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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyBlue Cross Nevada Therapy Limits Prior Auth | Open…
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    CurrentBlue Cross Blue Shield - NevadaPolicy N/A

    Behavioral Health Therapy Session Limitations

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    Behavioral health therapy services are subject to provider-type and recipient-specific annual session limits, prior authorization requirements, medical necessity criteria, billing rules, and applicable claim payment requirements in Nevada Medicaid managed care.

    Policy Summary
    PayerBlue Cross Blue Shield - Nevada
    PolicyBehavioral Health Therapy Session Limitations
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateDecember 1, 2022
    Next Review DateN/A
    Key ActionObtain prior authorization before providing additional therapy services once the applicable annual session limit is met.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    13Therapy codes subject to limits
    26Sessions under 18 without authorization
    18

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    Sessions age 18+ without authorization
    No limitPT 20 session limit
    180 daysClean claim filing limit
    90 daysDispute appeal filing limit

    Coverage and Service Limitations

    Base coverage and authorization criteria

    Therapy services may be reimbursed without prior authorization only when all of the following criteria are met:

    ALL of the following

    • The billed service uses one of the listed behavioral health therapy codes.
    • The applicable annual session limit has not been met, or an approved prior authorization is present for services beyond the limit.
    • The provider type is eligible for the applicable therapy service.

    Provider-type-specific limits

    Coverage and session limitations vary by billing provider type:

    ONE of

    • PT 14 (Behavioral health outpatient treatment): up to 26 sessions per calendar year for recipients under 18, or up to 18 sessions per calendar year for recipients age 18 and older, without prior authorization.
    • PT 26 (Psychologist): up to 26 sessions per recipient per calendar year without prior authorization.
    • PT 20 (Physician, M.D., or osteopath, D.O.): no session limit.
    • PT 82 (Behavioral health rehabilitative treatment): therapy codes are not covered.

    Psychotherapy service limitations

    Individual, group, and family psychotherapy sessions are combined when applying the calendar-year limitation.

    ALL of the following

    • For child and adolescent services, the applicable CASII-based limitation is 10 to 26 combined sessions without prior authorization.
    • For adult services, the applicable LOCUS-based limitation is 6 to 18 combined sessions without prior authorization.
    • When the applicable limitation is met, the recipient must continue to meet medical necessity and the provider must obtain prior authorization for continued services.

    Codes, Limits, and Timely Filing

    Therapy codes subject to session limitationsmixedCovered
    90832Psychotherapy service code subject to behavioral therapy session limitations
    90833Psychotherapy service code subject to behavioral therapy session limitations
    90834Psychotherapy service code subject to behavioral therapy session limitations
    90836Psychotherapy service code subject to behavioral therapy session limitations
    90837Psychotherapy service code subject to behavioral therapy session limitations
    90838Psychotherapy service code subject to behavioral therapy session limitations
    90839Psychotherapy service code subject to behavioral therapy session limitations
    90845Psychotherapy service code subject to behavioral therapy session limitations
    90846Psychotherapy service code subject to behavioral therapy session limitations
    90847Psychotherapy service code subject to behavioral therapy session limitations
    1–10 of 13
    1/2
    Provider-type-specific therapy treatmentmixed
    PT 14Behavioral health outpatient treatment provider type
    PT 26Psychologist provider type
    PT 20Physician, M.D., or osteopath, D.O. provider type
    PT 82Behavioral health rehabilitative treatment provider type
    Excluded provider typemixedNot Covered
    PT 82Behavioral health rehabilitative treatment therapy codes are not covered
    PT 14 Limit: Recipients Under 18
    Provider typePT 14 — Behavioral health outpatient treatment
    Recipient ageUnder 18
    Annual limit without prior authorization26 sessions per recipient per calendar year
    PT 14 Limit: Recipients Age 18 and Older
    Provider typePT 14 — Behavioral health outpatient treatment
    Recipient age18 and older
    Annual limit without prior authorization

    Authorization, Billing, and Verification Actions

    Prior Authorization

    Prior Authorization Required After Session Limit

    Obtain prior authorization before providing additional behavioral therapy services once the applicable annual session limitation has been met.

