Guide

Covered services and carve-outs: the schedule inside the contract

Summary

Your contract's covered-services schedule lists the CPT and HCPCS codes the payer agrees to reimburse under that agreement, but whether a listed code actually pays turns on the payer's separate medical and reimbursement policies. Behavioral health is often carved out to a managed behavioral health vendor, so a service the plan covers may be paid by a different entity. Read the schedule, the policies, and the carve-out language together before the first visit.

By Gale Editorial · Updated 2026-07-26. Every figure cited to a dated source. How we write.

What "covered services" means inside the contract

In a payer contract, covered services are the procedures — identified by CPT and HCPCS code — that the plan agrees to reimburse when you deliver them to one of its members under that agreement. They usually sit in a schedule or exhibit attached to the contract, and the list is that payer's own. It is not a universal menu, and two contracts you sign in the same month can cover different code sets.

The schedule is only half the answer. A code appearing on your fee-schedule exhibit means the payer has agreed to price it; it does not promise payment on any particular claim. Payment is still gated by the plan's medical-necessity and reimbursement rules, by the member's specific benefit design, and by whether the service was carved out to another entity. Treat reading a payer contract as reading three documents at once: the agreement, the schedule, and the policies the schedule points to.

Where the binding answer actually lives

The contract names which codes are eligible; the payer's published medical and reimbursement policies tell you when each one actually pays. National commercial payers post these libraries online — Anthem maintains its provider policies 1Ref 1Anthem (2026).Anthem Provider Policies.Named example that a national commercial payer publishes its medical and reimbursement policies on its provider portal, where the binding coverage rules behind a listed code live., Aetna publishes clinical policy bulletins 2Ref 2Aetna (2026).Aetna Clinical Policy Bulletins.Named example that Aetna publishes its clinical policy bulletins on its provider portal — the reimbursement rules that gate whether a covered code is paid., UnitedHealthcare posts its policies and protocols 3Ref 3UnitedHealthcare (2026).UnitedHealthcare Policies and Protocols.Named example that UnitedHealthcare posts its policies and protocols on its provider portal, which control how a covered code adjudicates., and Cigna publishes its coverage and claims policies 4Ref 4Cigna (2026).Cigna Coverage and Claims Policies.Named example that Cigna publishes its coverage and claims policies on its provider portal, which govern payment of a listed code. — and the version in force on your date of service controls, not the copy you skimmed at signing.

Before the first visit, pull the policy for each code you expect to bill and read it against your intended documentation. Note the policy's effective date, any frequency limits, and any prior-authorization trigger. Your contract controls where the two disagree, but the policies are how the payer's claim system will actually adjudicate — so they are the closest thing you have to a preview of the remittance. Every payer's numbers are its own; do not assume one payer's rule travels to another.

Carve-outs: covered by the plan, paid by someone else

A carve-out is a service the health plan covers on paper but hands to a separate company to manage and pay — most often behavioral health, routed to a managed behavioral health organization. Medicaid is the single largest payer for behavioral health in the United States, and its coverage design varies by state 5Ref 5Centers for Medicare & Medicaid Services (2026).Behavioral Health Services.That Medicaid is the largest U.S. payer for behavioral health and its coverage design varies by state — the basis for the carve-out framing and the point that the entity paying a claim may differ from the plan on the card., so the entity adjudicating your claim may not be the insurer named on the member's card.

For a solo clinician the practical trap is being in-network with the plan but out-of-network with the carve-out vendor, or the reverse. Confirm which entity processes behavioral-health claims during eligibility verification, before the session rather than after the denial. These MBHO carve-outs — and, in public coverage, Medicaid BH carve-outs — carry their own network, their own fee schedule, and their own claim address. A provider dropped by the carve-out can lose the paying relationship while the underlying plan contract looks entirely intact.

Government payers set covered services by rule, not negotiation

Medicare and Medicaid do not negotiate covered services with a solo practice — they publish them, and enrollment binds you to the published set. Medicare covers psychiatric diagnostic evaluation and psychotherapy, and since 2024 it recognizes marriage and family therapists and mental health counselors as enrolled provider types; its Medicare Learning Network booklet lists the eligible provider types, covered codes, telehealth rules, and incident-to limits for behavioral health 6Ref 6Centers for Medicare & Medicaid Services (2025).Medicare and Mental Health Coverage.That Medicare covers psychiatric diagnostic evaluation and psychotherapy and, since 2024, recognizes MFTs and mental health counselors, with the MLN booklet listing eligible provider types, covered codes, telehealth rules, and incident-to limits..

Medicaid is state-administered on top of federal rules, so the covered-services list, the fee schedule, and the billing manual all come from your state's Medicaid agency rather than a national schedule. Read the booklet or manual for the product you enrolled in and match your intended codes against it before you see the first covered member. A service Medicare or your state covers is still bound by that program's documentation and supervision conditions, so coverage and payability are not the same thing here either.

Adding a service or a second clinician

Adding a second clinician changes the covered-services question, because whose services the contract pays for is not always whose NPI appears on the claim. Under Medicare, billing an auxiliary provider's services incident-to your own requires direct supervision, an employment or contract relationship, and a physician-initiated course of treatment that you continue to actively manage 7Ref 7Office of the Federal Register (2026).42 CFR 410.26 — Services and supplies incident to a physician's professional services.The incident-to conditions (direct supervision, an employment or contract relationship, and a physician-initiated course of treatment) that govern billing an auxiliary provider's covered services.. Miss a condition and the service is not billable that way, even though the code is "covered."

