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Behavioral health business glossary
The words you meet when you open, license, credential and bill a therapy practice or a treatment program, in plain English: levels of care (IOP, PHP, OP), the Texas license and credentials (CDTF, LCDC, QCC), insurance enrollment (NPI, CAQH, PECOS, TMHP), authorizations and reviews (UR, concurrent review, SCA), claims (per diem, UB-04, 837I/837P, ERA/EFT) and the laws that govern it all (Part 2, EKRA, the Texas Patient Solicitation Act). Each term has its own link to share, and points to the guide that goes deeper.
Updated October 24, 2026. Written by the team that runs a licensed Texas PHP, IOP and outpatient program. Rules change; regulatory terms link to their source.
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Behavioral health business glossary
#
- 270 / 271 eligibility inquiry and response #
- The electronic transactions (X12 standard) that ask a health plan whether a member is covered and return the benefits. A 271 rarely answers everything for a level of care like IOP or PHP, so admissions teams still call. Deeper: the VOB checklist · spotting a carve-out in the 271
- 835 electronic remittance advice #
- The electronic explanation of what a plan paid, adjusted or denied on each claim line. See ERA / EFT.
- 837I / 837P electronic claims #
- The electronic claim transactions defined by X12 and required under HIPAA. The 837I (institutional) is the electronic version of the UB-04; the 837P (professional) is the electronic version of the CMS-1500. A program may send either, depending on what each plan's contract asks for. Deeper: per diem claims in Cima EHR
A
- Accreditation Joint Commission, CARF, COA #
- An outside review of a program against national standards. It usually isn't required for a Texas IOP or PHP license, but TRICARE requires IOP and PHP programs to be accredited by Joint Commission, CARF or COA, and many commercial plans contract with programs only once they are. Surveys happen after you open and have charts. Deeper: Joint Commission checklist · CARF survey prep · Program Launch + Accreditation
- Anti-Kickback Statute (AKS) #
- The federal criminal law against paying or receiving anything of value for referrals of services paid by federal health programs such as Medicare and Medicaid. For commercial and self-pay referrals to treatment programs, recovery homes and labs, see EKRA; in Texas, also the Patient Solicitation Act.
- ASAM Criteria #
- The American Society of Addiction Medicine's criteria for placing a person in a substance use level of care, based on six dimensions (the 4th edition calls them intoxication, withdrawal and addiction medications; biomedical conditions; psychiatric and cognitive conditions; substance use-related risks; recovery environment interactions; and person-centered considerations). Many plans review admissions and continued stays against them (ASAM). In the familiar numbering, outpatient is Level 1, intensive outpatient 2.1 and partial hospitalization 2.5; use the edition and names your payer's form uses. Deeper: the six dimensions in prior authorization
- Assignment of benefits #
- The client's signed request that their health plan pay the provider directly. It usually sits in the financial agreement in the intake packet.
B
- BAA business associate agreement #
- The contract HIPAA requires with every vendor that handles client information for you: EHR, email, phone and fax, telehealth, billing, lab, cloud storage, shredding, IT. Keep the signed BAAs in one folder; auditors ask early (HHS). Deeper: Cima EHR's BAA and security
- BHEC Behavioral Health Executive Council #
- The Texas agency over the boards that license professional counselors (LPC), marriage and family therapists (LMFT), social workers (LCSW) and psychologists (bhec.texas.gov). Chemical dependency counselors (LCDC) are licensed by HHSC instead. Deeper: checking your license lets you practice on your own
- Biopsychosocial assessment (BPS) #
- The comprehensive intake assessment: history, substance use, medical and mental health, family, work, legal and supports, and for SUD care a rating on each ASAM dimension. The treatment plan is built from it, and reviewers read it at the first authorization.
C
- CAQH ProView #
- The online profile most commercial and Medicaid managed care plans read instead of a paper credentialing application: licenses, NPI, education, work history, malpractice and disclosures in one place (CAQH ProView). You authorize each plan to see it, and it must be re-attested every 120 days or plans can't use it. Deeper: credentialing · credentialing documents checklist
- CARF #
- CARF International, one of the two common accreditors for behavioral health programs, alongside Joint Commission (carf.org). After a survey, programs answer findings with a Quality Improvement Plan. Deeper: CARF survey prep
- Carve-out MBHO, behavioral health manager #
- When the medical plan on the card hands its mental health and substance use benefits to a separate company (for example Optum, Carelon or Magellan) that runs the network, authorizations and often the claims. You contract and get authorizations with that company, not the plan on the card. Deeper: behavioral health carve-outs
- CDTF chemical dependency treatment facility #
- The Texas license a program needs before it treats substance use disorders, issued by HHSC under Texas Health and Safety Code chapter 464 and 26 TAC chapter 564 (HHSC). The application includes HHSC forms 3207 and 3208 and an operational plan; after filing, the program must show it meets the rules within 6 months. Deeper: the HHSC license · the license steps in the IOP checklist
- CHOW change of ownership #
- A change in who owns a licensed program or enrolled provider, including a sale of the company or of a controlling share. Licenses, Medicaid and Medicare enrollments and plan contracts don't automatically follow the new owner: each agency and plan has its own notice or new-application rule, sometimes with deadlines before the closing date. For a Texas CDTF, check HHSC's current 26 TAC 564 rule, and have a health-care attorney plan the sequence before you sign a purchase agreement.
