payer. Our docs cover general STC testing tips. Here’s more specific guidance for behavioral health services:
Step 1. Start with STC 30 (Health Benefit Plan Coverage) Begin with STC 30 as your baseline. It’s supported by all medical payers and returns broad information on medical benefits.
When you use STC 30 in the request, medical payers are required to return benefits for STC MH (Mental Health), if they apply to the patient’s plan, in the response.
MH is a broad STC. It can cover lots of different services and procedures. The payer may also include benefits for more specific behavioral health STCs, as shown in the example below.
Example: Eligibility response containing several behavioral health STCs
{"benefitsInformation":[{"code":"B",// Co-pay"coverageLevelCode":"IND",// Individual"serviceTypeCodes":["A4",// Psychiatric"A6",// Psychotherapy"22"// Social work ],"benefitAmount":"20",// $20 co-pay for the above services...}],...}
{"benefitsInformation":[{"code":"B",// Co-pay"coverageLevelCode":"IND",// Individual"serviceTypeCodes":["A4",// Psychiatric"A6",// Psychotherapy"22"// Social work ],"benefitAmount":"20",// $20 co-pay for the above services...}],...}
{"benefitsInformation":[{"code":"B",// Co-pay"coverageLevelCode":"IND",// Individual"serviceTypeCodes":["A4",// Psychiatric"A6",// Psychotherapy"22"// Social work ],"benefitAmount":"20",// $20 co-pay for the above services...}],...}
{"benefitsInformation":[{"code":"B",// Co-pay"coverageLevelCode":"IND",// Individual"serviceTypeCodes":["A4",// Psychiatric"A6",// Psychotherapy"22"// Social work ],"benefitAmount":"20",// $20 co-pay for the above services...}],...}
{"benefitsInformation":[{"code":"B",// Co-pay"coverageLevelCode":"IND",// Individual"serviceTypeCodes":["A4",// Psychiatric"A6",// Psychotherapy"22"// Social work ],"benefitAmount":"20",// $20 co-pay for the above services...}],...}
Step 2. Test STC MH (Mental Health) Next, send an eligibility request for STC MH to get a baseline response that’s more focused on behavioral health. The response may include more detailed behavioral health benefits than the response for STC 30.
Step 3. Test more specific behavioral health STCs Depending on your services, try one or more STCs from the following table. They’re more specific than STC 30 and STC MH, and may return more detailed benefit information.
Note: The table’s Widely supported column shows STCs that are supported by most payers. This support is based on payer guidance from CAQH CORE, which defines industry-wide operating rules for eligibility checks.
STC
Description
Widely supported
22
Social Work
67
Smoking Cessation
A4
Psychiatric
A5
Psychiatric - Room and Board
A6
Psychotherapy
✅
A7
Psychiatric - Inpatient
✅
A8
Psychiatric - Outpatient
✅
AI
Substance Abuse
✅
AJ
Alcoholism
AK
Drug Addiction
BC
Day Care (Psychiatric)
BD
Cognitive Therapy
CE
Mental Health Provider – Inpatient
CF
Mental Health Provider – Outpatient
CG
Mental Health Facility - Inpatient
CH
Mental Health Facility - Outpatient
CI
Substance Abuse Facility - Inpatient
CJ
Substance Abuse Facility - Outpatient
RT
Residential Psychiatric Treatment
For example, if you’re checking benefits for psychotherapy, test both CF (Mental Health Provider – Outpatient) and A6 (Psychotherapy) to see which returns the benefits you’re looking for.
We recommend sending one STC per request. Many payers don’t support multiple STCs in a single check. If you use multiple STCs, some payers may reject the request while others may return a default response or only use the first STC provided.
Step 4. Test telehealth STCs (if needed) Some payers use separate STCs for telehealth. If you’re checking telehealth benefits for behavioral health services, try these STCs as well:
STC
Description
98
Professional (Physician) Visit – Office
9
Other Medical
Step 5. Compare to the baseline Compare the payer’s responses for STCs 30, MH, and any others you tested to see which one returns the benefit details you need. Use that STC in future eligibility checks for the service with that payer.
Repeat the process for each payer you support. You can’t assume that STCs that work for one payer will apply to another.
2. Identify telehealth benefits
Many payers return telehealth benefits separately from in-person benefits in eligibility responses.