    • Applies to the applicable behavioral therapy codes and recipient session limits.
    • PT 14 limits are 26 sessions per calendar year for recipients under 18 and 18 sessions for recipients age 18 and older; PT 26 has a 26-session limit, PT 20 has no limit, and PT 82 services are not covered.
    • PT 20 and PT 26 providers billing therapy codes under PT 14 are subject to PT 14 limits.
    Denial Risk

    Claims Without Authorization Will Be Denied

    Claims for covered behavioral therapy codes that exceed the applicable session limitation without prior authorization will be denied.

    Terms and Abbreviations

    CASII
    TermCASII
    Full nameChild and adolescent service intensity instrument
    Policy useBasis for a range of psychotherapy session limitations for children and adolescents
    LOCUS
    TermLOCUS
    Full nameLevel of care utilization system
    Policy useBasis for a range of psychotherapy session limitations for adults
    Policy Summary
    PayerBlue Cross Blue Shield - Nevada
    PolicyBehavioral Health Therapy Session Limitations
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateDecember 1, 2022
    Next Review DateN/A
    Key ActionObtain prior authorization before providing additional therapy services once the applicable annual session limit is met.
    SourceLink
    On This Page
    Coverage and Service LimitationsCodes, Limits, and Timely FilingAuthorization, Billing, and Verification ActionsTerms and Abbreviations
    18 sessions per recipient per calendar year
    PT 26 Annual Limit
    Provider typePT 26 — Psychologist
    Annual limit26 sessions per recipient per calendar year
    Authorization conditionSessions are allowed without prior authorization within the annual limit
    PT 20 Annual Limit
    Provider typePT 20 — Physician, M.D., or osteopath, D.O.
    Annual session limitNo limit
    Coverage conditionApplicable therapy codes are not subject to an annual session limit for PT 20
    PT 82 Coverage Status
    Provider typePT 82 — Behavioral health rehabilitative treatment
    Coverage statusNot covered
    Claims statusBehavioral health rehabilitative treatment therapy codes are not covered
    Child and Adolescent Psychotherapy Limitation
    PopulationChildren and adolescents
    Services countedIndividual, group, and family therapy sessions combined
    Limit without prior authorization10 to 26 sessions under CASII
    Adult Psychotherapy Limitation
    PopulationAdults
    Services countedIndividual, group, and family therapy sessions combined
    Limit without prior authorization6 to 18 sessions under LOCUS
    Calendar-Year Reset
    Reset dateJanuary 1 of each calendar year
    Applicable servicesServices subject to calendar-year limitations
    Session countingAll sessions billed on behalf of the recipient count toward the new calendar year's limits from January 1
    Clean Claim Timely Filing
    Filing typeClean claims
    Deadline180 days
    Deadline measured fromDate of service
    Dispute Appeal Timely Filing
    Filing typeDispute appeal for an improperly adjudicated covered service
    Deadline90 days
    Deadline measured fromDate of the original EOP, EOB, or RA
  1. Include the prior authorization number on claims for services provided under an approved authorization in order to be paid.

    2. Unsupported block type: billing_rule

    Prior Authorization

    Request Authorization for Continued Medically Necessary Therapy

    When the applicable service limitation is met and the recipient continues to meet medical necessity, submit a prior authorization request for continued therapy.

    • If approved, provide services only as described in the approved authorization.
    • Include the approved prior authorization number on claims.
    Billing Rule

    Manage Authorizations Across Calendar Years

    Manage prior authorizations according to the calendar-year service limitations, which restart January 1 each year.

    • For calendar-year limitations, end-date authorization requests on December 31 when appropriate.
    • If an approved authorization spans one calendar year into the next, services may be delivered according to the approved authorization; however, all sessions still count toward the limit beginning January 1 of each calendar year.
    Prior Authorization

    Submit Behavioral Health Authorization Requests

    Submit behavioral health prior authorization requests using the preferred electronic method whenever possible.

    • Submit behavioral health requests through Availity at www.Availity.com.
    • If fax submission is preferred, obtain the correct forms from the provider website at https://providers.anthem.com/nevada-provider/home.
    • Consult Medicaid services manual chapter 400 for documentation requirements, prior authorization requirements, and limitations when additional guidance is needed.
    Documentation Required

    Verify Eligibility and Authorization at Each Visit

    Verify member eligibility and prior authorization requirements at every visit.

    • Submit all required claims information on a clean claim within 180 days of the date of service.
    • Failure to follow these requirements may result in claim denials being upheld.
    PA
    AbbreviationPA
    MeaningPrior authorization
    When requiredOnce the applicable therapy session limitation has been met or to exceed the limitation