Quick Explanation
Denial code MH26 indicates that a claim or quality reporting measure was denied because there is no documented evidence that a required substance use screening was completed for the patient. This typically occurs during annual wellness exams, preventive visits, or behavioral health evaluations where screening is a mandatory component of the service or quality metric. Without the specific HCPCS, CPT, or Category II codes indicating completion on the claim, payers will deny the service.
Common Causes for MH26
Denials with code MH26 typically happen for the following specific reasons:
- Failure to append the appropriate CPT Category II code or HCPCS code (e.g., G0442 for alcohol screening, G0443 for brief intervention) to prove completion of the screening.
- Incomplete clinical documentation in the electronic health record (EHR) showing that a validated screening tool (such as DAST-10, AUDIT, or CRAFFT) was actually administered and scored.
- Omitting the necessary documentation or billing modifiers when a patient was ineligible for the screening due to cognitive impairment or other clinical exclusions.
- Billing for a comprehensive preventive or psychiatric service that inherently mandates a substance use screening component without fulfilling or documenting that specific element.
How to Prevent MH26 Denials
To avoid receiving this denial in the future, implement these specific checks:
- Configure EHR clinical decision support alerts to prompt providers to perform and document validated substance use screenings during all eligible preventive and behavioral health encounters.
- Establish automated billing rules that link primary preventive/wellness codes with the appropriate screening HCPCS codes (e.g., G0442, G0443) or CPT Category II quality codes when the EHR documentation requirements are met.
- Train clinical and coding staff on the specific documentation requirements for SBIRT (Screening, Brief Intervention, and Referral to Treatment) services, including the tool used and total time spent.
- Regularly audit preventive care claims to ensure quality reporting measures and screening codes are correctly aligned before submission.
Appeal Letter Template for MH26
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: MH26 - Substance use screening not completed
Dear Appeals Department,
I am writing to appeal the denial of the above-referenced claim, which was denied with code MH26: "Substance use screening not completed".
We are appealing the denial of the submitted service under denial code MH26 (Substance use screening not completed). A detailed review of the clinical documentation for the date of service [Insert Date of Service] confirms that a validated substance use screening was successfully completed utilizing the [Insert Screening Tool, e.g., AUDIT/DAST-10] tool. The provider documented the patient's responses, calculated the clinical score, and formulated an appropriate plan of care in strict accordance with CMS Screening, Brief Intervention, and Referral to Treatment (SBIRT) guidelines. Because the medical record fully substantiates that the substance use screening was completed and medically necessary, we respectfully request that this denial be reversed and the claim be processed 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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