- Clearinghouse #
- The service that carries your electronic claims (837s) to each plan and brings back acknowledgments, rejections and remittances (835s), and runs eligibility checks (270/271). You enroll your NPI and tax ID with it, then add each plan's payer ID. Deeper: what claims cost in Cima EHR
- CLIA certificate of waiver #
- The federal certificate a site needs to run waived lab tests, including instant urine drug-test cups, applied for on form CMS-116 (CMS CLIA). It renews every two years; confirmation testing still goes to a reference lab.
- CMS-1500 professional claim #
- The paper claim form for professional services, with HCPCS or CPT codes on each line; maintained by the National Uniform Claim Committee (NUCC). Its electronic version is the 837P. Programs often bill per diem codes such as H0015 on it.
- Concurrent review continued-stay review #
- The plan's review, while the client is in care, of whether to approve more days or visits. Reviewers look for change: progress on each plan goal, updated ASAM ratings, attendance, drug screens and the step-down plan. We draft the continued-stay note about 5 days before the last approved day. Deeper: continued-stay reviews · UR reviews prompted in Cima EHR
- Corporate practice of medicine (CPOM) #
- The doctrine that limits who may own a business that employs or contracts with physicians to practice medicine. Texas has a strong version, so ownership and how a medical director is paid are questions for a health-care attorney before you sign. Cima Consulting isn't a law firm.
- Credentialing and contracting #
- Credentialing is the plan checking that a clinician or facility is qualified (licenses, education, history, malpractice). Contracting is the agreement on rates, codes and terms that follows. You're in network only when both are done and the plan gives you an effective date. Most plans take 60 to 120 days from a complete application. Deeper: how long it takes, by kind of plan
D
- Denial vs. rejection #
- A rejection is a claim the clearinghouse or plan wouldn't accept (bad ID, missing field); fix and resend it. A denial is a processed claim the plan won't pay (no authorization, not covered, timely filing, credentialing); it needs a corrected claim or an appeal. Sort denials by reason every week and fix the cause.
E
- Effective date #
- The first day a plan treats you as in network. Get it, and your provider ID, in writing. Claims for that plan's members before it usually deny, so see them as self-pay or under a single case agreement until then.
- EKRA Eliminating Kickbacks in Recovery Act #
- The federal law (18 U.S.C. 220) that makes it a crime to pay or receive anything of value for referrals to recovery homes, clinical treatment facilities or laboratories, whoever pays for the care, commercial plans and self-pay included. No payments, gifts or free rent for referrals, and run any marketing deal or percentage-based arrangement past your attorney. Deeper: referrals, the legal way · money and referrals for recovery homes
- ERA / EFT #
- Electronic remittance advice (the 835: what was paid and why) and electronic funds transfer (direct deposit). Enroll in both with each plan, often through its portal or Availity, so payments post to claims automatically and land in the business account.
- Exclusion check LEIE, SAM, state Medicaid list #
- Searching the HHS-OIG List of Excluded Individuals/Entities (LEIE), SAM.gov and your state's Medicaid exclusion list for every staff member and contractor, before hire and monthly. Nobody excluded can work on services billed to federal health programs. Deeper: staff credential file checklist
F
- Fee schedule #
- Two meanings: your own standard charge for each code (set it at or above what your best-paying plan allows, so you never bill a plan less than it would pay), and a plan's list of what it pays you per code under your contract. Get the plan's in writing before you sign.
- FindTreatment.gov #
- SAMHSA's locator of state-licensed treatment programs, which many referrers search (findtreatment.gov). Request a listing once your license is issued.
G
- Good faith estimate (GFE) #
- The written estimate of expected charges the federal No Surprises Act requires for uninsured and self-pay clients before services. A client billed at least $400 more than the estimate can dispute the bill (CMS).
- Governing body #
- The owners or board legally responsible for a program. It meets on a schedule, keeps minutes, approves policies each year, and appears on license and accreditation applications along with everyone who owns 5% or more.
