CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2025 Commercial Outpatient Behavioral Health Prior Authorization Codes

Lists CPT/HCPCS codes and service categories for which prior authorization may be required for Blue Cross and Blue Shield of Oklahoma commercial outpatient behavioral health services and describes utilization management processes and service definitions.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Commercial Outpatient Behavioral Health Prior Authorization Codes

Policy CodePolicy N/A

Change TypeAdministrative update (coding/authorization list)

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionCheck member eligibility and benefits via Availity or the preferred portal and request prior authorization when required before rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleexample codes listed

36 sessionsrTMS course length

>=20 hrs/wkPHP intensity

>=3 hrs/dayIOP intensity

Coverage and Prior Authorization Criteria

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Coverage and Prior Authorization Criteria Summary

Prior authorization may be required for the listed services; presence of a code on the list does not imply coverage under a member's contract. Providers must verify eligibility and benefits prior to requesting authorization.

Check member eligibility and benefits via Availity® Essentials or your preferred web vendor portal prior to requesting authorization.

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

The provider is usually responsible for requesting prior authorization when the member is seeing an in‑network provider; in some cases the plan may require the member to request prior authorization.

For some services or members, prior authorization may be managed by Blue Cross and Blue Shield of Oklahoma (BCBSOK); for other services/members BCBSOK has contracted with Carelon Medical Benefits Management for utilization management and related services.

Once a prior authorization request is received and processed, the decision will be communicated to the provider.

Obtaining prior authorization is not a guarantee of benefits or payment; the terms of the member's health plan control available benefits.

If you have questions, call the prior authorization number on the member's ID card.

Behavioral Health Service Codes and Key Service Parameters

Behavioral Health CPT/HCPCS CodesmixedCovered

97151	Applied Behavior Analysis (ABA) - Behavior Identification Assessment by Physician/Qualified Health Professional
97152	ABA - Behavior Identification Support Assessment by Technician
97153	ABA - Adaptive Behavior Treatment by Technician
97154	ABA - Group Adaptive Behavior Treatment by Technician
97155	ABA - Adaptive Behavior Treatment by Physician/Qualified Health Professional
97156	ABA - Family Adaptive Behavior Treatment Guidance by Physician/Qualified Health Professional
97157	ABA - Multiple-Family Adaptive Behavior Treatment Guidance
97158	ABA - Group Adaptive Behavior Treatment by Physician/Qualified Health Professional
0362T	ABA - Behavior Identification Support Assessment, each 15 minutes (HCPCS temporary code)
0373T	ABA - Adaptive Behavior Treatment, each 15 minutes (HCPCS temporary code)

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rTMS Course Sessions

rTMS course (typical)1 daily session, 5 days/week up to 6 weeks, then 3-week taper (3, 2, 1 sessions) — total ~36 sessions; may repeat after 6-month cessation period. Therapy cannot be administered same day as PHP, IOP, ECT, or ABA services.

Partial Hospitalization (PHP) Minimum Weekly Hours

Partial Hospitalization Program (PHP) minimum weekly hoursTypically 5–8 hours/day, 5 days/week; not less than 20 hours of treatment services per week.

IOP Minimum Daily/Session Hours

Intensive Outpatient Program (IOP) minimum hours per day/sessionAt least 3 hours per day, two or more days per week.

Provider Responsibilities and How to Request Authorization

Prior Authorization

Prior Authorization Requirements and Responsibilities

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. A prior authorization is not a guarantee of benefits or payment. The terms of the member's plan control the available benefits. Usually, the provider is responsible for requesting prior authorization before performing a service if the member is seeing an in‑network provider. Sometimes, a plan may require the member to request prior authorization for services. Once a prior authorization request is received and processed, the decision is communicated to the provider. Obtaining prior authorization is not a substitute for checking eligibility and benefits.

