Blue Cross’ Change to Adjustment Disorder Treatment Coverage Related to Ensuring Proper Billing for Appropriate Diagnoses
Blue Daily
| 3 min read
Blue Cross Blue Shield of Michigan is committed to keeping health care affordable and accessible for our members. We believe that quality care should be accessible to every member while maintaining a sustainable and affordable health care system. Working with our provider partners to ensure that members have access to safe, effective, evidence-based treatments for their conditions aligns with these core beliefs.
In November, Blue Cross made a policy change for adjustment disorders that subjected any claim submitted by behavioral health providers for services beyond six months to a clinical edit and denial.
This change is rooted in ensuring that providers are billing for the appropriate diagnosis, which promotes efficacy and improves member outcomes. We have a responsibility, as stewards of our members’ and customers’ premiums, to ensure payments for treatments are appropriate and beneficial to our members. Here’s more about what adjustment disorder is, why we made this change and how we believe it will benefit the health outcomes of our members.
Understanding adjustment disorder and how Blue Cross data suggests diagnoses may be overrepresented
Adjustment disorders are strong reactions to stress or trauma. A stressor in this context could be a positive or negative event that causes short-term symptoms that affect a person’s thoughts, behaviors and emotions.
Adjustment disorder is listed in the Diagnostic and Statistical Manual of Mental Disorders as a time-limited condition that is in response to an inciting adverse event that usually resolves in six months. While symptoms for adjustment disorders typically go away six months after the end of the stressful event, we understand that some adjustment disorder diagnoses can become chronic or long-lasting, especially if the stressor is persistent or the disorder goes untreated.
Chronic adjustment disorders can develop into other serious mental health conditions, such as anxiety or depressive disorders, that could have lifelong consequences if not appropriately diagnosed and treated early.
Between June 2024 and May 2025, Blue Cross has received 75,000 claims involving continuous adjustment disorder episodes of longer than six months – with thousands more surpassing 12 months. This data suggests adjustment disorder diagnoses may be overrepresented.
Failure to routinely reassess patient symptoms and update the diagnosis is a quality concern that could result in ineffective or inappropriate treatment. Ongoing review and documentation of an accurate and current diagnosis – with associated medically necessary treatment – is a fundamental expectation for all health care services.
Practicing transparency and working together to eliminate barriers is the only path forward to ensure optimal outcomes for our members. We believe this policy change reflects those core beliefs.
If an adjustment disorder is chronic and not better explained with an alternative diagnosis, there is a process for requesting a clinical editing reconsideration.
We are committed to working collaboratively with behavioral health providers in our shared goal of delivering high-quality, clinically appropriate and affordable health care to our members. Over the last year, Blue Cross has provided several in-person and virtual Behavioral Health Summits, “lunch and learn” events and webinars to bring awareness to other programs and resources available to support providers and offer assistance with issues they may be struggling with, including credentialing or billing.
Feedback from our network partnerships – and a desire to further assist the continuum of care – led us to expand access to supportive services that coordinate with behavioral health and primary care providers, and crisis and urgent care programs that ensure all members have access to the right care at the right time.
We know our members and your patients are best served when they can access high quality, appropriate behavioral health care services. Working together to eliminate barriers and being transparent is the only path forward to ensure optimal outcomes for our members.
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