CurrentColorado Rocky Mountain Health PlansPolicy N/A

Behavioral health prior authorization requirements for RMHP RAE/PRIME Medicaid

Prior authorization requirements and single-case agreement rules for behavioral health services where Rocky Mountain Health Plans (RMHP) RAE/PRIME Medicaid is the primary payer; affects participating and non-participating behavioral health providers and admitting facilities.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyBehavioral health prior authorization requirements for RMHP RAE/PRIME Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionFax prior authorization requests and documentation to 888-240-2689 or email rmhpbhvm@uhc.com; admitters may notify by calling 800-421-6204.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~30codes requiring SCA/authorization (approx.)

888-240-2689fax for prior auth

800-421-6204behavioral health phone

bh.sca.requests@uhc.comSCA initiation email

Behavioral Health Prior Authorization & Notification Criteria

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Behavioral health prior authorization and notification criteria

Services that require prior authorization, notification, or a single-case agreement are listed below by service type and code.

Behavioral health inpatient hospitalization — Requires prior authorization; applies to all admissions to freestanding inpatient psychiatric facilities or hospital psychiatric facilities.

ALL of the following

CPT/HCPCS code: H0017

ALL of the following

Revenue code: 0911

ALL of the following

CPT/HCPCS code: H0019

ALL of the following

CPT/HCPCS codes: H0035, H0016

ALL of the following

CPT/HCPCS codes: S9480, revenue code 905

ALL of the following

CPT/HCPCS codes: H2033, T2022

ALL of the following

CPT/HCPCS codes: H0036, T2022

ALL of the following

CPT code: 90870

ALL of the following

CPT codes: 96132-96139, 96146, 96130-96131

ALL of the following

CPT codes: 96116, 96121

ALL of the following

CPT/HCPCS code: H0011

ALL of the following

CPT/HCPCS code: H2036 with modifier U7 (Modifier HD for Special Connections cases)

ALL of the following

CPT/HCPCS code: H2036 with modifier U5 (Modifier HD for Special Connections cases)

ALL of the following

CPT/HCPCS code: H2036 with modifier U3 (Modifier HD for Special Connections cases)

ALL of the following

CPT/HCPCS code: H2036 with modifier U1 (Modifier HD for Special Connections cases)

ALL of the following

CPT/HCPCS codes: G0137, H0015, revenue code 906

ALL of the following

CPT/HCPCS code: H0016

ALL of the following

CPT codes: 90832-90838, 90839-90840, 90846-90853

Note: If the patient is an RMHP DSNP member, refer first to the Medicare prior authorization list; if not covered there, refer to the Medicaid prior authorization list provided here.

Codes, Thresholds, and Service-Level Rules

Outpatient psychotherapy (single-case agreement)CPTCovered

90832	Psychotherapy 30 minutes
90833	Psychotherapy with E/M 30 minutes
90834	Psychotherapy 45 minutes
90836	Psychotherapy with E/M 45 minutes
90837	Psychotherapy 60 minutes
90838	Interactive psychotherapy 30 minutes
90839	Psychiatric crisis intervention, first 60 minutes
90839+ET	Psychiatric crisis intervention with E&M (modifier ET)
90840	Psychiatric crisis intervention, each additional 30 minutes
90846	Family psychotherapy without patient present

1–10 of 13

1/2

Behavioral health facility and specialty service codesmixedCovered

H0017	Psychiatric residential treatment (acute treatment unit)
H0019	Qualified residential treatment program (QRTP) services
H0035	Partial hospitalization program (PHP)
S9480	Behavioral health intensive outpatient program (IOP)
H2033	Multisystemic therapy (MST)
H0036	Functional family therapy (FFT)
90870	Electroconvulsive therapy (ECT)
96132-96139,96146,96130-96131	Neuropsychological and psychological testing and related codes
96116	Neurobehavioral status exam
96121	Psychological testing administration and scoring

