Quick Explanation
Denial code BH85 indicates that a claim for behavioral health or substance use disorder services was denied because the clinical documentation failed to show that mandatory harm reduction strategies were implemented. Payers require evidence of proactive risk-mitigation efforts, such as overdose education or naloxone prescriptions, when treating patients with high-risk substance use disorders. Without clear documentation of these preventative measures in the medical record, the service is deemed non-compliant with standard care pathways.
Common Causes for BH85
Denials with code BH85 typically happen for the following specific reasons:
- Failure to document the prescription of or referral for overdose reversal medications, such as naloxone, for patients diagnosed with severe opioid use disorder.
- Absence of documented counseling regarding safe injection practices, infectious disease prevention, or referral to syringe service programs during high-risk substance use visits.
- Treatment plans that lack structured, patient-centered harm reduction goals or fail to show active patient engagement in risk-reduction planning.
- Non-compliance with specific state Medicaid or commercial payer policies that mandate harm reduction protocols as a prerequisite for behavioral health reimbursement.
How to Prevent BH85 Denials
To avoid receiving this denial in the future, implement these specific checks:
- Implement structured templates within the Electronic Health Record (EHR) that mandate clinicians to document harm reduction discussions, education, and intervention offerings.
- Conduct routine clinical documentation improvement (CDI) audits to verify that substance use disorder care plans contain clear, actionable harm reduction strategies.
- Provide regular training to behavioral health providers on ASAM (American Society of Addiction Medicine) criteria and state-specific billing rules concerning harm reduction.
- Establish automated alerts or clinical decision support tools in the EHR to flag high-risk patients who require documented harm reduction protocols before claim submission.
Appeal Letter Template for BH85
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: BH85 - Harm reduction strategies not implemented
Dear Appeals Department,
I am writing to appeal the denial of the above-referenced claim, which was denied with code BH85: "Harm reduction strategies not implemented".
We are formally appealing the denial of this claim under code BH85. A comprehensive review of the patient's medical record for the date of service demonstrates that appropriate, evidence-based harm reduction strategies were actively implemented and thoroughly documented, in strict alignment with the American Society of Addiction Medicine (ASAM) National Practice Guidelines and SAMHSA clinical recommendations. Specifically, the clinical notes reflect that the provider conducted a detailed risk-benefit counseling session, delivered overdose prevention education, and secured a viable plan for emergency intervention, meeting all requisite medical necessity criteria for substance use disorder management. As the documented care fully satisfies the payer's guidelines for integrated harm reduction, we respectfully request that this denial be reversed and the claim be processed for full 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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