Before you bill an associate's visits under your own number, run the incident-to conditions against your actual setup — who supervises, who initiated the plan of care, and whether the payer even recognizes the arrangement for your discipline. Commercial payers set their own supervision and rendering-provider rules in policy, so confirm each payer's position rather than assuming the Medicare rule carries over. When the conditions are not met, the visit is not lost — it is billed under the rendering clinician's own credentialing instead.

A pre-first-visit check on what the contract covers

Before you treat the first member under a new contract, confirm the covered-services picture end to end. This is a short check that prevents the most common category of clean-looking denial — a service that was never payable under this specific agreement in the first place.

Confirm	Where to look	Why it matters
The code is on your fee-schedule exhibit	The schedule attached to the contract	A code not listed may not be priced at all
The reimbursement policy for the code	The payer's provider-policy library	Frequency limits and documentation rules live here, not in the contract
Whether behavioral health is carved out	The member's plan and your eligibility check	The carve-out vendor, not the plan, may pay the claim
Prior-authorization triggers	The medical policy and your contract	An unauthorized covered service still denies
Your enrolled provider type and codes	The Medicare MLN booklet or your state Medicaid manual	Enrollment, not negotiation, sets the government covered set

Keep the answers with your executed contract in a single file, so the next question — a denial, an audit, a new hire — starts from what you actually agreed to rather than from memory.

Common questions

No. The covered-services schedule names which codes the payer will reimburse under your agreement; the fee schedule sets the dollar amount for each. They often travel together as exhibits, but a code can appear on one and not the other. Read both, and confirm the reimbursement policy behind each code, because pricing a service is not the same as agreeing to pay every claim for it.

Pull the payer's published medical or reimbursement policy for that CPT code from its provider portal, check the effective date, and read the coverage criteria, frequency limits, and any prior-authorization trigger. For Medicare, use the Medicare Learning Network booklet for behavioral health; for Medicaid, use your state agency's billing manual. Do this before the visit, not after the remittance arrives.

A carve-out means the health plan delegates behavioral-health coverage to a separate managed behavioral health organization that runs its own network, fee schedule, and claims process. You can be in-network with the plan yet out-of-network with the carve-out vendor. Verify which entity adjudicates behavioral-health claims during eligibility, because a claim sent to the wrong payer denies even when the service is genuinely covered.

Sometimes, but not automatically. Under Medicare's incident-to rules a supervising clinician can bill an auxiliary provider's services only with direct supervision, an employment or contract relationship, and a course of treatment the supervising clinician initiated and manages. Commercial payers set their own rules in policy. Confirm each payer recognizes the arrangement for your discipline before billing an associate's visits under your number.

No. Covered means the payer agrees the service is eligible under the plan; payment still depends on medical necessity, the member's benefit design, correct authorization, and clean documentation. A covered service denies routinely when a frequency limit is hit, authorization is missing, or the claim goes to a carve-out vendor. Treat coverage as necessary but not sufficient, and read the reimbursement policy for the details.

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References

1.Anthem (2026). Anthem Provider Policies. Anthem provider portal. link ✓Named example that a national commercial payer publishes its medical and reimbursement policies on its provider portal, where the binding coverage rules behind a listed code live.
2.Aetna (2026). Aetna Clinical Policy Bulletins. Aetna provider portal. link ✓Named example that Aetna publishes its clinical policy bulletins on its provider portal — the reimbursement rules that gate whether a covered code is paid.
3.UnitedHealthcare (2026). UnitedHealthcare Policies and Protocols. UnitedHealthcare provider portal. link ✓Named example that UnitedHealthcare posts its policies and protocols on its provider portal, which control how a covered code adjudicates.
4.Cigna (2026). Cigna Coverage and Claims Policies. Cigna provider portal. link ✓Named example that Cigna publishes its coverage and claims policies on its provider portal, which govern payment of a listed code.
5.Centers for Medicare & Medicaid Services (2026). Behavioral Health Services. Medicaid.gov. linkThat Medicaid is the largest U.S. payer for behavioral health and its coverage design varies by state — the basis for the carve-out framing and the point that the entity paying a claim may differ from the plan on the card.
6.Centers for Medicare & Medicaid Services (2025). Medicare and Mental Health Coverage. CMS Medicare Learning Network (MLN1986542). link ✓That Medicare covers psychiatric diagnostic evaluation and psychotherapy and, since 2024, recognizes MFTs and mental health counselors, with the MLN booklet listing eligible provider types, covered codes, telehealth rules, and incident-to limits.
7.Office of the Federal Register (2026). 42 CFR 410.26 — Services and supplies incident to a physician's professional services. eCFR. link ✓The incident-to conditions (direct supervision, an employment or contract relationship, and a physician-initiated course of treatment) that govern billing an auxiliary provider's covered services.

https://www.gale.care/for-providers/ct-scope-covered-services · 7 sources. Competitor details are cited to dated public sources and maintained as they change; figures are estimates, not commitments. Synthetic demonstration.

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