01
Claim Verification
Verified that all 10 behavioral health claims were processed correctly with no billing or coding errors.
Case StudyBehavioral HealthPayer Contract Analysis
Carelon
Reimbursement Rates Were Too Low
How Ambit Global Solution identified the real problem and initiated a contract rate review for a behavioral health practice.
Root Cause AnalysisContract ReviewNo Billing Errors Found
Executive Summary
Overview
A behavioral health practice approached Ambit Global Solution after noticing that Carelon Behavioral Health payments were substantially lower than every other commercial payer — and even lower than New Hampshire Medicaid rates.
Our team performed a comprehensive reimbursement analysis, verified that the claims were processing correctly, and determined that the issue was not billing or coding — it was the provider's contracted fee schedule.
Client
Behavioral Health Practice
Payer
Carelon Behavioral Health
State
New Hampshire
The Challenge
What Was Breaking
The provider was experiencing reimbursement that was significantly below market rates. The practice wanted to determine:
- Whether the payments were incorrect
- Whether a fee schedule review could be requested
- If contract renegotiation was possible without full recredentialing
Our Investigation
How We Approached It
Ambit Global Solution conducted a detailed, four-step reimbursement review to isolate the true source of the shortfall.
02
Fee Schedule Comparison
Compared paid amounts against the Carelon contracted fee schedule to confirm accuracy of payments.
03
Commercial Payer Benchmarking
Benchmarked reimbursement against every other commercial payer in the practice's portfolio.
04
Medicaid Rate Review
Reviewed New Hampshire Medicaid reimbursement rates to establish a floor for comparison.
The Key Finding
It Wasn't a Billing Error — It Was the Contract
The claims were not being underpaid because of a billing error. The reimbursement was accurate according to the provider's current Carelon New Hampshire contracted rates.
The real issue was the contract itself. During a review of 10 behavioral health claims, we found that the average Carelon reimbursement was approximately 42% lower than the practice average from other commercial insurance plans.
42%
Gap Below Commercial Benchmark
- Claims were processing correctly — no billing or coding errors
- Carelon NH rates were dramatically below commercial payer averages
- The gap was present across all major psychiatric evaluation codes
- The issue required a contract review, not a claim appeal
Contract Reimbursement Analysis
Carelon Rates vs. Commercial Benchmark
We compared Carelon contracted reimbursement rates with the practice average reimbursement from other commercial payers. The review identified significant gaps across multiple behavioral health CPT codes.
| CPT Code | Service Description | Carelon Contracted Rate | Commercial Benchmark | Revenue Gap |
|---|---|---|---|---|
| 99205 | New Patient Office Visit (High Complexity) | $72 | $336.57 | 79% |
| 99204 | New Patient Office Visit (Moderate Complexity) | $72 | $254.82 | 72% |
| 99213 | Est. Patient Office Visit (Low Complexity) | $29 | $117.23 | 75% |
| 99214 | Est. Patient Office Visit (Mod. Complexity) | $32 | $172.56 | 81% |
| 99215 | Est. Patient Office Visit (High Complexity) | $52 | $229.74 | 77% |
| 90833 | Psychotherapy Add-On (30 min) | $9 | $73.45 | 88% |
Based on comparison with the practice's other commercial payer contracts. The analysis demonstrated that Carelon reimbursement was significantly below the practice's benchmark commercial reimbursement across all major psychiatric evaluation, medication management, and psychotherapy CPT codes.
Measurable Results
Impact
10
Claims Reviewed & Validated
42%
Below Commercial Benchmark
20–40%
Potential Improvement Identified
$320
Est. Recovery on 10 Claims
What We Delivered
- 10 Carelon behavioral health claims reviewed and validated
- Confirmed that all claims were processing correctly
- Quantified the reimbursement gap at 42% below commercial benchmarks
- Identified a potential 20–40% improvement opportunity once contracted rates are renegotiated
Action Taken by Ambit Global Solution
What Happened Next
Our team contacted Carelon Behavioral Health Provider Services directly and discussed the reimbursement concern with the payer on behalf of the practice.
Carelon Confirmed the Following
- 1A request for rate increase review was submitted to the Carelon Contracting Department
- 2The practice should follow up after 30 business days
- 3A rate increase can be processed without recredentialing if approved
- 4No special form or written request is required for the initial review
- 5If denied, the provider may submit a formal appeal requesting a contracted rate review
- 1
Identify
Recognized payment anomaly — rates below Medicaid floor
- 2
Analyze
Reviewed 10 claims; compared against all commercial payers
- 3
Confirm
Verified claims were accurate — issue is the contracted rate
- 4
Advocate
Contacted Carelon directly; submitted rate review request
- 5
Escalate
Submitted formal request to Carelon Contracting Department
The Outcome
Key Takeaway
By identifying the true cause of the problem, Ambit Global Solution was able to take targeted action that corrects the issue at its source.
Confirmed the applicable Carelon New Hampshire fee schedule
Verified that claims were processing correctly with no billing errors
Determined that the reimbursement issue was contractual, not operational
Initiated a formal contract rate review request with Carelon
Why Practices Choose Ambit Global Solution
Beyond Claim Correction
Many medical billing companies stop after correcting claim errors. Our team goes further.
We analyze payer contracts, validate fee schedules, identify reimbursement opportunities, and advocate for providers when contract rates are not competitive — turning a reactive billing function into a proactive revenue strategy.
Payer Contract Analysis
Deep review of contracted rates against commercial benchmarks
Fee Schedule Validation
Confirm accurate reimbursement per contracted terms
Opportunity Identification
Surface hidden revenue gaps before they compound
Provider Advocacy
Direct engagement with payers on your behalf
What Sets Us Apart
Root Cause First
We find why revenue is leaking, not just where
Payer Intelligence
Deep knowledge of payer contracts and fee schedules
Full Advocacy
We contact payers directly and initiate reviews for you
Closing CTA
Your Contract Could Be Costing You Revenue
Every engagement starts with a complimentary reimbursement review. We'll identify exactly where your contracted rates fall short and quantify what recovery looks like for your practice.
- HIPAA Compliant
- Healthcare RCM Specialists
- Behavioral Health Experts
- No Commitment Required