Quick Explanation
This denial occurs when a behavioral health provider's treatment plan contains clinical goals that lack objective, quantifiable, or time-bound metrics, making therapeutic progress impossible to track. Payers require behavioral health documentation to demonstrate medical necessity through clearly defined, measurable outcomes rather than subjective statements of improvement. Ensuring all behavioral goals follow SMART (Specific, Measurable, Achievable, Relevant, Time-bound) criteria is essential for clinical validation and reimbursement.
Common Causes for BH35
Denials with code BH35 typically happen for the following specific reasons:
- The treatment plan outlines subjective goals (e.g., 'patient will feel less anxious') without defining specific measurement scales, frequency, or target benchmarks.
- Lack of a specified timeline or target date for achieving the outlined behavioral objectives within the documentation.
- Using non-quantifiable clinical language like 'improve coping skills' or 'increase self-esteem' without attaching standardized behavioral assessment scores or objective behavioral observation metrics.
- Failing to update the treatment plan to reflect progress or adjust goals that have already been met or are no longer clinically relevant during concurrent reviews.
How to Prevent BH35 Denials
To avoid receiving this denial in the future, implement these specific checks:
- Implement the SMART goal framework across all behavioral health treatment plans, ensuring every goal has a defined baseline, measurement tool, and target date.
- Utilize standardized clinical assessment scales (such as GAD-7, PHQ-9, or DSM-5 cross-cutting measures) to establish objective baselines and track quantifiable progress.
- Conduct regular internal clinical documentation audits to verify that behavioral objectives are clearly defined and updated before claims are submitted.
- Provide clinical staff with regular training on payer-specific medical necessity guidelines regarding behavioral health treatment plan documentation requirements.
Appeal Letter Template for BH35
If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.
[Your Practice Header]
[Date]
[Payer Name]
[Appeals Department Address]
RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: BH35 - Behavioral goals not measurable
Dear Appeals Department,
I am writing to appeal the denial of the above-referenced claim, which was denied with code BH35: "Behavioral goals not measurable".
Upon review of the clinical documentation for the dated service, we respectfully request a reconsideration of the denial for code BH35. The patient's treatment plan establishes clear, objective, and measurable behavioral goals that align with CMS and industry-standard behavioral health clinical guidelines. Specifically, the patient's progress is actively monitored using standardized, validated assessment tools (e.g., GAD-7 score reduction target from 15 to under 10 within 8 weeks) and documented behavioral frequencies (e.g., reducing panic episodes to less than one per week). These measurable metrics demonstrate that the treatment provided is highly structured, clinically necessary, outcomes-driven, and designed to systematically track therapeutic efficacy. We have enclosed the complete clinical notes and the corresponding treatment plan illustrating these objective metrics, and we request that this claim be reprocessed and approved for payment.
Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].
We respectfully request that you reprocess this claim for payment.
Sincerely,
[Your Name]
[Title]
[Practice Name]
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