CurrentAnthemPolicy ACADPEC-0374-17

Behavioral health covered services and authorization overview

This document governs Anthem's behavioral health (BH) coverage overviews, Medi‑Cal and Medicare BH covered/noncovered services, provider types, severity determination tools for county programs, EPSDT services for members under 21, and authorization requirements for select Medicare inpatient services. It affects Anthem providers and contracted county/Medi‑Cal/Medicare stakeholders in California.

Policy Summary

PayerAnthem

PolicyBehavioral health covered services and authorization overview

Policy CodePolicy ACADPEC-0374-17

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization for listed inpatient, selected outpatient (e.g., TMS, ECT), psychological testing, partial hospitalization, and specified Medicaid ABA codes when the table indicates 'Authorization = Yes'.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare & Medi‑Calprograms covered

Under 21EPSDT

~20+ codesAuth required

H-codesMedicaid ABA

1-855-817-5786

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Covered and Noncovered Behavioral Health Services

inv-01: Covered Services

Covered BH services (selected):

Medicare covered BH services list: Includes acute inpatient psychiatric hospitalization services; professional services in institutes for mental disorders; professional services for sub-acute outpatient detoxification; observation and emergency services; electroconvulsive therapy (ECT); partial hospitalization (Level I and Level II); mental health procedure codes; psychological testing services; collaborative care and case management services.

From Medicare covered services list (Medicare section)

Medi-Cal covered BH services list: Includes inpatient professional services when a member is in a medical unit; mental health outpatient services for mild to moderate illness; applied behavioral analysis (EPSDT) and developmental screening for members under 21; psychological testing services; select outpatient evaluation and management services.

From Medi‑Cal covered services list

inv-02: Not Covered (Medi‑Cal)

Medi‑Cal noncovered services:

Medi‑Cal noncovered: Services for the treatment of severe mental illness are listed as noncovered under the Medi‑Cal section.

Explicit noncovered item

Medi‑Cal noncovered - substance use: Services provided for the treatment of substance use disorders are listed as noncovered under the Medi‑Cal section.

Explicit noncovered item

inv-03: Severity scoring and referral logic

Severity determination and referral tiering (Sacramento County tool):

Scoring process: Evaluator scores each element (risk, clinical complexity, life circumstances, co-occurring conditions) on a 0–3 scale, selecting the highest score in which at least one criterion is met; scores are summed to a composite total.0-3 per element

Use tool scoring instructions

Referral tiers mapping: Total composite score maps to referral disposition: Tier 1 (total 1–4) = health plan (PCP or contracted provider); Tier 2 (total 5–8) = health plan contracted providers outreach; Tier 3 (total 9–12) = county referral to county clinic or contracted agency.Tier 1: 1–4; Tier 2: 5–8; Tier 3: 9–12

Tier mapping per Sacramento County tool

inv-04: L.A. Care severity/referral criteria

L.A. Care severity determination rules (summary):

MCO consultation/referral rules: Members with one circumstance in List A AND one in List B require MCO behavioral health consultation; members with two or more in List A plus one in List B require referral to the county department of mental health; members with two or more in List B require referral to the county department of mental health.

Referral thresholds per L.A. Care

Representative List A/B items: Examples include: symptomatic after two standard psychiatric medication trials; psychotic symptoms (paranoia, hallucinations, delusions); history of bipolar/manic episodes; multiple psychiatric hospitalizations or incarcerations; significant functional impairment; substance addiction with failed screening/brief intervention.

Representative circumstances described in List A/B

The policy identifies specific Medi‑Cal services that are not covered. Explicitly listed noncovered items include services provided for the treatment of severe mental illness and services provided for the treatment of substance use disorders.

Certain services are specific to Medicaid (Medi‑Cal) and are listed with their Medicaid billing codes and authorization designations. These Medicaid‑only H‑codes apply to Medicaid enrollees and include both ABA and substance‑screening services; for example, H0031, H0032, H2012, H2014, H2019 are ABA services identified as Medicaid primary/secondary and have an authorization rule = Yes for participating providers, while screening codes H0049 and H0050 are listed with authorization rule = No.

For Medi‑Cal (state Medicaid) the document both lists explicit noncovered services and enumerates Medicaid‑only covered H‑codes with authorization indicators. Noncovered Medi‑Cal items include treatment of severe mental illness and treatment for substance use disorders (noncovered). Separately, Medicaid‑only behavioral health H‑codes such as H0031, H0032, H2012, H2014, H2019 are included as covered Medicaid services but are designated with authorization rule = Yes for participating providers.

