CurrentBlue Cross Blue Shield - OklahomaPolicy PSY301.021

Behavioral Health Procedure Code Preauthorization List (ABA, ECT, rTMS, Psychological Testing, PHP/IOP/RTC)

This document lists behavioral health procedure codes and describes program definitions and preauthorization requirements for inpatient, partial hospitalization, residential, ABA, IOP, ECT, psychological/neuropsychological testing, and rTMS services; it is intended for providers submitting claims to the Blue Cross Blue Shield plan (Commercial outpatient benefit) to determine if prior authorization is required.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyBehavioral Health Procedure Code Preauthorization List (ABA, ECT, rTMS, Psychological Testing, PHP/IOP/RTC)

Policy CodePolicy PSY301.021

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionVerify member eligibility and benefits (for example via Availity®) to determine whether preauthorization is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

36rTMS typical course (sessions)

20+Partial Hospitalization min hrs/week

5 days/weekTypical PHP frequency

97151-97158ABA codes listed

96101-96146

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Coverage Criteria and Program Definitions

The policy clarifies the Residential Treatment Center (RTC) definition and explicit exclusions. An RTC is described as a licensed facility providing a defined course of therapeutic intervention in a controlled residential environment with 24‑hour medical monitoring and nursing services. The policy specifically excludes facilities whose primary purpose is long‑term social support rather than intensive clinical care — examples include halfway houses, wilderness programs, supervised living, group homes, and boarding houses even if counseling services are provided. Providers must ensure facilities meet applicable state licensure or recognized national accreditation and other credentialing requirements described by the plan.

Procedure Codes and Billing Categories

Applied Behavior Analysis (ABA) 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

Electroconvulsive Therapy CodesCPT

90870	Electroconvulsive therapy (includes necessary monitoring)
00104	Anesthesia for electroconvulsive therapy

Psychological and Neuropsychological Testing CodesCPT

96101	Psychological Testing, per hour with psychologist or physician
96102	Psychological Testing, per hour with technician
96103	Psychological Testing administered by computer
96105	Assessment of Aphasia, per hour
96110	Developmental screening, per instrument
96111	Developmental testing with interpretation and report
96116	Neurobehavioral Status Exam, per hour
96118	Neuropsychological testing, per hour with psychologist or physician
96119	Neuropsychological testing, per hour with technician
96120	Neuropsychological testing, by computer

1–10 of 21

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rTMS CodesCPT

90867	TCRANIAL MAGN STIM TX PLAN
90868	Subsequent delivery and management, per session
90869	Subsequent motor threshold re-determination

Partial Hospitalization minimum weekly hours

Minimum weekly treatment hours>= 20 hours per week (Partial Hospitalization Treatment Program is typically 5–8 hours/day, 5 days/week; not less than 20 hours/week)

Typical daily scheduleTypically 5–8 hours per day

Typical weekly frequencyTypically 5 days per week

Provider Responsibilities and Authorization Requirements

Note

Verify Eligibility and Benefits

Verify member eligibility and benefits prior to rendering services. Check Availity® or the member's preferred vendor to determine coverage, benefit limits, and whether preauthorization is required for the planned service.

Use Availity® or equivalent clearinghouse to confirm member-specific coverage and prior authorization requirements.
The presence of a procedure code in provider materials does not guarantee coverage under the member's contract.

Prior Authorization

Prior Authorization May Be Required

Prior authorization may be required for many behavioral health services and specific procedure codes (including Applied Behavior Analysis codes listed under policy PSY301.021). Obtain prior authorization when indicated to avoid claim denials or delayed payment.

Applied Behavior Analysis (ABA) codes (e.g., 97151, 97152, 97153, 97158, 0362T) are associated with Medical Policy PSY301.021 and may require prior authorization.
Partial hospitalization (PHP), intensive outpatient (IOP), residential treatment, and other higher levels of care frequently require preauthorization—verify per member benefits.

Key Program Definitions

Partial Hospitalization Treatment Program (PHP)

DefinitionA 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 spend days in treatment; behavioral healthcare typically 5–8 hours per day and not less than 20 hours per week.