- Grievance #
- A client complaint handled formally: acknowledged, investigated and answered in writing, with an appeal and outside options (the licensing board, the state agency, the health plan, the accreditor, HHS for privacy). The process is given at intake and posted. Deeper: the grievance procedure in the intake packet
H
- HCPCS codes H0015, S9480, S0201 #
- The code set (alongside CPT) used on professional claims. Programs commonly bill a daily code: H0015 for SUD intensive outpatient, S9480 for mental health intensive outpatient, S0201 for partial hospitalization. Each plan decides which codes it accepts, so confirm in every contract. Deeper: billing codes and authorizations
- HHSC Texas Health and Human Services Commission #
- The Texas agency that licenses chemical dependency treatment facilities and chemical dependency counselors, runs Texas Medicaid and contracts its managed care plans (hhs.texas.gov).
- HIPAA #
- The federal privacy, security and breach notification rules for health information. For a new practice or program: a written security risk analysis, policies, a notice of privacy practices, BAAs with vendors, and yearly training (HHS Security Rule). Substance use records also fall under Part 2.
I
- IOP intensive outpatient program #
- Structured treatment several days a week while the client lives at home: groups, individual sessions and family work. Most payers expect at least 9 hours a week for adult IOP (ASAM Level 2.1 for substance use). Commonly billed per day: H0015 (SUD) or S9480 (mental health), or revenue codes 0906 and 0905 on a UB-04. Medicare has paid for IOP since 2024 only through hospitals, community mental health centers and a few other provider types (CMS). Deeper: how to start an IOP or PHP in Texas · IOP opening checklist · an EHR for IOP and PHP
J
- Joint Commission #
- The accreditor that surveys behavioral health care programs under its Behavioral Health Care and Human Services standards (fact sheet). Findings are answered with Evidence of Standards Compliance; full surveys recur about every 3 years. Deeper: Joint Commission behavioral health checklist · compliance calendar
L
- LCDC Licensed Chemical Dependency Counselor #
- The Texas license for substance use counselors, issued by HHSC; counselor interns work toward it under supervision. LCDCs are qualified credentialed counselors in Texas SUD programs, but they generally can't bill Medicare on their own. Deeper: an EHR for addiction counselors
- LegitScript certification #
- A third-party certification Google and Meta require before addiction treatment providers can advertise. Apply once the license is issued; it takes weeks.
- Level of care #
- How intensive a service is: outpatient, intensive outpatient, partial hospitalization, residential and inpatient, plus withdrawal management. A step up or down between levels is a new authorization. See OP, IOP and PHP.
- LPC, LCSW, LMFT #
- Texas's licensed professional counselor, licensed clinical social worker and licensed marriage and family therapist, licensed through BHEC's boards. Associates (LPC Associate, LMFT Associate) practice under an approved supervisor. Since January 1, 2024, Medicare pays LPCs (as mental health counselors) and LMFTs (CMS). Deeper: how to start a private practice in Texas
M
- MCO managed care organization; STAR, STAR+PLUS, STAR Kids, CHIP #
- A health plan that manages care for its members. Most Texas Medicaid and CHIP clients are in managed care programs (STAR, STAR+PLUS, STAR Kids, CHIP) run by plans that differ by service area, so after enrolling with TMHP you credential with each plan in yours. Deeper: Texas Medicaid and managed care
- Medical necessity #
- The plan's test for paying: this person needs this service, at this level, now, under the plan's criteria (often ASAM for substance use). The assessment, treatment plan and each note must show it; it's the first thing a payer auditor reads. Deeper: chart audit checklist
- Mock survey #
- A practice survey run the way the accreditor or state surveyor does it (leadership, environment and record tracers, a chart sample and personnel files), with a written fix list to finish before the real one. Deeper: mock surveys and other services
- MOUD / MAT medications for opioid use disorder #
- Medications for opioid and alcohol use disorders, from your medical director, a partner prescriber or an opioid treatment program. Turning clients away because they take them can violate the ADA.
N
- NARR National Alliance for Recovery Residences #
- The national standards body for recovery residences, which describes four levels of support, from peer-run homes to homes with clinical services (NARR levels). Its state affiliates certify homes; in Texas that's TROHN. Deeper: how to open a sober living home in Texas
- NPI National Provider Identifier; Type 1 and Type 2 #
- The 10-digit HIPAA identifier on every claim, free from NPPES. Type 1 belongs to an individual clinician for life; Type 2 belongs to an organization (a practice or program) and is tied to its EIN. Each carries a taxonomy. Deeper: getting your NPIs
- Notice of privacy practices (NPP) #
- The HIPAA notice telling clients how their information is used and shared and what rights they have, given at intake with a signed acknowledgment, posted in the office and on your website. SUD programs add the Part 2 section.
