Understanding VOB in Behavioral Health (Part 2): What to Ask, What to Track, and How to Get It Right

Now that we’ve covered why the Verification of Benefits (VOB) process matters and where things often go wrong, it’s time to get practical.

This post walks you through what to ask when verifying behavioral health benefits, how to document the answers, and how to build a consistent workflow that protects your revenue and supports your clinical team. Whether you’re new to the VOB process or training staff to take it over, this is the structure you want to build around.

Before you ever pick up the phone to verify a member’s benefits, it’s critical to make sure you’re fully prepared. A well-structured VOB call is only as good as the information you bring to it—and having complete, accurate details upfront can make or break the outcome.

Here’s what you should always have in hand before making that first call:

This might seem basic, but it’s one of the most overlooked steps—especially when staff are rushing during intake. The front provides key plan details and the member ID, while the back contains critical phone numbers (including the one you’ll call for benefits), payer addresses, and sometimes carve-out information for behavioral health.

🔎 Pro tip: Watch for cards with multiple plan logos—especially when dealing with third-party administrators or behavioral health carve-outs.

This isn’t just for compliance—it ensures that you’re documenting the correct individual, validating demographics, and aligning with payer expectations for member identification.

Before verifying benefits for a particular level of care, it’s important that the member understands what benefits you’re trying to access—and consents to using them. This is especially important when:

• You’re billing out-of-network
• You anticipate high member responsibility
• The member is covered for multiple levels of care (e.g., IOP, PHP, RTC)

Clarity upfront avoids confusion later—especially when you’re navigating reimbursement issues or member responsibility disputes.

Once you’re on the phone with a payer, your goal isn’t just to confirm coverage—it’s to extract as much accurate, applicable, and actionable information as possible. A half-complete VOB can leave you stuck with denials, rework, or unpaid balances. This section walks through what you need to ask—and why each piece matters.

Before diving into coverage details, make sure all the basics are right—name, date of birth, policyholder info—so you don’t waste time verifying benefits for the wrong person:

• Member’s full name and date of birth
• Subscriber’s name, date of birth (if different), and relationship to member (self, spouse, dependent, etc.)
• Member’s address
• Member services phone number (log for their future reference)

You’ll likely already have this information from the member’s insurance card and photo ID, but it’s still important to confirm it directly with the payer. Sometimes members enroll under an alternative name—like “Joe” instead of “Joseph”—and even small mismatches can create issues during claims processing. Verifying subscriber details and confirming the correct member services number also helps ensure you’re working with accurate, up-to-date information from the start.

Once the member is confirmed, verify the insurance plan’s structure and routing. What’s printed on the card is just the start:

🔎 Pro tip: Always confirm who the subscriber is—especially for dependents or spouses. Policies often split behavioral health coverage between subscriber and dependent levels.

• Insurance company name — especially for BCBS plans, confirm the correct state affiliation using the three-letter prefix at BCBS.com
• Provider line phone number
• Member ID number – verify what’s on the card matches what the system shows
• Group number – essential for claim routing and payer-specific benefits (especially UMR, Aetna, etc.)
• Plan type – PPO, HMO, EPO, POS (determines OON eligibility)
• Payer ID – where the claims get submitted (vital for clearinghouses or EDI systems)
• Claims mailing address – confirm accuracy for paper claims or backup documentation

🔎 Pro tip: For BCBS plans, make sure to use tools like the Blue Shield of CA Claims Routing Tool to determine where to send claims based on prefix.

Now that you’ve confirmed the basics, dig into the eligibility:

• Is the policy active? (ask if there are pending terminations)
• Effective date and termination date, if available
• Does the policy run on a calendar year or plan year? If plan year, ask for the exact benefit period
• Is the policy subject to pre-existing condition clauses?
• Does the plan offer out-of-network benefits?
• Is this the primary insurance? If not, stop and request full info for the primary payer
• Are there any other policies on file (secondary, tertiary, Medicare, Medicaid, supplemental)?
• When was the last coordination of benefits (COB) updated?

If the policy is inactive, there is no reason to continue asking further details on the benefits of the policy. Document the termination date, then move on to grabbing the rep’s name (first and last initial) along with a reference number. Document the date and time of the call, and then follow-up with the member to identify if they have any other alternative coverage.

🔎 Pro tip: If COB is outdated, you risk denials for other coverage being “active” in the system—even if the member swears it isn’t. Always have the member update COB and then re-verify benefits afterwards for increased confidence.

This is where your Utilization Review process begins. Ask about authorization requirements by level of care, using all relevant codes. A generic “yes, it’s covered” isn’t enough—get specific.

Sample Codes to Ask About by Level of Care:

Level of Care	HCPCS	REV	CPT (if applicable)
Detox (DTX)	H0009 / H0010	0126 / 0128 / (1000 – payer specific)	—
Residential (RTC)	H0017 / H0018	1001 (MH) / 1002 (SUD)	—
Partial Hospitalization (PHP)	S0201 (SUD) / H0035 (MH)	0912 / (0911/0913 – payer specific)	—
Intensive Outpatient (IOP)	H0015 (SUD) / S9480 (MH)	0906 (SUD) / 0905 (MH)	—
Outpatient (OP)	—	0914 (individual), 0915 (group)	90832 (IND30), 90834 (IND45), 90837 (IND60), 90853 (group)

🚨Please note: The above codes are subject to change over time, and individual payers reserve the right to request claims be submitted with differing procedure codes, such as Optum’s recent change of ASAM 3.7 DTX code from 0126 to 1000. Please use the above codes as a guide, but always defer to your Certified Billing/Coding Professional!

