CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Commercial Outpatient Behavioral Health Prior Authorization Codes

List of CPT/HCPCS codes and utilization management rules for outpatient behavioral health services indicating which services may require prior authorization for Blue Cross Blue Shield of New Mexico members and applicable networks.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCommercial Outpatient Behavioral Health Prior Authorization Codes

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionCheck member eligibility and request prior authorization when required before providing listed outpatient behavioral health services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPT/HCPCS listbehavioral health codes listed (ABA, rTMS, ECT, psychological testing)

Required (some)Prior authorization

36 sessionsrTMS course

≥20 hrs/wkPHP hours

Coverage Criteria and Prior Authorization Rules

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Prior authorization

Covered with utilization management; prior authorization may be required for some members/services.

Prior authorization requirement: Prior authorization is required for some members/services/drugs before services are rendered to confirm medical necessity as defined by the member's health benefit plan.

Prior authorization is not a guarantee of benefits or payment; the member's plan controls benefits. Providers are usually responsible for requesting authorization before performing a service for in-network members; verify requirements via Availity or the vendor portal.

Level-of-care service descriptions

Service descriptions that define level-of-care elements relevant to medical necessity determinations.

Partial Hospitalization: PHP is a structured program typically 5–8 hours/day, 5 days/week (not less than 20 hours/week), medically supervised by physician and nursing staff; a psychiatrist must see the patient face-to-face at least weekly; program must be licensed in-state or nationally accredited and meet credentialing requirements; participants do not require 24-hour supervision.>=20 hours/week

Intensive Outpatient Program (IOP): IOP is a freestanding or hospital-based program that provides services at least 3 hours/day, two or more days/week for mental illness, substance use disorder treatment, or co-occurring conditions; programs for complex co-occurring conditions should provide integrated assessment, treatment and discharge planning.>=3 hours/day, >=2 days/week

Applied Behavior Analysis (ABA): Applied behavior analysis is a method of therapy to improve or change specific behaviors for members diagnosed within the pervasive and specific developmental disorders category of ICD-10; billed using specified ABA CPT/HCPCS codes.

Outpatient Electroconvulsive Therapy (ECT): ECT involves brief electrical stimulation of the brain while the member is under anesthesia for severe psychiatric disorders; frequency varies with level of care (typically 2–3 times/week inpatient; when outpatient, frequency may change to once every 3–4 weeks).

Billed by facility/clinic.

Psychological/Neuropsychological Testing: Psychological and neuropsychological testing involves administration of tests to measure samples of behavior; prior authorization is required only in some cases and BCBSNM will notify the provider when authorization is needed.

rTMS coverage guidance

rTMS treatment course and utilization rules considered in medical necessity and authorization decisions.

rTMS course: Typical course: daily sessions 5 times/week for up to 6 weeks, followed by a 3-week taper (week 1: 3 sessions; week 2: 2 sessions; week 3: 1 session) for a total of approximately 36 sessions; course may be repeated after a 6-month cessation period if needed.~36 sessions

rTMS cannot be administered the same day as PHP, IOP, ECT, or ABA services; prior authorization may be required for some members/services.

rTMS therapy cannot be administered on the same day as Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), Electroconvulsive Therapy (ECT), or Applied Behavior Analysis (ABA) care level services. This exclusion applies to scheduling and billing: a session of repetitive transcranial magnetic stimulation must not be provided on a date when the member is also receiving PHP, IOP, ECT, or ABA services.

Relevant CPT / HCPCS Codes and Key Coding Details

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
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/neuropsychological testing and rTMS codesCPT

96105	Assessment Of Aphasia
96110	Developmental Screen W/Score
96112	Devel Tst Phys/Qhp 1St Hr
96113	Devel Tst Phys/Qhp Ea Addl
96116	Nubhvl Xm Phys/Qhp 1St Hr
96121	Nubhvl Xm PhylQhp Ea Addl Hr
96125	Cognitive Test By Hc Pro
96127	Brief Emotional/Behav Assmt
96130	Psycl Tst Eval Phys/Qhp 1St
96131	Psycl Tst Eval Phys/Qhp Ea

1–10 of 20

1/2

inv-08: Partial hospitalization weekly hours — >= 20 hours per week

Partial hospitalization weekly hoursNot less than 20 hours of treatment services per week (typically 5–8 hours/day, 5 days/week)

Staffing and supervisionMedically supervised by a physician and nurse with psychiatrist face-to-face at least once weekly

Licensure/accreditationProgram must be licensed in the state or nationally accredited per Claim Administrator credentialing policy

inv-09: rTMS course length — Up to 36 sessions (5x/week up to 6 weeks plus 3-week taper)

Maximum sessions per courseUp to 36 sessions per treatment course

Delivery scheduleTypically 5 sessions per week for up to 6 weeks, followed by a 3-week taper (3 sessions week 1, 2 sessions week 2, 1 session week 3)

Repeat course allowanceCourse may be repeated after a 6-month cessation period if needed

What Providers Must Do / Watch For

Prior Authorization

Prior Authorization Required

Prior authorization may be required for certain outpatient behavioral health CPT/HCPCS codes (including but not limited to listed rTMS codes such as 90868 and 90869). Verify prior authorization requirements for the member and service before rendering care.