02 – Telehealth provided other than in the patient’s home
10 – Telehealth provided in the patient’s home
Example: Deductible for psychotherapy telehealth
{"benefitsInformation":[{"code":"C",// Deductible"serviceTypeCodes":["A6"],// Psychotherapy"eligibilityAdditionalInformationList":[{"codeListQualifier":"Mutually Defined","codeListQualifierCode":"ZZ","industryCode":"02",// Telehealth provided other than in the patient’s home...}],...},...],...}
{"benefitsInformation":[{"code":"C",// Deductible"serviceTypeCodes":["A6"],// Psychotherapy"eligibilityAdditionalInformationList":[{"codeListQualifier":"Mutually Defined","codeListQualifierCode":"ZZ","industryCode":"02",// Telehealth provided other than in the patient’s home...}],...},...],...}
{"benefitsInformation":[{"code":"C",// Deductible"serviceTypeCodes":["A6"],// Psychotherapy"eligibilityAdditionalInformationList":[{"codeListQualifier":"Mutually Defined","codeListQualifierCode":"ZZ","industryCode":"02",// Telehealth provided other than in the patient’s home...}],...},...],...}
{"benefitsInformation":[{"code":"C",// Deductible"serviceTypeCodes":["A6"],// Psychotherapy"eligibilityAdditionalInformationList":[{"codeListQualifier":"Mutually Defined","codeListQualifierCode":"ZZ","industryCode":"02",// Telehealth provided other than in the patient’s home...}],...},...],...}
{"benefitsInformation":[{"code":"C",// Deductible"serviceTypeCodes":["A6"],// Psychotherapy"eligibilityAdditionalInformationList":[{"codeListQualifier":"Mutually Defined","codeListQualifierCode":"ZZ","industryCode":"02",// Telehealth provided other than in the patient’s home...}],...},...],...}
Some payers may include telehealth details as free-text notes in the additionalInformation.description field. Look for phrases like:
Many payers outsource behavioral health benefits to a separate administrator. That's called a carveout. For example, many Blue Cross Blue Shield (BCBS) plans carve out mental health benefits to Magellan, a specialized mental health payer.
When that happens, your eligibility response may confirm the patient has mental health coverage but not show other details, like co-pays or limitations.
Payers don’t typically return detailed carveout benefits in eligibility responses, but many return the carveout admin’s information in a benefitsRelatedEntities object. That information is often enough to run a second eligibility check for the patient with the carveout administrator.
Example: Carveout administrator for mental health services
{"benefitsInformation":[{"code":"U",// Contact Following Entity for Eligibility or Benefit Information"serviceTypeCodes":["MH"],// Mental Health..."benefitsRelatedEntities": [{"entityIdentifier":"Third-Party Administrator","entityType":"Non-Person Entity","entityName":"Acme Health Payer","entityIdentificationValue":"123456789",// Patient's member ID with the carveout admin"contactInformation":{"contacts":[{"communicationMode":"Telephone","communicationNumber":"1234567890"}]}},...},{"code":"D",// Benefit Description"serviceTypeCodes":["MH"],"additionalInformation":[{"description":"BEHAVIORAL HEALTH MANAGED SEPARATELY"}]}],...}
{"benefitsInformation":[{"code":"U",// Contact Following Entity for Eligibility or Benefit Information"serviceTypeCodes":["MH"],// Mental Health..."benefitsRelatedEntities": [{"entityIdentifier":"Third-Party Administrator","entityType":"Non-Person Entity","entityName":"Acme Health Payer","entityIdentificationValue":"123456789",// Patient's member ID with the carveout admin"contactInformation":{"contacts":[{"communicationMode":"Telephone","communicationNumber":"1234567890"}]}},...},{"code":"D",// Benefit Description"serviceTypeCodes":["MH"],"additionalInformation":[{"description":"BEHAVIORAL HEALTH MANAGED SEPARATELY"}]}],...}
{"benefitsInformation":[{"code":"U",// Contact Following Entity for Eligibility or Benefit Information"serviceTypeCodes":["MH"],// Mental Health..."benefitsRelatedEntities": [{"entityIdentifier":"Third-Party Administrator","entityType":"Non-Person Entity","entityName":"Acme Health Payer","entityIdentificationValue":"123456789",// Patient's member ID with the carveout admin"contactInformation":{"contacts":[{"communicationMode":"Telephone","communicationNumber":"1234567890"}]}},...},{"code":"D",// Benefit Description"serviceTypeCodes":["MH"],"additionalInformation":[{"description":"BEHAVIORAL HEALTH MANAGED SEPARATELY"}]}],...}
{"benefitsInformation":[{"code":"U",// Contact Following Entity for Eligibility or Benefit Information"serviceTypeCodes":["MH"],// Mental Health..."benefitsRelatedEntities": [{"entityIdentifier":"Third-Party Administrator","entityType":"Non-Person Entity","entityName":"Acme Health Payer","entityIdentificationValue":"123456789",// Patient's member ID with the carveout admin"contactInformation":{"contacts":[{"communicationMode":"Telephone","communicationNumber":"1234567890"}]}},...},{"code":"D",// Benefit Description"serviceTypeCodes":["MH"],"additionalInformation":[{"description":"BEHAVIORAL HEALTH MANAGED SEPARATELY"}]}],...}
{"benefitsInformation":[{"code":"U",// Contact Following Entity for Eligibility or Benefit Information"serviceTypeCodes":["MH"],// Mental Health..."benefitsRelatedEntities": [{"entityIdentifier":"Third-Party Administrator","entityType":"Non-Person Entity","entityName":"Acme Health Payer","entityIdentificationValue":"123456789",// Patient's member ID with the carveout admin"contactInformation":{"contacts":[{"communicationMode":"Telephone","communicationNumber":"1234567890"}]}},...},{"code":"D",// Benefit Description"serviceTypeCodes":["MH"],"additionalInformation":[{"description":"BEHAVIORAL HEALTH MANAGED SEPARATELY"}]}],...}
Plans often limit the number of covered visits for behavioral health services within a benefit period. Visit limits can appear in several places within benefitsInformation objects. Not all payers use the same fields.
