CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Procedures Requiring Prior Authorization — Behavioral Health (coverage criteria)

Lists CPT/HCPCS codes for behavioral health services that require prior authorization for BCBSNM commercial non-HMO members and explains authorization expectations for providers checking eligibility and benefits.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyProcedures Requiring Prior Authorization — Behavioral Health (coverage criteria)

Policy CodePolicy N/A

Change TypeInformational update — no material changes

Effective DateSep 18, 2023

Next Review DateN/A

Key ActionObtain prior authorization for listed behavioral health CPT/HCPCS codes when required and verify member eligibility and benefits before providing services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9/18/2023authorization effective

Multipleservice categories

97151–97158, 90867–90869example codes

External UM possiblerouting note

Coverage Criteria Overview

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

The presence of CPT and HCPCS codes on this list does not by itself indicate that a service is covered under a member's benefits. Coverage depends on the individual member benefit contract and plan design; providers should consult the member benefit booklet or contact BCBSNM customer service to determine specific coverage. This list is not exhaustive, codes may change, and prior authorization routing may be managed by BCBSNM or an external utilization management vendor. Providers must check member eligibility and benefits prior to rendering services to confirm whether prior authorization is required and which vendor or process to use.

CPT / HCPCS Codes

Applied Behavior Analysis and ECT codesCPT

97151	Bhv Id Assmt By Phys/Qhp
97152	Bhv Id Suprt Assmt By 1 Tech
97153	Adaptive Behavior Tx By Tech
97154	Grp Adapt Bhv Tx By Tech
97155	Adapt Behavior Tx Phys/Qhp
97156	Fam Adapt Bhv Tx Gdn Phy/Qhp
97157	Mult Fam Adapt Bhv Tx Gdn
97158	Grp Adapt Bhv Tx By Phy/Qhp
0362T	Bhv Id Suprt Assmt Ea 15 Min
0373T	Adapt Bhv Tx Ea 15 Min

1–10 of 11

1/2

Psychological and Neuropsychological testing codesCPT

96110	Developmental Screening, Per Instrument
96112	Devel Tst Phys/Qhp 1St Hr
96113	Devel Tst Phys/Qhp Ea Addl
96116	Neurobehavioral Status Exam, Per Hour
96121	Each Additional Hour For Neurobehavioral Status Exam
96125	Standardized Cognitive Testing, Per Hour
96127	Brief Emotional/Behavior Assessment
96130	Psychological Interpretation And Reporting Following Testing, First Hour
96131	Each Additional Hour Of 96130
96132	Neuropsychological Interpretation And Reporting Following Testing, First Hour

1–10 of 15

1/2

rTMS procedure codesCPT

90867	Tcranial Magn Stim Tx Plan
90868	Repetitive Transcranial Magnetic Stimulation (rTMS) Subsequent Delivery And Management, Per Session
90869	Subsequent Motor Threshold Re-Determination

Provider Responsibilities & Authorization Rules

Note

Verify Eligibility & Benefits

Providers must check member eligibility and benefits before providing services to confirm coverage, prior authorization requirements, and the correct utilization management vendor. Eligibility and benefits may be verified via electronic 270 transactions through Availity (availity.com) or other vendor portals. Obtaining prior authorization does not replace the requirement to verify eligibility and benefits.

Prior Authorization

Prior Authorization Required for Listed Behavioral Health Codes

Prior authorization is required for the behavioral health and related codes listed in this policy unless otherwise noted in the updates column. These prior authorization requirements are effective September 18, 2023. Providers must obtain prior authorization from BCBSNM or the designated utilization management vendor as indicated; services performed without a required prior authorization will be denied for payment and providers may not seek reimbursement from members.

Effective date: September 18, 2023
Affected code categories include Applied Behavior Analysis (CPT 97151–97158, 0362T, 0373T), Psychological/Neuropsychological testing codes (96110, 96112, 96113, 96116, 96121, 96138, 96139, 96146) and behavioral health procedures (e.g., 90867, 90868, 90870).
Some services (e.g., Psychological/Neuropsychological Testing, rTMS, ABA codes) have been moved to Recommended Clinical Review as of 9/18/2023; BCBSNM will notify providers when prior authorization is required for specific testing services.

Denial Risk

Denial Risk if Prior Authorization Not Obtained

Services that require prior authorization but are delivered without an approved prior authorization will be denied for payment. Providers may not bill members for services denied for lack of required prior authorization.

Denial risk applies to the codes and services listed in this policy if prior authorization is not obtained.
Prior authorization approval does not guarantee payment — verify member contract benefits.