Codes, Revenue Codes, and Time Units

Prior Authorization

Prior Authorization and Provider Actions

Provider action: Prior Authorization Required for listed Medicare and Medicaid inpatient services, select observation/partial hospitalization, ECT, psychological testing, and Medicaid-only services. Authorization is required before billing for codes marked 'Yes' in the tables below. Prior authorization triggers include inpatient admission (per‑day CPTs 99221–99233), inpatient psychiatric revenue codes (e.g., 114/124/134/144/154, 190), electroconvulsive services (anesthesia and facility codes), partial hospitalization events (3+ hours or as indicated), and behavioral health specialty services listed under Medicaid-only H‑codes and neuropsychological/psychological testing codes. When authorization is required, providers must obtain confirmation ID and document authorization in the medical record.

Codes requiring authorization (selection)
Prior authorization required for listed Medicaid BH services
Prior authorization triggers for select inpatient services
Authorization required for listed Medicaid-only services and selected codes
Severity scoring documentation
Documentation expectations
Medication trial consideration

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Confirm authorization for selected high‑risk procedure codes

Obtain authorization for the specific codes marked "Yes" in the policy tables — examples include anesthesia/facility ECT (104, 901), TMS session codes (90867–90869), selected psychological/neuropsychological testing (96101–96103, 96118–96120), and Medicaid ABA H-codes (H0031, H0032, H2012, H2014, H2019).

104, 901 (ECT anesthesia/facility) — authorization = Yes (chunk 24)
90867–90869 (TMS) — authorization = Yes (chunk 34)
96101–96103, 96118–96120 (psych testing) — authorization = Yes (chunk 28, 30, 42)
H0031, H0032, H2012, H2014, H2019 (ABA) — authorization = Yes (chunk 36)

Prior Authorization

Prior authorization required for specified Medicaid behavioral health codes

For Medicaid behavioral health services, prior authorization is required for the Medicaid-only H-codes listed and for many inpatient professional and psychological testing CPTs when the table indicates "Authorization rule for par providers = Yes." Submit authorization requests per Medicaid rules to avoid claims denials.

H0031, H0032, H2012, H2014, H2019 — Authorization = Yes (chunk 36)

Criteria by Level of Care

inv-45: Inpatient/Observation/Partial Hospitalization

Admission, continued stay, and discharge guidance for higher levels of care (Medicare and Medi‑Cal contexts):

Admission indications (Medicare/Medi‑Cal): Acute inpatient psychiatric hospitalization and facility inpatient psychiatric revenue codes indicate admission-level services; admission and authorization are managed per Medicare rules and county severity determinations.

High-level admission guidance

Continued stay/authorization: Medicare inpatient professional CPT codes (e.g., 9922x, 9923x series) and selected Medicaid inpatient professional codes have authorization rules for participating providers; continued stay requires meeting Medicare/local authorization policies and documented medical necessity.

Continued stay tied to authorization tables (see coding/authorization sections)

inv-46: Partial Hospitalization

Partial Hospitalization program (PH) guidance:

Specific Treatment Modalities and Rules

inv-50: ECT, Partial Hospitalization

ECT and Partial Hospitalization treatment modality rules:

ECT coverage and auth: Electroconvulsive therapy (ECT) is listed as a covered service; associated anesthesia (104) and facility fee (901) entries are marked 'Yes' for authorization for participating providers, while the ECT procedure code 90870 is marked 'No' for authorization under Medicare listings.

See Medicare ECT code entries

Partial hospitalization as treatment modality: Partial hospitalization (PH) is recognized as a treatment modality (Level I/II) and PH revenue/CPT codes require authorization for participating providers per Medicare listings.

Refer to PH code entries for per-code authorization

inv-51: ECT / TMS

TMS and related procedural authorization notes:

Applied Behavior Analysis Services

inv-49: ABA services

ABA service coding and authorization (Medicaid-only):

ABA codes and units: H0031 (functional behavioral assessment) — event; H0032 (supervision/parent training) — event; H2012 (direct service by QAS provider) — 60 minutes; H2014 (skills training/social skills group, paraprofessional) — 15 minutes; H2019 (direct service by QAS paraprofessional) — 15 minutes.

All H-codes listed here carry 'Authorization rule for par providers = Yes' except H0049/H0050 which are screening codes marked 'No'

Authorization requirement: H0031, H0032, H2012, H2014, H2019 require prior authorization for participating providers under Medicaid as indicated in the Medicaid-only services table.

Authorization required per Medicaid table

Definitions and Code Group Notes

inv-42: Severity scoring tool

Tool descriptionCounty-based severity scoring tool with four elements (risk, clinical complexity, life circumstances, co-occurring conditions) scored 0–3 each.

Scoring instructionSelect the highest score in which at least one criterion is met (start in 'severe' column); if none apply score zero.

Referral mappingSum element scores to a composite total used to determine referral tier (per county guidance).

inv-43: ABA service codes

H0031Functional behavioral assessments (ABA) — unit = Event; authorization rule for par providers = Yes.

