The VOB checklist for treatment admissions

1. Before you check: get the card right

Most bad VOBs start with bad inputs. Before anything else, get a photo of the front and back of the card and confirm:

• The member's name and date of birth exactly as the plan has them, and whether the caller is the subscriber or a dependent (if a dependent, you need the subscriber's name and date of birth too).
• The member ID with its prefix. Blue Cross plans use a three-character prefix that tells you which plan actually holds the benefits.
• The group number, and whether the plan is through an employer, the marketplace, Medicaid, Medicare or TRICARE.
• The phone numbers on the back. A separate "behavioral health" or "mental health and substance use" number usually means a carve-out (below).

2. What an electronic check tells you

A real-time eligibility check (the 270/271 transaction your clearinghouse sends) answers the money questions in seconds, usually for the "mental health" and "substance use" service types:

Item	What to look for
Active coverage	Active today, and the plan's start and end dates. A plan ending this month changes the conversation.
Deductible	Individual and family, in and out of network, and how much is already met.
Out-of-pocket maximum	The most the member will pay this plan year, and how much is left. This is the number families care about most.
Coinsurance and copays	For outpatient behavioral health; some plans list a different copay for facility or intensive services.
Network	Whether out-of-network benefits exist at all. HMO and EPO plans often have none.
Prior authorization	Whether the plan says auth is required. Treat "not indicated" as "ask," not as "no."
Other payers	A carve-out or another insurer named in the response. Bill the wrong one and the claim comes back.

Payers rarely send level-of-care details electronically: how many PHP or IOP days are covered, precertification rules, or whether residential is covered at all. That's what the call is for.

3. What still needs a call, by level of care

Call the behavioral health number, give your organization's NPI and tax ID, and ask for each level of care you might use:

• Is it covered in network and out of network, and at what coinsurance after the deductible?
• Is prior authorization or precertification required, who handles it (the plan or a carve-out), and how far ahead must you request it?
• How are days or units approved: how many at first, and when is the first continued-stay review?
• Which codes and claim form do they expect for per diem PHP or IOP (for example a revenue code on a UB-04, or a HCPCS code on a CMS-1500)?
• Any limits: visit caps, exclusions for your facility type or provider type, or medical-necessity criteria they use (many plans use ASAM criteria for substance use).

Before you hang up, write down the rep's name, the date and time, and the call reference number. If a claim is denied against what the rep told you, that reference number is your appeal.

Carve-outs

Many medical plans hand behavioral health to a separate company, such as Optum, Carelon or Magellan. The medical plan's check may show coverage while the carve-out holds the actual benefits and authorizations. When the card or the eligibility response points to one, run the check and make the call with the carve-out. Our guide to behavioral health carve-outs lists how to spot them.

4. Authorizations: the part that gets lost

A VOB isn't finished when benefits are known; it's finished when the authorization is on file and someone owns its last day.

• Record the auth number, level of care, approved days or units, start and end dates, and the reviewer's name.
• Put the last authorized day on a calendar with a reminder about 5 days ahead, so the continued-stay review is written and sent before the auth runs out, not after.
• When a client steps down (PHP to IOP, IOP to outpatient), the new level usually needs its own authorization.

For what to send and when, see the prior authorization guide.

5. Six mistakes that become denials

1. Checking the subscriber instead of the dependent, or the other way around.
2. Missing the carve-out and authorizing with the wrong company.
3. Taking "auth not required" from an electronic response for a level of care the response never mentioned.
4. No reference number for the call, so there's nothing to appeal with.
5. Not re-checking at admission. Coverage verified on Friday can end on the first of the month.
6. Letting an authorization lapse because nobody owned its last day.

Fully insured or self-funded?

Ask, or look at the card: a plan regulated by the Texas Department of Insurance usually shows "TDI" or "DOI" on the card, and a self-funded employer plan doesn't. Self-funded plans follow federal ERISA rules instead of Texas insurance law, so Texas prompt-pay and appeal rules may not apply; TDI explains the difference. Note which kind it is on the VOB.

Going deeper: how auths work level by level is in the prior authorization guide, the questions admissions teams ask most are in the Quick VOB FAQ, and if you're weighing a VOB service, see VOB software vs outsourcing. Programs that also want the authorizations and continued-stay reviews tracked on the chart can use Cima EHR for IOP and PHP.

6. What to keep in the chart

File one VOB record per check: the benefits as returned, what the rep said by level of care with their name and reference number, the authorization details, who did the check and when. Surveyors and payer auditors both look for it, and your billing team will thank you.

This guide is general information, not legal or billing advice. Payer rules differ by plan and change; confirm with each plan and your contracts.