{"benefitsInformation":[{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"benefitsServiceDelivery":[{"timePeriodQualifierCode":"23",// Calendar year"quantityQualifierCode":"VS",// Visits"quantity":"52",// 52 allowed visits per calendar year},...],...},{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"benefitsServiceDelivery":[{"timePeriodQualifierCode":"29",// Remaining"quantityQualifierCode":"VS",// Visits"quantity":"23",// 23 covered visits remaining},...],...},...],...}
{"benefitsInformation":[{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"benefitsServiceDelivery":[{"timePeriodQualifierCode":"23",// Calendar year"quantityQualifierCode":"VS",// Visits"quantity":"52",// 52 allowed visits per calendar year},...],...},{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"benefitsServiceDelivery":[{"timePeriodQualifierCode":"29",// Remaining"quantityQualifierCode":"VS",// Visits"quantity":"23",// 23 covered visits remaining},...],...},...],...}
{"benefitsInformation":[{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"benefitsServiceDelivery":[{"timePeriodQualifierCode":"23",// Calendar year"quantityQualifierCode":"VS",// Visits"quantity":"52",// 52 allowed visits per calendar year},...],...},{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"benefitsServiceDelivery":[{"timePeriodQualifierCode":"29",// Remaining"quantityQualifierCode":"VS",// Visits"quantity":"23",// 23 covered visits remaining},...],...},...],...}
{"benefitsInformation":[{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"benefitsServiceDelivery":[{"timePeriodQualifierCode":"23",// Calendar year"quantityQualifierCode":"VS",// Visits"quantity":"52",// 52 allowed visits per calendar year},...],...},{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"benefitsServiceDelivery":[{"timePeriodQualifierCode":"29",// Remaining"quantityQualifierCode":"VS",// Visits"quantity":"23",// 23 covered visits remaining},...],...},...],...}
{"benefitsInformation":[{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"benefitsServiceDelivery":[{"timePeriodQualifierCode":"23",// Calendar year"quantityQualifierCode":"VS",// Visits"quantity":"52",// 52 allowed visits per calendar year},...],...},{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"benefitsServiceDelivery":[{"timePeriodQualifierCode":"29",// Remaining"quantityQualifierCode":"VS",// Visits"quantity":"23",// 23 covered visits remaining},...],...},...],...}
Free-text notes Other payers include visit limits as free-text descriptions in the additionalInformation.description field. Look for a numeric visit cap, time period, or other restriction.
{"benefitsInformation":[{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"additionalInformation":{"description":"52 VISITS PER CALENDAR YEAR."}},...],...}
{"benefitsInformation":[{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"additionalInformation":{"description":"52 VISITS PER CALENDAR YEAR."}},...],...}
{"benefitsInformation":[{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"additionalInformation":{"description":"52 VISITS PER CALENDAR YEAR."}},...],...}
{"benefitsInformation":[{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"additionalInformation":{"description":"52 VISITS PER CALENDAR YEAR."}},...],...}
{"benefitsInformation":[{"code":"F",// Limitations"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient"additionalInformation":{"description":"52 VISITS PER CALENDAR YEAR."}},...],...}
Note: Technically, HIPAA doesn’t allow payers to send visit limits as free text, but some do anyway. If you see this, let us know. We can work with the payer to get it fixed.
Last date of service
Payers don’t typically include a full service history in their eligibility responses. But you can sometimes get the last date of service. This date is important if there’s a frequency limit, like a specific number of covered visits per week or month, for a benefit.