O
- OP outpatient #
- Individual, family or group sessions below IOP intensity (ASAM Level 1 for substance use), usually billed per session with CPT codes rather than a daily rate. The usual step-down after IOP.
- Out-of-network #
- Care from a provider without a contract with the client's plan. The client's out-of-network benefits (if any) apply, often with higher costs; a single case agreement can set an in-network-style rate for one client.
P
- Part 2 42 CFR Part 2 #
- The federal rule protecting substance use disorder records from programs that hold themselves out as treating SUD and are federally assisted (eCFR). Most disclosures need the client's written consent with specific elements; since the 2024 final rule (compliance date February 16, 2026) one consent can cover treatment, payment and health care operations, and records can't be used in proceedings against the client without consent or a qualifying court order (final rule). Deeper: the Part 2 consent in the intake packet · Part 2 in Cima EHR
- Texas Patient Solicitation Act #
- Texas Occupations Code chapter 102, which bans offering or accepting anything of value for securing or soliciting patients for a licensed provider, whoever pays (Occupations Code ch. 102). Together with EKRA and the AKS, it rules out paid referrals and patient brokering.
- PECOS #
- Medicare's online enrollment system (Provider Enrollment, Chain and Ownership System). Each clinician, the practice and a reassignment of benefits are enrolled there; there's no application fee for individual clinicians or clinician groups, and enrollment is revalidated about every 5 years (pecos.cms.hhs.gov). Deeper: Medicare enrollment
- Peer-to-peer #
- A call between the treating clinician and the plan's reviewer about a proposed denial. In Texas, before a utilization review agent issues an adverse determination on medical necessity, it must offer the treating provider that chance. Deeper: denials and peer-to-peers
- Per diem #
- A daily rate: one charge for a program day that meets the level's required hours, instead of a charge per group or session. Common for PHP and IOP (S0201, H0015, S9480, or revenue codes 0905, 0906, 0912, 0913). A day short of its hours shouldn't be billed. Deeper: per diem billed only on days that meet their hours
- PHP partial hospitalization program #
- The most intensive outpatient level: treatment most of the day, most days of the week, while the client sleeps at home. Most payers expect about 20 hours a week (ASAM Level 2.5 for substance use). Commonly billed S0201 or revenue codes 0912 and 0913. Medicare pays for PHP only through hospitals and community mental health centers. Deeper: how to start an IOP or PHP in Texas · IOP / PHP Program Launch
- Prior authorization precertification, preauthorization #
- The plan's approval of a level of care before it's delivered (or within a set time after admission). PHP and residential commonly need it; IOP often does. Without it, the claim is usually denied even when the care was right. Deeper: prior authorization for SUD and mental health
- PTAN Provider Transaction Access Number #
- The number Medicare issues once an enrollment is approved, used with the NPI on Medicare's portals and on later applications, including Texas Medicaid for LPCs and LMFTs.
Q
- QCC qualified credentialed counselor #
- Under 26 TAC chapter 564, the counselors who may provide counseling in a licensed Texas chemical dependency treatment facility, such as LCDCs and certain other licensed professionals; counselor interns work under QCC supervision. Check each hire against the rule's current definition. Deeper: staffing a Texas program · staff credential file checklist
- QSO qualified service organization #
- Under Part 2, an outside organization (billing, lab, EHR, IT) that serves a program under a written agreement and may receive SUD records for that service. Under the 2024 rule, HIPAA business associates count as QSOs. Deeper: Quick VOB's Part 2 terms
R
- Recovery residence sober living home #
- A safe, alcohol- and drug-free home for people in recovery. Texas doesn't license them; certification is voluntary, and a 2023 law has HHSC set minimum standards consistent with NARR's and Oxford House's and approve only those two as accrediting organizations (HB 299). Deeper: how to open a sober living home in Texas · Recovery Residence Launch
- Recredentialing and revalidation #
- The repeat checks that keep you in network: plans recredential about every 3 years, Medicare revalidates about every 5, and Texas Medicaid at least every 5 (HHSC suggests filing 120 days early). A missed one can end your participation. Deeper: keeping credentials current
- Revenue code #
- The four-digit code on a UB-04 line that says what kind of service it was, maintained by the NUBC. Behavioral health programs commonly use 0905 (mental health IOP), 0906 (SUD IOP), 0912 and 0913 (partial hospitalization), as each plan's contract allows.
