CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2024 Commercial Outpatient Behavioral Health Prior Authorization Codes Effective 1/1/2024

A searchable code list identifying CPT/HCPCS codes related to outpatient behavioral health services for which prior authorization may be required for BCBS Oklahoma networks, with service descriptions and utilization management notes effective 1/1/2024 (part 1 of 2).

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2024 Commercial Outpatient Behavioral Health Prior Authorization Codes Effective 1/1/2024

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review Date

Key ActionObtain prior authorization when required.

POLICY UPDATE CHANGES

No material clinical/coverage changes.

36rTMS Typical Total Sessions

6 monthsrTMS Repeat Interval

multipleCPT/HCPCS Codes Listed

Part 2Document segment

2024-01-01Effective date stated in header

This is a searchable CPT/HCPCS code list for outpatient behavioral health services (Partial Hospitalization, ABA, IOP, ECT, Psychological/Neuropsychological Testing) maintained by BCBSOK, effective 2024-01-01. It covers codes for services that may require prior authorization and indicates utilization management routing for the Blue Choice Preferred PPO, Blue Choice PPO, and Blue Traditional networks; prior authorization and vendor handling are managed by BCBSOK or contracted Carelon Medical Benefits Management as noted in the list.

Key metadata

Effective date2024-01-01

Policy titleCommercial Outpatient Behavioral Health Prior Authorization Codes

PayerBlue Cross Blue Shield - Oklahoma

Policy numberN/A

StatusCURRENT

Document segment/partPart 2 of 2

Scope summaryA searchable code list identifying CPT/HCPCS codes related to outpatient behavioral health services for which prior authorization may be required for BCBS Oklahoma networks, with service descriptions and utilization management notes effective 1/1/2024 (part 1 of 2).

Prior authorization & coverage rules

Prior Authorization Requirement Overview

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

Code list prior auth: Prior authorization may be required for listed CPT/HCPCS codes as of January 1, 2024 for Blue Choice Preferred PPO, Blue Choice PPO, and Blue Traditional networks.
Coverage controlled by member contract: Presence of a code on the list does not guarantee coverage; member benefit contract controls coverage and benefits.
Provider responsibility: Providers are usually responsible for requesting prior authorization before performing a service if the member is seeing an in-network provider.
Vendor routing for prior authorization: Some services/members may require prior authorization through BCBSOK; others via contracted Carelon Medical Benefits Management.
Testing prior authorization notification: BCBSOK will notify the provider if prior authorization is required for Psychological/Neuropsychological Testing in specific cases.

Service-level Constraint: rTMS/ECT/Overlap

Coverage/authorization constraints for brain stimulation therapies:

rTMS typical course and total sessions: Repetitive Transcranial Magnetic Stimulation (rTMS) treatment course is usually 1 session daily, 5 times/week for up to 6 weeks, followed by a 3-week taper (3 sessions week 1, 2 sessions week 2, 1 session week 3) for a typical total of 36 sessions.Typical total of 36 sessions per treatment course
rTMS repeat interval: The rTMS treatment course may be repeated after a 6-month cessation period if needed.May be repeated after a 6-month cessation period
Same-day prohibition: rTMS/ECT therapy cannot be administered on the same day as a Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), Electroconvulsive Therapy (ECT), or Applied Behavior Analysis (ABA) care level service; billing for same-day service may be denied.

CPT / HCPCS codes referenced

Repetitive Transcranial Magnetic Stimulation (rTMS) and related procedure codesmixed

97151	Bhv Id Assmt By Phys/Qhp (listed as rTMS in document)
97152	Bhv Id Suprt Assmt By 1 Tech (listed as rTMS in document)
97153	Adaptive Behavior Tx By Tech (listed as rTMS in document)
97154	Grp Adapt Bhv Tx By Tech (listed as rTMS in document)
97155	Adapt Behavior Tx Phys/Qhp (listed as rTMS in document)
97156	Fam Adapt Bhv Tx Gdn Phy/Qhp (listed as rTMS in document)
97157	Mult Fam Adapt Bhv Tx Gdn (listed as rTMS in document)
97158	Grp Adapt Bhv Tx By Phy/Qhp (listed as rTMS in document)
0362T	Bhv Id Suprt Assmt Ea 15 Min (listed as rTMS in document) - HCPCS Category III code
0373T	Adapt Bhv Tx Ea 15 Min (listed as rTMS in document) - HCPCS Category III code

