CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2023Commercial Bh Outpatient Benefit Prehauthorization Code List 09 25 23

A listing of CPT/HCPCS procedure codes and service categories related to behavioral health outpatient services for which prior authorization may be required for certain BCBSOK commercial non-HMO members as of January 1, 2023.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2023Commercial Bh Outpatient Benefit Prehauthorization Code List 09 25 23

Policy CodePolicy N/A

Change TypeCode additions/updates (effective 01/01/2023)

Effective DateJan 1, 2023

Next Review Date

Key ActionObtain prior authorization through BCBSOK or the specified utilization management vendor for listed services; services without required prior authorization will be denied for payment.

SourceLink

POLICY UPDATE CHANGES

Updates = Add effective 01/01/2023 for multiple CPT codes (96113, 96116, etc.).

multipleCodes listed (partial document)

2023-01-01Effective/Reference Date

36Typical rTMS total sessions per course

5x/weekrTMS weekly frequency

6 months

Minimum repeat cessation period (rTMS)

Policy summary and scope

This is a non-exhaustive list of CPT/HCPCS procedure codes related to behavioral health outpatient services for which prior authorization may be required for some BCBSOK commercial non-HMO members (effective 2023-01-01). The presence of a code on this list does not guarantee coverage because member benefits vary; BCBSOK will notify providers when prior authorization is required for specific testing services.

Policy summary header

Effective Date2023-01-01

Policy Title2023Commercial Bh Outpatient Benefit Prehauthorization Code List 09 25 23

PayerBlue Cross Blue Shield - Oklahoma

Policy NumberN/A

StatusCURRENT

Scope SummaryA listing of CPT/HCPCS procedure codes and service categories related to behavioral health outpatient services for which prior authorization may be required for certain BCBSOK commercial non-HMO members as of January 1, 2023.

Prior authorization requirement

Prior Authorization Requirement

Prior authorization may be required for the following services/categories for some commercial non-HMO members (e.g., PPO, Blue Choice PPO, Blue Options, Blue HPN) as of January 1, 2023:

ANY of the following

Partial Hospitalization Treatment Program (PHP) — typically 5 to 8 hours per day, 5 days per week (not less than 20 hours/week); must be licensed or nationally accredited; psychiatrist sees patient face-to-face at least once a week; medically supervised by physician and nurse; participants do not require 24-hour supervision.
Intensive Outpatient Programs (IOP) — freestanding or hospital-based program providing services at least 3 hours/day, two or more days/week for mental illness or substance use disorder; integrated care for co-occurring conditions.
Applied Behavior Analysis (ABA) — therapy for diagnoses within pervasive and specific developmental disorders (ICD-10 category).

Code lists and coding notes

Applied Behavior Analysis / ABA and related CPT codes (prior auth may be required)CPT

97151	Bhv Id Assmt By Phys/Qhp (psychological testing / behavior identification assessment by physician/qualified healthcare professional)
97152	Bhv Id Suprt Assmt By 1 Tech (behavior identification support assessment by 1 technician)
97153	Adaptive Behavior Tx By Tech (adaptive behavior treatment by technician)
97154	Grp Adapt Bhv Tx By Tech (group adaptive behavior treatment by technician)
97155	Adapt Behavior Tx Phys/Qhp (adaptive behavior treatment by physician/qualified healthcare professional)
97156	Fam Adapt Bhv Tx Gdn Phy/Qhp (family adaptive behavior treatment guidance by physician/QHP)
97157	Mult Fam Adapt Bhv Tx Gdn (multiple-family adaptive behavior treatment guidance)
97158	Grp Adapt Bhv Tx By Phy/Qhp (group adaptive behavior treatment by physician/QHP)
0362T	Bhv Id Suprt Assmt Ea 15 Min (behavior identification support assessment each 15 min)
0373T	Adapt Bhv Tx Ea 15 Min (adaptive behavior treatment each 15 min)

Psychological and Neuropsychological Testing CPT codes (prior auth may be required)CPT

96105

Assessment Of Aphasia, Per Hour (psychological/neuropsychological testing service code)

Electroconvulsive Therapy (ECT) CPT code (prior auth may be required)CPT

90870

Electroconvulsive Therapy (Includes Necessary Monitoring)

Repetitive Transcranial Magnetic Stimulation (rTMS) and related CPT/HCPCS codesmixed

0362T	rTMS related (also listed under ABA codes as Bhv Id Suprt Assmt Ea 15 Min in document context)
0373T	rTMS related (also listed as Adapt Bhv Tx Ea 15 Min in document context)

Psychological and Neuropsychological Testing - Covered/ManagedCPTCovered

96105	Assessment Of Aphasia, Per Hour
96110	Developmental Screening, Per Instrument
96112	Devel Tst Phys/QHP 1st Hr
96113	Devel Tst Phys/QHP Ea Addl
96116	Neurobehavioral Status Exam, Per Hour
96121	Each Additional Hour For Neurobehavioral Status Exam (Must Be Used With 96116, Not A Stand Alone Code)
96125	Standardized Cognitive Testing, Per Hour
96127	Brief Emotional/Behavior Assessment
96130	Psychological Interpretation And Reporting Following Testing, By Qualified Health Care Professional, First Hour
96131	Each Additional Hour Of 96130 (Not A Stand Alone Code)

1–10 of 17

1/2

Repetitive Transcranial Magnetic Stimulation (rTMS) - Covered/ManagedCPTCovered

90867	Tcranial Magn Stim Tx Plan (rTMS)
90868	Subsequent Delivery And Management, Per Session (rTMS)
90869	Subsequent Motor Threshold Re-Determination (rTMS)

Note: certain codes are indicated as Not A Stand Alone Code (e.g., 96121, 96131, 96133, 96137, 96139) and must be reported only in conjunction with their primary codes.