1–10 of 15

1/2

IOP session threshold

Behavioral health IOP session thresholdPrior authorization required for behavioral health IOP services greater than 15 sessions

SUD IOP threshold

SUD IOP thresholdPrior authorization required after 15 sessions for ASAM level 2.1 SUD IOP

ASAM 3.7 withdrawal management threshold

ASAM 3.7 withdrawal management thresholdNotification required at admission; prior authorization required for 5 or more days

MST/FFT authorization timing

MST/FFT authorization timingNotification at admission; prior authorization required after 90 days

How to Request Authorizations, SCAs, and Operational Steps

Prior Authorization

How to request authorization — Participating and non-participating providers may fax requests and documentation to 888-240-2689 or email rmhpbhvm@uhc.com; admitting facility may notify by calling 800-421-6204

Participating and non-participating providers must request prior authorization for non-emergent behavioral health services. Requests and supporting documentation may be faxed to 888-240-2689 or emailed to rmhpbhvm@uhc.com. For questions or to notify an admitting facility, call 800-421-6204. Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services except emergent or urgent care.

Fax: 888-240-2689
Email: rmhpbhvm@uhc.com
Behavioral health questions / admissions notification: 800-421-6204

Prior Authorization

Single-case agreement initiation — Certain CPT psychotherapy and related codes do not require authorization for out-of-network providers but do require a single-case agreement for payment

For RMHP RAE/PRIME Medicaid plans, certain CPT psychotherapy codes do not require prior authorization for out-of-network providers but do require a single-case agreement (SCA) for payment. To initiate an SCA, email bh.sca.requests@uhc.com.

Affected CPT codes: 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90839+ET, 90840, 90846, 90847, 90849, 90853

Prior Authorization

Service-level prior authorization requirements — Specific higher-acuity behavioral health services (inpatient psychiatric, PRTF, PHP, IOP, MST, FFT, ECT, neuropsych testing, ASAM levels, etc.) require notification or prior authorization

Higher-acuity and specialty behavioral health services require prior authorization or notification as specified per service. Providers must obtain prior authorization for inpatient psychiatric hospitalizations, PRTF, psychiatric residential treatment (H0017, Rev code 0911, H0019), PHP (H0035/H0016), many ASAM levels (H0011, H2036 with appropriate modifiers), ECT (90870), neuropsychological/psychological testing (96130–96139, 96146, 96116, 96121), IOP (S9480, rev code 905) when exceeding session limits, MST/FFT (H2033, H0036; T2022) and other specified services. Notification at admission is required for certain services; prior authorization is required after time thresholds or for lengths of stay as noted. RMHP DSNP members should consult the Medicare prior authorization list first.

Inpatient psychiatric hospitalization: prior authorization required for all admissions
PRTF / psychiatric residential treatment: H0017; Rev code 0911 — prior authorization required
PHP: H0035 / H0016 — prior authorization required
IOP: S9480, Rev code 905 — pre-service notification; authorization required if >15 sessions
MST / FFT: H2033, H0036, T2022 — notification at admission; authorization after 90 days
ECT: 90870 — prior authorization required
Neuropsych/psych testing: 96130–96139, 96146, 96116, 96121 — prior authorization required
ASAM levels (various): H0011, H2036 (+ modifiers) — notification/prior authorization per level and duration

Key Terms

Single-case agreement (SCA)

DefinitionSingle-case agreement (SCA) — a payment arrangement required for certain out-of-network CPT codes where authorization is not required but a special agreement is needed for payment.

How to initiateInitiate SCA requests via email to bh.sca.requests@uhc.com

Typical scopeApplies to specified outpatient psychotherapy and related CPT/HCPCS codes for out-of-network providers

Emergency or urgent care

DefinitionEmergency or urgent care — services for which prior authorization is not required.

Provider noteAdmitting facility may give notification by calling 800-421-6204; questions about behavioral health services call 800-421-6204

Out-of-network exceptionOut-of-network providers must request prior authorization for all procedures and services except emergent or urgent care