1–10 of 11

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Psychological/Neuropsychological and Testing codes (listed as potentially requiring prior authorization in some cases)CPT

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

1–10 of 17

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Other codes referenced in rTMS/ECT sectionsCPT

90867	Tcranial Magn Stim Tx Plan (listed under rTMS)
90868	Tcranial Magn Stim Tx Deli (listed under rTMS)
90869	Tcran Magn Stim Redetemine (listed under rTMS)

The published code list is partial (this document is part 1 of 2), not exhaustive, may be updated throughout the year, and presence of a code on the list does not guarantee coverage under a member's benefit contract; providers should verify benefits and authorization requirements. Code list is informational and not exhaustive.

What providers must do

Prior Authorization

Obtain prior authorization when required

Obtain prior authorization when required. Applies to listed outpatient behavioral health services.

Applies to listed outpatient behavioral health services.

Documentation Required

Confirm eligibility and benefits before requesting prior authorization

Confirm member eligibility and benefits before requesting prior authorization. Verify member-specific plan provisions, coverage limitations, and prior authorization requirements through the Availity Essentials portal or other eligibility tools prior to submitting an authorization request.

Use the Availity Essentials portal to check eligibility and benefits before requesting prior authorization.

Prior Authorization

Vendor routing for prior authorization

Vendor routing for prior authorization: some prior authorizations are managed directly by Blue Cross Blue Shield of Oklahoma (BCBSOK) and others are managed by a contracted vendor (Carelon). Confirm which organization manages the authorization for the member's network/product when initiating the request.

Billing Rule

rTMS/ECT same-day prohibition

rTMS/ECT same-day prohibition: Repetitive Transcranial Magnetic Stimulation (rTMS) may not be billed on the same day as Partial Hospitalization (PHP), Intensive Outpatient Program (IOP), Electroconvulsive Therapy (ECT), or Applied Behavior Analysis (ABA) services. Billing for same-day service may be denied.

Affected codes: 97151, 97152, 97153, 97154, 97155
Billing impact: billing for same-day service may be denied

Prior Authorization

Some psychological/neuropsychological testing prior authorization

Some psychological and neuropsychological testing services require prior authorization in certain cases. Prior authorization is case-dependent; BCBSOK will notify the provider when prior authorization is required for testing services.

Affected codes: psychological/neuropsychological testing codes (case-dependent prior authorization)

Documentation Required

Communicating prior authorization decisions

Prior authorization decisions are communicated to the requesting provider. If you have questions about an authorization decision, contact the phone number on the member's ID card.

Billing Rule

Code list is informational and not exhaustive

The code list is informational and not exhaustive. Providers should check member benefits and eligibility, and confirm prior authorization requirements for services not listed; coverage and medical necessity determinations are made at the time of claim adjudication.

Key terms

Definitions

Partial Hospitalization Treatment Program (PHP)A planned program (hospital or substance use disorder treatment facility) providing behavioral healthcare typically 5-8 hours/day, 5 days/week (not less than 20 hours/week), medically supervised, psychiatrist face-to-face at least once weekly.

Intensive Outpatient Program (IOP)Freestanding or hospital-based program providing at least three hours/day, two or more days/week for treatment of mental illness or substance use disorders.

Availity® EssentialsA web portal operated by Availity, LLC for checking eligibility and benefits and other administrative exchanges.

Carelon Medical Benefits ManagementAn independent company contracted by BCBSOK to provide utilization management and related services for certain members/services.

OpenPayer

2024 Commercial Outpatient Behavioral Health Prior Authorization Codes Effective 1/1/2024

Policy summary and scope

Prior authorization & coverage rules

CPT / HCPCS codes referenced

What providers must do

Key terms

Operational notes & FAQs

Document dates and changes