Staffing and physician involvementStaffed similarly to the day shift of an inpatient unit; medically supervised by a physician and nurse; psychiatrist must see the patient face-to-face at least weekly and be available as needed.

Licensure/accreditation requirementProgram must be licensed in the state where located or accredited by a national organization recognized by the Claim Administrator and meet credentialing requirements.

Supervision levelParticipants do not require 24-hour supervision and are not considered residents at the program.

Residential Treatment Center (RTC)

PHP / IOP / RTC Level-of-Care Criteria

PHP / IOP / RTC

Covered when ALL of the following program-level requirements are met:

Partial Hospitalization Program (PHP): Planned program for mental illness or substance use disorder typically 5–8 hours/day, 5 days/week (not less than 20 hours/week); staffed similarly to the day shift of an inpatient unit with medical supervision by a physician and nursing staff; psychiatrist must see the patient face-to-face at least weekly; participants do not require 24-hour supervision; facility must be licensed or accredited as required by the Claim Administrator.>=20 hours/week

Verify facility licensure/accreditation and member eligibility/benefits for preauthorization requirements.

Intensive Outpatient Program (IOP): Program provides services at least three hours per day on two or more days per week and may address co-occurring mental health and substance use conditions with integrated assessment, treatment, and discharge planning.>=3 hours/day

Verify member eligibility/benefits for preauthorization.

Applied Behavior Analysis (ABA) Coverage Criteria

Applied Behavior Analysis (ABA)

Applied behavior analysis services and program expectations:

ABA listing: Applied Behavior Analysis (ABA) procedure and T‑codes are listed (97151–97158, 0362T, 0373T) and cross-referenced to the ABA medical policy PSY301.021.

Providers must verify member eligibility/benefits to determine if prior authorization is required.

Service description: ABA is a therapeutic method to improve or change specific behaviors for members with diagnoses in the pervasive and specific developmental disorders category of ICD‑10.

Services are subject to the ABA medical policy and preauthorization rules as applicable.

ECT and rTMS Coverage Criteria

ECT / rTMS

Electroconvulsive therapy and rTMS service-level expectations:

ECT: Electroconvulsive therapy is an outpatient facility/clinic‑billed treatment involving brief electrical stimulation of the brain under anesthesia; monitoring and anesthesia (e.g., code 00104) are included as indicated. Frequency may be 2–3 times/week when inpatient, and as an outpatient may change to once every 3–4 weeks per clinical need.

Verify member eligibility/benefits for preauthorization; bill facility/clinic appropriately.

rTMS: Repetitive transcranial magnetic stimulation is a facility/clinic brain stimulation therapy typically delivered as one daily session, five times per week for up to six weeks followed by a three‑week taper (total about 36 sessions); course may be repeated after a six‑month cessation. rTMS cannot be administered on the same day as PHP, IOP, ECT, or ABA care level services.36 sessions typical

Verify preauthorization requirements and document treatment course per medical policy; use CPT codes 90867, 90868, 90869 as appropriate.

Visit and Session Limits

rTMS — typical course/session limit

Typical total sessions (course)36 sessions (typical treatment course: up to 6 weeks plus 3-week taper)

Session frequencyUsually 1 session per day, 5 days per week during initial course

Administration constraintCannot be administered on the same day as PHP, IOP, ECT, or ABA care-level services

Background and Program Context

Partial Hospitalization Programs (PHP) and Intensive Outpatient Programs (IOP) are structured, day‑time levels of care for mental health and substance use disorders. A Partial Hospitalization Program (PHP) is a planned hospital‑ or facility‑based program where patients attend treatment typically 5–8 hours per day and not less than 20 hours per week; staffing parallels the day shift of an inpatient unit and a psychiatrist provides face‑to‑face evaluation at least weekly. An Intensive Outpatient Program (IOP) provides services for at least 3 hours per day on two or more days per week and may address co‑occurring conditions with integrated assessment, treatment, and discharge planning.

Providers should verify member eligibility and benefits (for example via Availity®) to determine whether preauthorization is required for these programs and ensure the facility is properly licensed or accredited per the administrator's credentialing policy.