Note

Provider note — clinical review & notification

Psychological and neuropsychological testing and certain behavioral health treatments may require case-by-case review. Preserve all source details and follow forthcoming BCBSNM notifications regarding when prior authorization is required for these services.

Example services noted for review: Psychological/Neuropsychological Testing (various 96xxx series codes), Repetitive Transcranial Magnetic Stimulation (rTMS) protocols, Partial Hospitalization programs.
BCBSNM will notify providers if prior authorization is required for these testing services.

Background and Scope

This policy groups multiple behavioral health service categories for which prior authorization may be required, including Applied Behavior Analysis (ABA), electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), Partial Hospitalization Programs (PHP), Intensive Outpatient Programs (IOP), and psychological and neuropsychological testing. Briefly: ABA targets behavior change for developmental disorders; PHP is a hospital- or facility-based program typically providing 5–8 hours per day (not less than 20 hours/week) with psychiatrist oversight at least weekly; IOP provides at least 3 hours/day on two or more days per week; rTMS is an outpatient brain stimulation therapy usually delivered once daily, five times per week for up to six weeks (with a taper and potential repeat after a 6-month cessation); and psychological/neuropsychological testing includes standardized test administration, scoring, and interpretation services. These service categories are listed because they have associated CPT/HCPCS codes that may require prior authorization effective September 18, 2023.

Service Definitions

Applied Behavior Analysis (ABA) — definition

DefinitionApplied Behavior Analysis (ABA) is a method of therapy utilized to improve or change specific behaviors of members who have a diagnosis within the Pervasive and specific developmental disorders category of ICD-10.

Typical settingTherapy services are listed under behavioral health prior-authorization requirements and may be billed using CPT/HCPCS ABA-specific codes (see coding section).

ScopeUsed to address specific behavioral targets for members with pervasive and specific developmental disorders.

rTMS — definition

DefinitionRepetitive Transcranial Magnetic Stimulation (rTMS) is a form of outpatient brain stimulation therapy used to treat psychiatric conditions in a facility/clinic setting.

Typical regimenUsually one daily session, five times per week for up to 6 weeks, followed by a 3‑week taper (3 sessions, then 2, then 1) for a total of 36 sessions.

Repeat courseA treatment course may be repeated after a 6‑month cessation period if needed.

Partial Hospitalization (PHP) — definition and typical hours

DefinitionPartial Hospitalization Program (PHP) is a Claim Administrator‑approved planned program of a hospital or substance use disorder treatment facility for treatment of mental illness or substance use disorder in which patients attend the program during the day rather than reside there.

Typical hoursTypically provides 5–8 hours per day and not less than 20 hours of treatment services per week.

Staffing and oversightStaffed similarly to an inpatient unit, medically supervised by a physician and nurse, with a psychiatrist seeing the patient face‑to‑face at least weekly and otherwise available to provide assistance and direction.

Intensive Outpatient Program (IOP) — definition

DefinitionIntensive Outpatient Program (IOP) is a freestanding or hospital‑based program that provides services for at least three hours per day, two or more days per week to treat mental illness, substance use disorders, or co‑occurring conditions.

PurposeOffers structured treatment without 24‑hour supervision; may specialize in integrated care for co‑occurring mental illness and addiction/substance use disorders.

Program expectationsPrograms that treat severe or complex co‑occurring conditions provide integrated assessment, treatment, and discharge planning services tailored to both mental illness and addiction needs.

Applied Behavior Analysis (ABA) Criteria

Applied Behavior Analysis (ABA)

Applied Behavior Analysis (ABA) service descriptions and CPT/HCPCS codes that require prior authorization.

ABA description: Applied behavior analysis is a method of therapy utilized to improve or change specific behaviors of members who have a diagnosis within the Pervasive and specific developmental disorders category of ICD-10.

Codes requiring prior authorization: The following CPT/HCPCS codes for ABA services require prior authorization: 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T.

Codes and descriptions are listed in the coding section and are managed by BCBSNM (effective 9/18/2023).

ECT and rTMS Treatment Criteria

Repetitive Transcranial Magnetic Stimulation (rTMS)

rTMS regimen: A treatment course is usually 1 daily session, 5 times per week for up to 6 weeks, followed by a 3-week taper (3 sessions, then 2, then 1); course may be repeated after a 6-month cessation period.36 sessions total

Therapy cannot be administered on the same day as other specified treatments.

Electroconvulsive Therapy (ECT)

ECT frequency note: Electroconvulsive therapy (ECT) involves brief electrical stimulation of the brain under anesthesia; typically administered 2–3 times per week for inpatients and may change to once every 3–4 weeks when outpatient.

Code 90870 (Electroconvulsive Therapy, includes necessary monitoring) is listed and managed by BCBSNM (effective 9/18/2023).