Examples: 90868, 90869 (rTMS) — prior authorization may apply for some members/services.
Prior authorization decisions are communicated to the provider after request is processed.

Step Therapy

No Step Therapy Specified

No step therapy policies are specified in this document for behavioral health treatments. Providers should not assume a step therapy requirement exists based on this policy.

Note

Eligibility and Verification

Always check member eligibility and benefits through Availity Essentials (availity.com) or your preferred vendor portal to confirm whether prior authorization or pre-notification is required for the requested service.

Confirm whether BCBSNM or Carelon manages the authorization for the member.
Eligibility/benefit confirmation is required before obtaining prior authorization.

Denial Risk

Prior Authorization Consequences

Failure to obtain a required prior authorization before services are rendered may result in denial of payment. Obtaining prior authorization does not guarantee benefits or payment; the member's benefit contract controls coverage.

Providers are usually responsible for requesting prior authorization for in-network services.
If unclear, call the authorization number on the member's ID card.

Background and Policy Scope

Outpatient behavioral health services described here include structured levels of care and modality-specific therapies. A Partial Hospitalization Program (PHP) is a medically supervised, daytime program typically delivered about 5–8 hours per day, 5 days per week (minimum >= 20 hours/week), with required program licensure/accreditation and weekly face-to-face psychiatrist involvement. An Intensive Outpatient Program (IOP) provides structured outpatient treatment for mental health or substance use disorders for at least >= 3 hours/day on >= 2 days/week and can include integrated care for co-occurring conditions. Applied Behavior Analysis (ABA) comprises therapy to improve or change specific behaviors for developmental diagnoses and is billed using the ABA CPT/HCPCS codes listed in the policy. Repetitive Transcranial Magnetic Stimulation (rTMS) is a clinic- or facility-based brain stimulation therapy typically delivered 5 times per week for up to 6 weeks followed by a 3-week taper (total ~36 sessions); rTMS may be repeated after a 6-month cessation period. Prior authorization may be required for some members/services and providers should verify eligibility and authorization requirements before scheduling services.

Service Definitions

inv-15: Partial Hospitalization Treatment Program (PHP) — A planned program typically 5–8 hours/day, multiple days/week.

Typical daily schedulePlanned program typically 5–8 hours per day

FrequencyMultiple days per week (commonly 5 days/week) to meet >=20 hours/week

Supervision and psychiatrist involvementMedically supervised; psychiatrist to see patient face-to-face at least weekly

inv-16: Intensive Outpatient Program (IOP) — Program providing services at least three hours/day, two or more days/week.

Minimum daily durationProvides services at least 3 hours per day

Minimum weekly frequencyProvided two or more days per week

ScopeTreats mental illness, substance use disorders, or co-occurring conditions with integrated care when applicable

inv-17: Repetitive Transcranial Magnetic Stimulation (rTMS) — Brain stimulation therapy typically delivered 5x/week up to 6 weeks with a 3-week taper (~36 sessions).

Typical deliveryBrain stimulation therapy usually delivered 5 times per week for up to 6 weeks

Tapering scheduleFollowed by a 3-week taper (3 sessions week 1, 2 sessions week 2, 1 session week 3) totaling ~36 sessions

Scheduling restrictionrTMS cannot be administered the same day as PHP, IOP, ECT, or ABA services

Applied Behavior Analysis Criteria

ABA

Applied Behavior Analysis (ABA) service description and coding context relevant to authorization.

ABA scope: Applied behavior analysis is therapy to improve or change specific behaviors for diagnoses within pervasive and specific developmental disorders (ICD-10 category); specific CPT/HCPCS codes for ABA and related services are identified in the policy.

Codes include 97151–97158, 0362T, 0373T (see coding section).

Specific Treatment Modalities

ECT

ECT use description for medical necessity and billing.

ECT use: ECT involves brief electrical stimulation of the brain under anesthesia for severe psychiatric disorders; frequency varies with level of care (2–3 times/week inpatient; may change to once every 3–4 weeks outpatient).

Billed by facility/clinic.

rTMS

rTMS criteria and course limits used for authorization decisions.

rTMS use: rTMS is a facility/clinic‑based brain stimulation therapy delivered per the described course (approximately 36 sessions including taper); the course may be repeated after a 6‑month cessation. The therapy cannot be administered on the same day as PHP, IOP, ECT, or ABA services.~36 sessions

Prior authorization may be required for some members/services.