S
- SCA single case agreement #
- A one-client agreement with a plan you're not contracted with, at a rate agreed in writing before admission, along with the authorization. New programs use them while facility contracts are pending. Deeper: credentialing and contracts for programs
- Superbill #
- An itemized statement (codes, diagnoses, dates, fees, the provider's NPI and tax ID) a self-pay client sends to their plan for out-of-network reimbursement. Deeper: superbills in Cima EHR
T
- 26 TAC 564 #
- Chapter 564 of Title 26 of the Texas Administrative Code: HHSC's rules for licensed chemical dependency treatment facilities, covering licensing, staff (including QCCs), client rights, assessments, treatment plans, records and safety. A program's policies are best matched to it rule by rule before filing. Rules are amended, so read the current text (HHSC).
- Taxonomy code #
- The 10-character code on an NPI record that says what kind of provider you are (for example a counselor, a clinical social worker, or a clinic or facility type), from the Health Care Provider Taxonomy code set maintained by the NUCC. It should match the license and what you put on claims and applications; a mismatch stalls credentialing.
- Timely filing limit #
- The deadline, set in each plan's contract or rules, for submitting a claim after the date of service. Miss it and the claim is denied with no appeal. Check it before you sign each contract.
- TMHP and PEMS #
- The Texas Medicaid & Healthcare Partnership administers Texas Medicaid enrollment and fee-for-service claims for HHSC (tmhp.com); providers enroll and revalidate online in its Provider Enrollment and Management System (PEMS). Enrollment alone doesn't put you in a managed care network; see MCO. Deeper: Texas Medicaid and managed care
- Tracer #
- A survey method where the surveyor follows one client's care through the program, from intake to discharge, asking staff what they do and where it's documented.
- TRICARE #
- The health program for military members, retirees and families, run through regional contractors (tricare.mil). It requires IOP and PHP programs to be accredited by Joint Commission, CARF or COA.
- TROHN Texas Recovery Oriented Housing Network #
- The Texas NARR affiliate, which certifies recovery residences at every NARR level (trohn.org). Deeper: TROHN certification
U
- UB-04 CMS-1450, institutional claim #
- The paper claim form for institutional and facility services, with a revenue code on each line, maintained by the National Uniform Billing Committee (NUBC). Its electronic version is the 837I. Some plans want IOP and PHP billed this way.
- UR utilization review #
- The plan's review of whether care is medically necessary at the level requested: prior authorization before, concurrent review during, and retrospective review after. "UR" also names the program staff who manage it: tracking every authorization's last day and sending reviews on time. Deeper: prior authorization guide
V
- VOB verification of benefits #
- Checking a client's coverage before admission: active coverage, benefits for the level of care, deductible and out-of-pocket, prior authorization and who manages the behavioral health benefit, with the call reference number. Deeper: the VOB checklist · Quick VOB
Questions
What's the difference between IOP and PHP?
Intensity. PHP is most of the day, most days (about 20 hours a week for most payers); IOP is a few hours on several days (at least 9 hours a week for adults). Both let the client live at home, and both are commonly billed per day. In Texas, a program offering either for substance use needs the HHSC chemical dependency treatment facility license.
What is the difference between credentialing and enrollment?
Enrollment usually means government programs (Medicare in PECOS, Texas Medicaid in TMHP's PEMS); credentialing usually means a plan's review of your qualifications before a contract. In practice you need both, and you're in network only from the effective date.
Is Part 2 the same as HIPAA?
No. HIPAA covers health information generally; Part 2 adds protection for substance use disorder records from federally assisted SUD programs, with its own consent and redisclosure rules. The 2024 rule moved Part 2 closer to HIPAA but didn't merge them.
Need the words turned into a plan?
On a free 30-minute call we'll tell you which of these apply to what you're opening, in what order, and what it costs.
Opening a program? The IOP / PHP Program Launch covers the license, policies, credentialing and billing. Our free checklists: all checklists.
Sources
- eCFR, 42 CFR Part 2; HHS, Part 2 final rule (February 16, 2024); HHS, HIPAA for professionals
- CMS, NPPES, PECOS, CLIA, No Surprises Act, CY 2024 outpatient rule, MFTs and mental health counselors
- Texas HHSC, hhs.texas.gov; TMHP; BHEC; Texas Legislature, Occupations Code ch. 102 and HB 299 (2023); 18 U.S.C. 220 (EKRA)
- The ASAM Criteria; X12; NUBC; NUCC; CAQH ProView; HHS-OIG, LEIE
- The Joint Commission, behavioral health care accreditation; CARF; TRICARE; NARR; TROHN; FindTreatment.gov
General information, not legal, billing or clinical advice. Cima Consulting isn't a law or accounting firm.