{"code":"A",// Co-insurance"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient..."benefitsDateInformation":{"latestVisitOrConsultation":"20250404"// Last service}}
{"code":"A",// Co-insurance"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient..."benefitsDateInformation":{"latestVisitOrConsultation":"20250404"// Last service}}
{"code":"A",// Co-insurance"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient..."benefitsDateInformation":{"latestVisitOrConsultation":"20250404"// Last service}}
{"code":"A",// Co-insurance"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient..."benefitsDateInformation":{"latestVisitOrConsultation":"20250404"// Last service}}
{"code":"A",// Co-insurance"serviceTypeCodes":["CF"],// Mental Health Provider – Outpatient..."benefitsDateInformation":{"latestVisitOrConsultation":"20250404"// Last service}}
5. Check for prior authorization and referral requirements
Psychiatry and intensive outpatient programs often require prior authorization or a referral before the payer will cover them.
Note: This section deals with prior authorization and referral requirements for medical benefits, not pharmacy benefits, like those related to psychiatrist-prescribed drugs.
Prior authorization
Prior authorization, also called pre-authorization or pre-certification, means the payer must approve care before it’s given. Otherwise, the service or procedure may not be covered.
To check if authorization is required, look at the authOrCertIndicator field in the benefitsInformation object for the related STC.
authOrCertIndicatorvalue
What it means
Y
Prior auth required
N
Not required
U
Unknown
Example: Prior authorization is required for substance abuse treatment
{"benefitsInformation":[{"code":"A",// Co-insurance"serviceTypeCodes":["AI"],// Substance abuse"authOrCertIndicator":"Y",// Prior authorization is required...},...],...}
{"benefitsInformation":[{"code":"A",// Co-insurance"serviceTypeCodes":["AI"],// Substance abuse"authOrCertIndicator":"Y",// Prior authorization is required...},...],...}
{"benefitsInformation":[{"code":"A",// Co-insurance"serviceTypeCodes":["AI"],// Substance abuse"authOrCertIndicator":"Y",// Prior authorization is required...},...],...}
{"benefitsInformation":[{"code":"A",// Co-insurance"serviceTypeCodes":["AI"],// Substance abuse"authOrCertIndicator":"Y",// Prior authorization is required...},...],...}
{"benefitsInformation":[{"code":"A",// Co-insurance"serviceTypeCodes":["AI"],// Substance abuse"authOrCertIndicator":"Y",// Prior authorization is required...},...],...}
If the authOrCertIndicator field isn’t present, you can assume authorization isn’t required. Payers may also include notes that clarify or override the authOrCertIndicator field in the additionalInformation.description field.
Referral requirements A referral is approval from a primary care provider (PCP) to see a specialist or receive certain services.
Referrals are less common in behavioral health, but some HMO plans still require them.
Payers don’t always provide referral information, and behavior varies. When it’s available, it appears as free-text in the additionalInformation.description field. Look for phrases like:
• "REFERRAL REQUIRED"
• "PCP AUTHORIZATION NEEDED"
Example: Referral is required for drug addiction treatment
{"benefitsInformation":[{"code":"A",// Co-insurance"serviceTypeCodes":["AK"],// Drug addiction"additionalInformation":[{"description":"PCP REFERRAL REQUIRED"}],...},...],...}
{"benefitsInformation":[{"code":"A",// Co-insurance"serviceTypeCodes":["AK"],// Drug addiction"additionalInformation":[{"description":"PCP REFERRAL REQUIRED"}],...},...],...}
{"benefitsInformation":[{"code":"A",// Co-insurance"serviceTypeCodes":["AK"],// Drug addiction"additionalInformation":[{"description":"PCP REFERRAL REQUIRED"}],...},...],...}
{"benefitsInformation":[{"code":"A",// Co-insurance"serviceTypeCodes":["AK"],// Drug addiction"additionalInformation":[{"description":"PCP REFERRAL REQUIRED"}],...},...],...}
{"benefitsInformation":[{"code":"A",// Co-insurance"serviceTypeCodes":["AK"],// Drug addiction"additionalInformation":[{"description":"PCP REFERRAL REQUIRED"}],...},...],...}
6. Run an eligibility check before each visit
Behavioral health patients often have recurring visits for services like therapy. Run an eligibility check before each appointment to get the most up-to-date co-pay, visit count, and last date of service.
Submitting claims promptly after each session also helps payers keep visit counts and service dates current, which reduces the risk of denials and unexpected costs for patients.
Get more tips
If you’re building eligibility workflows for the behavioral or mental health space, we can help. Contact us to set up a consultation.
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Stedi and the S design mark are registered trademarks of Stedi, Inc. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.
Stedi and the S design mark are registered trademarks of Stedi, Inc. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.