Check member eligibility and benefits first through Availity® Essentials (availity.com) or your preferred web vendor portal to confirm coverage, prior authorization requirements, and any vendor-specific routing.
For some services/members, prior authorization may be required through Blue Cross and Blue Shield of Oklahoma (BCBSOK).
For other services/members, BCBSOK has contracted with Carelon Medical Benefits Management for utilization management and related services.

Note

Authorization Decision and Limitations

The prior authorization decision (approval, partial approval, or denial) will be communicated to the provider after the request is processed. A prior authorization is not a guarantee of benefits or payment; the member's plan terms determine actual coverage. If you have questions about a decision, contact the number on the member's ID card or the UM vendor that processed the request.

Decisions may include approvals with specific limits or conditions, or denials based on medical necessity criteria.
Authorization does not replace benefit verification — always confirm member-specific benefits and any applicable exclusions or limits.

Documentation Required

How to Request / Where to Verify

To request prior authorization or verify authorization status:

Verify member eligibility and benefits first via Availity® Essentials (availity.com) or your preferred web portal.
If BCBSOK retains authorization for the service, follow instructions on the member's plan or the BCBSOK provider resources to submit the request.
If Carelon Medical Benefits Management manages the service for the member, submit prior authorization requests and inquiries to Carelon per their submission channels (web portal, fax, or phone) as specified by BCBSOK.
If unsure which vendor manages the prior authorization for a given member or service, call the prior authorization number on the member's ID card for guidance.
Keep documentation of the submitted request and any authorization number provided; this is not a guarantee of payment and member plan terms govern coverage.

Service Definitions

Partial Hospitalization Treatment Program

DefinitionA Claim Administrator–approved planned program of a hospital or substance use disorder treatment facility for mental illness or substance use disorder in which patients spend days (day treatment)

IntensityTypically 5–8 hours per day, 5 days per week (not less than 20 hours/week)

Clinical oversightMedically supervised by a physician and nurse; psychiatrist must see the patient face-to-face at least once weekly

Licensing/accreditationProgram must be licensed in the state where located or accredited by a national organization recognized by the Claim Administrator and meet credentialing requirements

Applied Behavior Analysis (ABA)

DefinitionApplied Behavior Analysis (ABA) is a method of therapy used to improve or change specific behaviors for members with diagnoses within the pervasive and specific developmental disorders category of ICD-10

Care level noteABA is listed as a distinct care-level service and cannot be administered the same day as rTMS when applicable

Service contextABA is provided as outpatient behavioral therapy under the Claim Administrator's utilization management processes

Intensive Outpatient Program (IOP)

DefinitionIntensive Outpatient Program (IOP): a freestanding or hospital-based program providing services for at least 3 hours per day, two or more days per week to treat mental illness, substance use disorders, or co-occurring conditions

Integrated carePrograms specializing in severe or complex co-occurring conditions offer integrated assessment, treatment, and discharge planning for both mental illness and substance use disorders

Typical beneficiariesParticipants with co-occurring conditions likely benefit more from programs addressing both conditions than programs focused solely on mental illness

Outpatient Electroconvulsive Therapy (ECT)

DefinitionOutpatient Electroconvulsive Therapy (ECT): brief electrical stimulation of the brain while the member is under anesthesia, billed by a facility/clinic

Typical frequency inpatient vs outpatientTypically 2–3 times per week if member is inpatient; when outpatient, frequency may change to once every 3–4 weeks

Service contextUsed to treat severe psychiatric disorders as part of the utilization management process

Repetitive Transcranial Magnetic Stimulation (rTMS)

DefinitionRepetitive Transcranial Magnetic Stimulation (rTMS): a form of brain stimulation therapy delivered in a facility/clinic setting to treat psychiatric conditions

Typical courseUsually 1 daily session, 5 times per week for up to 6 weeks, followed by a 3-week taper (total 36 sessions)

Scheduling restrictionrTMS cannot be administered on the same day as a PHP, IOP, ECT, or ABA care-level service