H0032Supervision/oversight, parent training (ABA) — unit = Event; authorization rule for par providers = Yes.

Visit Limits and Unitization

inv-54: No explicit visit limits stated in this section; units/time per code provided instead.

Visit limits policyNo explicit visit limits are stated in this section; service-level units and time per code are provided instead.

Unit-based billingProviders should bill using the listed unit/time per code (for example, psychotherapy codes reported by minutes or event as specified).

Authorization implicationSome codes list an authorization rule for participating providers; absence of stated visit limits does not remove per-code authorization requirements.

Authorization and Contact Information

Note

Contact Provider Services for Medicare inpatient prior authorization

Medicare inpatient prior authorization and general authorization questions can be directed to Provider Services at the number listed in the policy; use this contact to initiate or confirm authorization requirements.

Provider Services phone: 1-855-817-5786 (policy contact for authorizations and provider inquiries).

For authorization and Provider Services assistance call 1-855-817-5786. This number provides options for behavioral health inpatient and outpatient authorizations. An alternate number (formerly Beacon) 1-855-371-2283 will continue to operate and will route to the same Provider Services options through at least January 1, 2018.

Document History

October 2017policy_publicationLatest

Policy document ACADPEC-0374-17 published (Anthem behavioral health coverage overview for Medicare and Medi‑Cal).

Policy Summary

PayerAnthem

PolicyBehavioral health covered services and authorization overview

Policy CodePolicy ACADPEC-0374-17

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

99221–99233, 99231–99233 — Authorization = Yes for inpatient professional services (chunk 37)

96101–96103, 96118–96120 — Authorization = Yes for psychological testing under Medicaid (chunk 42)

Documentation Required

Document prior psychiatric medication trials for severity/referral

When L.A. Care severity criteria are used, document whether symptoms persist after two standard psychiatric medication trials — this medication-trial history is part of the referral/escalation criteria and should be included in authorization support materials.

Record and report whether the member remained symptomatic after two standard psychiatric medication trials (chunk 14).

Denial Risk

Request authorization for codes marked "Yes" to avoid denials

Ensure authorization is requested for codes flagged "Yes" in Medicaid/Medicare tables; failure to obtain required authorization may result in claim denial for those codes.

Services with "Authorization rule for par providers = Yes" require payer authorization (chunk 36).

Billing Rule

Verify per‑code authorization status and retain approval documentation

Confirm authorization requirements per-code before billing and obtain authorizations where the table indicates "Yes;" maintain authorization approval documentation with the claim to support payment.

Check per-code authorization flags (e.g., 190, 114–154 revenue codes; 99221–99233, 99238–99239) — many inpatient entries show Yes (chunks 18–20).

Documentation Required

Include Sacramento County severity element scores and composite total in authorization requests

When requesting authorization for higher levels of care, include the Sacramento County severity scoring elements (each scored 0–3) and the composite total to support level‑of‑care decisions and authorization determinations.

Document each element score (risk, clinical complexity, life circumstances, co-occurring conditions) using the 0–3 scale and provide the summed composite (chunks 6, 9, 10).

Documentation Required

Document service type, time units, and clinical justification for psych testing and ABA

For psychological testing and ABA services that require authorization, document the specific service, time units (per hour or per event), and supporting findings that justify testing or ABA intervention when submitting authorization requests.

Include test type and time units for psychological testing (e.g., 96101 per hour) when requesting authorization (chunk 28).
For ABA H-codes, document service type and unitization (e.g., H2012 = 60 min) and clinical justification (chunk 36).

Documentation Required

Provide detailed supporting documentation for psychological/neurobehavioral testing authorizations

When authorizing psychological and neurobehavioral testing, submit supporting documentation (test rationale, estimated hours or event basis, and interpretation/report plan) for codes such as 96101–96103 and 96118–96120, which are listed as requiring authorization.

96101, 96102, 96103, 96118, 96119, 96120 — Authorization = Yes; include test rationale and planned reporting (chunk 42).

Prior Authorization

Obtain authorization for select inpatient services flagged in the tables

Authorization is triggered for the inpatient revenue and professional service codes that list "Authorization rule for par providers = Yes" — participating providers must obtain authorization for those inpatient services prior to billing.

Examples: revenue code 190 (Inpatient psychiatric subacute) and CPTs 99221–99233 show Authorization = Yes (chunks 18, 19).

Prior Authorization

Adhere to per‑code prior authorization requirements across settings

Follow the per-code authorization indications in the policy tables: many inpatient, certain outpatient (TMS, ECT anesthesia/facility), psychological testing, partial hospitalization, and Medicaid ABA codes require prior authorization for participating providers.