Ask:

• Is preauthorization required for each?
• Which codes are accepted or preferred (some payers lean toward REV vs. HCPCS)
• What are the penalties if pre-auth is missed—denial or reduction in payment?

Also confirm:

• Who handles authorizations? (Is it the same company or a carve-out like Lucet, AmeriBen, Quantum, etc.?)
• What’s the phone number and prompt path for behavioral health pre-auth?
• Is there a specific way the precertification request needs to be submitted—like through Availity, fax, or another portal?
• Are there visit/day limits? Are they shared across levels or broken out individually?

Once you’ve confirmed coverage and authorization requirements, it’s time to get clear on the member’s financial responsibility. This part of the VOB call directly impacts admissions, reimbursement expectations, and your ability to plan for collections.

Here’s what to ask—and what to watch out for:

• What is the deductible?
  Ask separately for in-network (INN) and out-of-network (OON) amounts
• How much of the deductible has been met?
  Always ask for accumulations to date
• Does the deductible accumulate toward the out-of-pocket max (OOP max)?
  💡 This affects how quickly a plan will start covering more costs, especially for OON policies
• What is the coinsurance percentage?
  Ask for both INN and OON—e.g., plan covers 70%, member owes 30%
• Is there a flat copay instead? (More common for INN services)

• What is the member’s OOP max for INN and OON?
• How much has been met so far this benefit period?

🔎 Pro tip: Watch for cases where deductibles reset on a different cycle than OOP max (e.g., deductible resets Jan 1, but OOP resets in July).

Understanding how a plan reimburses is critical—especially if you’re billing out-of-network. Not all rates are created equal, and the wording in the VOB can give you key clues about whether a claim will pay well, poorly, or not at all.

Here’s a general order of reimbursement—from best to worst:

1. Percentage of billed charges (e.g., “90% of billed” is gold)
2. Usual & Customary (U&C/UCR) – always a strong option
3. Maximum Reimbursable Charge (MRC1/MRC2) – better than Allowable or Medicare
4. Allowable – varies by state; can be mediocre or worse
5. Medicare rates – often the lowest, sometimes as little as 10% or less of billed

Additionally, you’ll want to ask if the policy uses a third-party pricing network like Multiplan, Zelis, or Viant. These vendors may offer:

• Pre-payment negotiations (before a claim pays)
• Post-payment reconsiderations (after initial payment is issued)

Even if a policy doesn’t reimburse at a strong rate on its own, the ability to negotiate through a third-party network can make the total reimbursement well worth pursuing. Just keep in mind: when you accept a negotiated rate, you’re agreeing to adjust off the remaining patient balance and forfeit the right to balance bill. That’s the trade-off—but in many cases, it can significantly increase what you collect.

🔎 Pro tip: Policies from Cigna, UMR, Oxford, All Savers, and others are often negotiable—even if the plan doesn’t advertise it. Always check.

The last leg of any thorough VOB call is asking the hard (but often skipped) questions about limitations and exclusions. These details are easy to overlook—but they can completely derail claims adjudication.

Make sure to ask:

• Are there exclusions for substance use treatment?
  Some plans restrict SUD coverage entirely—or only allow coverage under very narrow conditions (e.g., detox only, or treatment must be court-mandated).
• Can a free-standing facility bill for services?
  Certain plans limit coverage to hospital-affiliated providers or require inpatient licensing for all behavioral health services.
• Is your facility’s accreditation sufficient?
  Even if you’re licensed by the state, the policy may require JCAHO or CARF accreditation—and may restrict which levels of care that applies to.
• Are there state-specific restrictions?
  Even if a policy allows out-of-state treatment, certain states may be excluded (California and Florida are common culprits).
• Are there visit caps or cumulative limitations?
  Find out whether the member has a finite number of visits or days—and whether that limit resets annually, on a plan year, or never.
• Anything unusual?
  If you’re verifying a less common service (e.g., EMDR, MAT, or case management), ask whether it’s covered—and if not, what the limitations are.

As always, document everything: date/time, rep’s name and last initial, and the reference number. That final reference number is your ticket if anything is disputed later.

🔎 Pro tip: Always include a “Notes” section in your VOB form to summarize special considerations or carve-out instructions—especially for policies with tricky IVRs, uncommon coverage quirks, or rep-specific disclaimers.

By now, you’ve seen just how layered a comprehensive VOB really is. It’s not just a yes/no question of “Does the member have benefits?” It’s a web of details—each with the potential to support or stall the entire treatment process.

The best VOBs are:

✅ Timely
✅ Documented
✅ Specific to your levels of care and codes
✅ Verified by phone (and confirmed via portal)
✅ Supported by reference numbers and detailed notes

You’re not just verifying coverage—you’re protecting your team’s ability to get reimbursed.

Now that you know what to ask, when to ask it, and why it matters—your next step is consistency.

Use our downloadable VOB template to streamline the process, eliminate gaps, and make sure your team never misses a critical question again.

Want to go deeper into related topics—like managing authorizations, appeal letters, or common denial traps? Let us know what you’d like to see next.

We’ll also release our downloadable VOB template—a fillable, organized guide with all the fields discussed in this post so your team never has to guess what to ask again.

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💾 And if you’re ready to start verifying smarter—[Download the VOB Template (coming soon!)].