Required actions, billing rules, and documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for the services and categories listed on this policy for some commercial non‑HMO members. Providers should obtain prior authorization when applicable before delivering services to avoid claim denials.

Partial Hospitalization Program (PHP)
Intensive Outpatient Program (IOP)
Applied Behavior Analysis (ABA)
Outpatient Electroconvulsive Therapy (ECT)
Repetitive Transcranial Magnetic Stimulation (rTMS)
Psychological/Neuropsychological testing (in some cases)

Documentation Required

Check Member Eligibility and Benefits

Key term definitions

Definitions

Partial Hospitalization Treatment Program (PHP)A planned, claim administrator approved program providing typically 5-8 hours/day, 5 days/week (>=20 hours/week) of behavioral health treatment; medically supervised; psychiatrist face-to-face weekly.

Intensive Outpatient Program (IOP)Program providing at least 3 hours/day, two or more days/week for treatment of mental illness or substance use disorders; may provide integrated care for co-occurring conditions.

Applied Behavior Analysis (ABA)Method of therapy to improve/change behaviors for members with diagnoses in the pervasive and specific developmental disorders ICD-10 category.

rTMSRepetitive transcranial magnetic stimulation — typical course 1 daily session, 5x/week up to 6 weeks, then 3-week taper (total ~36 sessions); may repeat after 6 months.

ECTOutpatient Electroconvulsive Therapy (ECT): brief electrical brain stimulation under anesthesia; frequency varies (2-3/week inpatient; once every 3-4 weeks outpatient).

Document changes and updates

2023-01-01update

Updates = Add effective 01/01/2023 for multiple CPT codes (96113, 96116, etc.).

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2023Commercial Bh Outpatient Benefit Prehauthorization Code List 09 25 23

Policy CodePolicy N/A

Change TypeCode additions/updates (effective 01/01/2023)

Effective DateJan 1, 2023

Next Review Date

Key ActionObtain prior authorization through BCBSOK or the specified utilization management vendor for listed services; services without required prior authorization will be denied for payment.

SourceLink

On This Page

Outpatient Electroconvulsive Therapy (ECT) — brief electrical brain stimulation under anesthesia; frequency varies (2-3/week inpatient; once every 3-4 weeks outpatient).

Repetitive Transcranial Magnetic Stimulation (rTMS) — typical course: daily sessions 5x/week up to 6 weeks, followed by a 3-week taper (3, 2, 1 sessions) for total ~36 sessions; repeatable after 6-month cessation;

rTMS cannot be administered the same day as PHP, IOP, ECT, or ABA service.

Psychological/Neuropsychological Testing — only requires prior authorization in some cases; BCBSOK will notify providers when prior authorization is required.

Prior authorization may be required for some commercial non-HMO members; providers will be notified when authorization is required. Providers must verify member eligibility and benefits (for example via Availity or other portal) before rendering services to confirm coverage, prior authorization requirements, and the correct utilization management vendor.

Verify eligibility and benefits for every patient prior to rendering services to confirm coverage, prior authorization requirements, and which utilization management vendor (if any) must be used.

Check eligibility and benefits via Availity® Provider Portal (availity.com) or other preferred vendor portal (electronic 270 transaction).
Confirm whether prior authorization must be obtained through BCBSOK or a designated utilization management vendor.
Obtain prior authorization where required — services performed without required prior authorization may be denied and providers may not bill members for denied services.

Billing Rule

rTMS Scheduling and Course Constraints

rTMS scheduling and billing constraints and typical treatment course.

Typical course: 1 session per day, 5 days per week for up to 6 weeks, followed by a 3‑week taper (week 1 = 3 sessions, week 2 = 2 sessions, week 3 = 1 session) — total approximately 36 sessions.
Typical frequency: daily treatments (5x/week) during the acute course.
Minimum cessation period before repeat course: 6 months (treatment course may be repeated after a 6‑month cessation period if clinically indicated).
Same‑day prohibition: rTMS 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.

Prior Authorization

Psychological / Neuropsychological Testing — Conditional Prior Authorization

Psychological and neuropsychological testing may require prior authorization only in certain cases. BCBSOK will notify providers when prior authorization is required for testing services.

97151
97152
97153

Billing Rule

Not a Stand‑Alone Code — Billing Constraint

Certain codes are designated as not to be billed as standalone services; ensure correct use and bundling when submitting claims.

96121
96131
96133
96137
96139

Documentation Required

Benefits Determination Is Not a Guarantee of Payment

A benefits determination or prior authorization decision is not a guarantee of payment. Providers must verify member eligibility and the member’s certificate of coverage for benefit limitations, exclusions, and member cost‑sharing.

Verify member eligibility and benefits prior to service delivery.
Prior authorization or eligibility confirmation does not override contract exclusions or limits — consult the member’s certificate of coverage.