CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2025 Commercial Outpatient Behavioral Health Prior Authorization Codes

Defines outpatient behavioral health service categories and CPT/HCPCS codes for which prior authorization may be required for Blue Cross and Blue Shield of Oklahoma commercial members, and describes utilization management processes and service definitions; affects in-network providers and facilities managing BCBSOK members.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Commercial Outpatient Behavioral Health Prior Authorization Codes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionConfirm member eligibility and request prior authorization via Availity or the vendor listed on the member ID before providing services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~40+behavioral health procedure codes included (examples shown)

2–3/wk or q3–4wkelectroconvulsive therapy frequency guidance

36typical total rTMS sessions

20+ hrs/wkPHP minimum weekly hours

Prior Authorization and Service Management

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General Prior Authorization and Service Management

Prior authorization may be required for listed outpatient behavioral health services; authorization decisions confirm medical necessity per the member's benefit plan and are not guarantees of payment.

Confirm member eligibility and benefits via Availity or preferred portal before requesting authorization.

A 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; obtaining authorization is not a guarantee of benefits or payment.

Usually the provider is responsible for requesting prior authorization for in-network services; in some plans the member may be required to request authorization.

Some prior authorization decisions are managed by Carelon Medical Benefits Management under contract with BCBSOK; contact and vendor details are available on the member ID card or via Availity/portal.

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

Service-specific notes

Psychological/Neuropsychological testing requires prior authorization in some cases; BCBSOK will notify the provider when authorization is required.
rTMS, ECT, PHP, IOP, and ABA services are defined with typical treatment schedules and may appear on the prior authorization/code list; refer to the code file for specific CPT/HCPCS entries and service definitions.

CPT / HCPCS Codes and Code-Specific Notes

Selected CPT/HCPCS codes that appear on the prior authorization listCPT | HCPCSCovered

97151	Behavior identification assessment by physician/qualified health professional
97152	Behavior identification support assessment by a technician
97153	Adaptive behavior therapy by technician
90870	Electroconvulsive therapy
90867	rTMS treatment planning
90868	rTMS delivery
96130	Psychological testing evaluation by physician/qualified health professional

(Additional rTMS related code listed in source)CPTCovered

90869

rTMS - Redetermine / Tcran Magn Stim (listed for rTMS related services)

inv-03: rTMS course sessions

Typical total sessionsTypically 36 sessions per treatment course (5 sessions/week up to 6 weeks plus a 3-week taper: 3 sessions in week 1, 2 sessions in week 2, and 1 session in week 3)

Weekly schedulingInitial intensive phase delivered 5 times per week for up to 6 weeks

Taper schedule3-week taper after the intensive phase (3, then 2, then 1 session) to complete the 36-session course

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

Concurrent care restrictionrTMS cannot be administered on the same day as PHP, IOP, ECT, or ABA services

What Providers Must Do

Prior Authorization

Prior authorization required; provider usually requests

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 provider is usually responsible for requesting prior authorization for in-network services.

Check member eligibility and benefits prior to requesting authorization via Availity or preferred portal.
Authorization decisions confirm medical necessity but do not guarantee payment; member plan terms control benefits.

Note

Authorizations may be managed by Carelon — confirm contact

Some prior authorization decisions and utilization management functions are managed by Carelon Medical Benefits Management under contract with BCBSOK; check the member's ID card or Availity/portal for the correct authorization contact number.

If unclear, call the authorization number on the member's ID card.
Always verify whether BCBSOK or Carelon manages the authorization for the specific service/member.

Prior Authorization

Psychological/Neuropsychological testing may require prior authorization

Psychological/Neuropsychological testing only requires prior authorization in some cases; BCBSOK will notify the provider if prior authorization is required for these testing services.

Do not assume authorization is required for all psychological testing—await BCBSOK notification when authorization is necessary.

Service Definitions and Program Descriptions

inv-07: Partial Hospitalization Treatment Program (PHP)

Service descriptionA claim administrator–approved planned program in a hospital or SUD treatment facility for mental illness or substance use disorder where patients receive structured behavioral health care during the day

Typical daily scheduleTypically 5–8 hours per day

Typical weekly hoursTypically 5 days per week (not less than 20 hours of treatment services per week)

Clinical staffing and oversightMedically supervised by a physician and nurse; psychiatrist must see the patient face-to-face at least once weekly (in person or by telephone) to provide direction

Residency/supervisionParticipants do not require 24‑hour supervision and are not considered residents of the program

inv-08: Intensive Outpatient Program (IOP)

Program settingFreestanding or hospital‑based program providing structured services to treat mental illness, addiction, or co‑occurring conditions

Minimum daily durationAt least 3 hours per day

Minimum weekly frequencyTwo or more days per week

Treatment componentsIntegrated assessment, treatment and discharge planning; programs for co‑occurring conditions provide aligned services for both mental illness and substance use

inv-09: Repetitive Transcranial Magnetic Stimulation (rTMS)

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

Typical courseUsually 5 sessions per week for up to 6 weeks, followed by a 3‑week taper (totaling 36 sessions)

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

Same‑day restrictionCannot be administered on the same day as PHP, IOP, ECT, or ABA services

inv-10: Electroconvulsive Therapy (ECT)

Therapy descriptionElectroconvulsive Therapy (ECT) involves brief electrical stimulation of the brain while the member is under anesthesia to treat severe psychiatric disorders

Inpatient frequency guidanceTypically administered 2–3 times per week when the member is admitted to an inpatient care level

Outpatient frequency guidanceOnce every 3–4 weeks when provided at an outpatient care level

Billing settingBilled by a facility/clinic

inv-11: Applied Behavior Analysis (ABA)

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

Codes referencedMultiple ABA CPT/HCPCS codes are listed (examples include 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T)

Coverage noteSpecific ABA CPT/HCPCS codes are included in the prior authorization/code list and managed per claim administrator rules

Service descriptionsCodes map to behavior identification assessment, behavior support assessment, adaptive behavior therapy, group adaptive behavior therapy, family adaptive behavior services, and time‑based billing (per 15 minutes) for ABA services