Partial hospitalization entries and many inpatient codes show Authorization = Yes (chunk 23).
TMS codes 90867–90869 and ECT-related anesthesia/facility codes 104 and 901 require authorization (chunks 34, 24).
Psychological testing codes 96101–96103 and 96118–96120 require authorization (chunks 28, 30, 42).
Medicaid ABA H-codes require authorization (chunk 36).

Prior Authorization

Secure authorization for Medicaid‑only H‑codes and other marked services

For Medicaid-only services and selected codes listed with "Authorization rule for par providers = Yes" (notably H-codes and certain inpatient/professional CPTs), obtain payer authorization before delivering services to avoid denial of payment.

H0031, H0032, H2012, H2014, H2019 — Authorization = Yes (chunk 36).

PH hours and LOC determination: Partial Hospital Program: three hours per day is considered outpatient level of care by Medicare; four or more hours per day is also considered outpatient level of care; applicable revenue and CPT codes require authorization for participating providers.3 hours = outpatient LOC; >=4 hours = outpatient LOC

Per Medicare partial hospitalization entries

inv-47: Inpatient / Observation / Emergency

Inpatient / observation / emergency professional services authorization notes:

Inpatient professional codes and auth: Specific inpatient revenue codes (e.g., 190, 114, 124, 134, 144, 154, 202) and inpatient professional CPTs (99221–99223, 99231–99233) list 'Authorization rule for par providers = Yes' indicating required prior authorization for participating providers.

Refer to Medicare/Medi‑Cal code tables for per-code authorization

Observation & ED services: Observation and emergency professional services (e.g., 99234–99235 may be listed with 'No' for authorization under Medicaid; many ED/observation CPTs are 'No' for authorization), and authorization requirements differ by code and payer.

See observation/emergency code tables

inv-48: Outpatient psychotherapy / IOP (codes listed)

Outpatient psychotherapy, health & behavior, and IOP coding notes:

Psychotherapy coding and auth: Psychotherapy and health & behavior intervention codes (e.g., 90832–90840, 90846–90853, 96150–96155) are covered services with specified time units; under Medicaid many of these outpatient codes have 'Authorization rule for par providers = No'.

Time units per CPT code; most outpatient psychotherapy codes do not require prior authorization for par providers under Medicaid

TMS authorization: Transcranial magnetic stimulation codes (90867, 90868, 90869) are listed with 'Authorization rule for par providers = Yes' under Medicare outpatient services.

Authorization required for TMS codes per Medicare section

inv-52: ABA

ABA services (Medicaid-only) and authorization:

ABA authorization requirement: Applied behavior analysis H-codes (H0031, H0032, H2012, H2014, H2019) are covered under Medicaid/EPSDT when medically necessary and are listed with 'Authorization rule for par providers = Yes' for participating providers.

Unitization specified per H-code (event, 60 min, 15 min)

inv-53: Psychotherapy, Health & Behavior Interventions

Psychotherapy, health & behavior interventions — coverage and authorization summary:

Psychotherapy and health & behavior coverage: Psychotherapy codes (e.g., 90832–90837, 90839–90840, 90846–90853) and health & behavior assessment/intervention codes (96150–96155) are covered; most outpatient psychotherapy and health & behavior codes are listed with 'Authorization rule for par providers = No' under Medicaid listings.

Time units per CPT/HCPCS code; documentation should reflect service type and time units

H2012Direct service by QAS provider (ABA) — unit = 60 min; authorization rule for par providers = Yes.

H2014Direct services: skills training/social skills group (QAS paraprofessional) — unit = 15 min; authorization rule for par providers = Yes.

H2019Direct service by QAS paraprofessional (ABA) — unit = 15 min; authorization rule for par providers = Yes.

inv-44: Psychotherapy codes

90832/90833Psychotherapy, 30 minutes (90832) and 30-minute add-on (90833) — unit = 30 min.

90834/90836Psychotherapy, 45 minutes (90834) and 45-minute add-on (90836) — unit = 45 min.

90837/90838Psychotherapy, 60 minutes (90837) and 60-minute add-on (90838) — unit = 60 min.

90839/90840Psychotherapy for crisis: first 60 minutes (90839) and additional 30-min add-on (90840).

90846/90847/90853Family and group psychotherapy codes (90846 family w/o patient, 90847 family w/ patient, 90853 group) — unit = Event.

This policy summarizes Anthem’s behavioral health coverage across Medicare and Medi‑Cal lines and clarifies Medicaid‑specific rules. It references Medi‑Cal exclusions — notably that services for the treatment of severe mental illness and services for the treatment of substance use disorders are listed as noncovered — and it provides Medicaid‑only code-level guidance (H‑codes) including authorization requirements for ABA and related services. Use these distinctions when determining coverage applicability for California members who are Medi‑Cal or dual‑eligible.