Compliance—
a Headway Guide
Navigating compliance for insurance can be time-consuming and stressful.
We’re committed to changing that.
Overview
Let's partner together to make insurance compliance easy and stress-free.
Documentation, coding, and billing
Proper documentation and billing practices are a big part of compliance. Getting them right requires a level of detail that may not be immediately intuitive, but once you’ve got it down, the process becomes second nature. We’re going to get there together.
You have two options when keeping documentation:
Headway templates
If you complete your notes on Headway, the templates we provide are optimized for documentation, coding and billing compliance, which also means we can guarantee protection from clawbacks.
We’re taking the guesswork out of what you need to do and when you need to do it—and cutting down on the amount of time note-taking takes, including options to pre-fill from previous notes or have AI generate a full progress note.
or
External notes
You can continue to take and store your notes using your preferred HIPAA-compliant method—on Headway, on a different EMR system, or offline.
In the event of a review or audit, you will be required to share your documentation with us. Other than Medicare and Medicaid plans, you usually have the option to confirm without adding a note to Headway.
Periodic reviews
Insurers sometimes perform audits to prevent fraud, waste, and abuse. Meanwhile, Headway will occasionally proactively review notes so that providers are prepared for potential audits. Reviews and audits like these help providers maintain a strong record of care, while ensuring clients are receiving care appropriate for their mental health concerns.
Don’t stress — this guide and our policies exist to help you avoid a disruptive audit.
How to be compliant
Proper documentation and billing are a large part of being compliant.
Documentation
Our documentation requirements follow standards outlined by the American Medical Association (AMA), Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), commercial insurers, and regulatory bodies.
Documentation of relevant aspects of client care, including documentation of medical necessity, should ideally be completed within 24 hours of visit, and no later than 72 hours. Read more about why these deadlines are important.
While there’s a lot of information across those standards, we've broken down the key details below:
Types of documentation*
Intake note
An intake note should be created when initiating a treatment relationship with a client.
The intake note is a crucial piece of documentation, which helps inform both your treatment plan and the rest of the care you provide for a given client. Broadly speaking, this note should include:
- reason for seeking treatment
- past treatment history
- past successes or struggles
Resources
Headway template
See intake note example
Review policy
Treatment plan
A treatment plan establishes objectives and monitors progress. The plan includes a diagnosis and clearly establishes medical necessity for treatment.
Plans must be:
- created within 14 days of the start of treatment or by the next session after the initial session, whichever comes first
- updated at least every 180 days for commercial plans, or 90 days for Medicaid plans, to ensure your client’s goals are up-to-date
- acknowledged by the client—via signature for in-person sessions or verbally for telehealth (Headway templates include a checkbox to acknowledge this)
Resources
See treatment plan example
Review policy
Progress notes
Progress notes should demonstrate a clear and comprehensive story of the client’s progress through treatment. Clear continuity of care is important — each note should lead into the next but also stand alone.
Progress notes should also refer back to the treatment plan and corresponding objectives. This ensures you’re providing a clear clinical record that supports both continuity of care and compliance requirements. Note that Headway templates automatically include these items, so you can rest assured you’ve got everything covered.
Resources
Headway template
See progress note example
Review policy
* Use these recommendations as guidelines. To the extent your license or a particular insurer has stricter requirements than those set forth here, please follow those requirements.
Headway clinical templates
Headway's templates are optimized to keep you compliant with insurance documentation requirements while saving time. Learn more about our templates here:
Billing
Our goal is to assist you in submitting claims with CPT (Current Procedural Terminology) codes that are consistent with the services you provide and meet medical necessity requirements. Headway’s session confirmation flow automatically checks your CPT codes and session details to make sure they are compatible, but you should still double check based on your own clinical expertise.
When coding, pay close attention to:
• Session length – ensure the code matches the documented time.
• Location of service – distinguish between in-person and telehealth, including whether audio-only or audio-visual
• Type of therapy – individual, family, or couples; (group when explicitly documented and covered by the patients’ insurer).
When in doubt, add more detail in your documentation to clearly support the CPT code billed.
Here is a breakdown of some commonly used codes below, and when you can use them.
A note on codes requiring medical necessity justification: For each, please ensure that diagnosis codes are documented at the highest level of specificity. Avoid unspecified codes when a more precise option is available. Read our full article on medical necessity.
Commonly Asked Questions
“Strong documentation and compliance are important ways we can advocate for our clients, ensuring that insurance companies understand clients' needs and recognize the exceptional care being delivered.”
Headway Clinical Team
Insurance reviews
Our job is to make working with insurance easy, including navigating reviews.
Why conduct reviews?
Reviews are conducted for the protection of our whole community — especially clients. Headway, as well as insurance companies, will periodically conduct reviews of claims and clinician records. This is done to help ensure accuracy and compliance with regulatory standards, as well as address possible instances of fraud, waste, or abuse.
These reviews also give us the opportunity to help you improve your documentation and/or coding practices.
What happens during a review?
We understand that the thought of reviews and audits can be distressing. We’re on your side and are here to help navigate a complex system.
On occasion, Headway or an insurer will initiate a review. We will sometimes review charting documentation to look out for things like commonly missing items or repeated mistakes. Insurers might also request to review documentation to make sure it meets their requirements.
In either case, Headway’s job is to help assist you through the process with minimal inconvenience.
How we provide guidance
We’ll start by highlighting documentation details that might need updates, with clear context on which notes to modify and any relevant deadlines.
Personalized feedback
For one-off errors, missing information, and other quick fixes, we’ll provide personalized feedback to help you update your documentation to meet insurers’ standards. You may have the chance to supplement existing notes with an addendum.
Escalated education
If there are more serious issues or a pattern of repeated problems, Headway will work with you directly to identify the problems and address any concerns.
For more details on escalations, including situations involving fraud, waste, and abuse, please refer to our full Curative Action Policy.
Commonly Asked Questions
“As your practice partner, we’re here to help you develop consistent, compliant practices so we can navigate the complexities of the industry on your behalf.”
Headway Clinical Team
Getting help
Headway is here to provide the support you need.
Find answers to common questions from providers
For additional questions about compliance or Headway in general, contact our support team.
Disclaimer
This document should be used for general informational purposes only. The contents do not constitute legal advice and should not be used as a substitute for advice from your legal counsel.
Use this guide as a reference, not as a definitive source of information regarding chart documentation requirements. We must work to ensure that all services submitted for reimbursement meet medical necessity and are based on accurate, complete, and timely documentation. It is the sole responsibility of every clinician to submit a complete accurate record of the services they provide and to document services in compliance with all applicable laws, best practices, and regulations.