CurrentColorado Rocky Mountain Health PlansPolicy N/A

Florida Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Governs prior authorization requirements for participating behavioral health providers for UnitedHealthcare Exchange Plans members in Florida for inpatient and outpatient behavioral health services; applies to submission of prior authorization requests and notes exceptions for emergency/urgent care and out-of-network coverage.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyFlorida Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review Date

Key ActionTo request prior authorization, submit your request online via the Prior Authorization and Notification tool accessible through Sign In on UHCProvider.com.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1, 2024policy effective date

Multipleprocedure code list size

Onlinesubmission method

Emergency/urgentprior auth exceptions

Authorization and Coverage Criteria

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Authorization coverage stance

Services listed require prior authorization. Refer to the member-specific benefit plan for coverage terms. Prior authorization is not required for emergency or urgent care; these plans have no non-emergent out-of-network coverage and no coverage outside the service area.

Services listed require prior authorization for participating behavioral health providers for Exchange Plans members in Florida.

When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan vary by state.

Prior authorization is not required for emergency or urgent care.

For these benefit plans, members have no non-emergent out-of-network coverage and no coverage outside of the service area.

To request prior authorization, submit your request online via the Prior Authorization and Notification tool accessible through Sign In on UHCProvider.com.

Provider Submission Requirements & Service Lists

Prior Authorization

Prior Authorization Required

Prior authorization is required for the services and codes listed below for behavioral health providers. Submit requests online via the Prior Authorization and Notification tool accessible through Sign In on the provider portal. Prior authorization is not required for emergency or urgent care. When determining coverage, reference the member-specific benefit plan document. Members may have no non-emergent out-of-network coverage or coverage outside the service area for these plans.

Submit online via the Prior Authorization and Notification tool (Sign In on the provider portal).
Prior authorization not required for emergency or urgent care.
Verify member-specific benefit plan for coverage details and out-of-network applicability.

Prior Authorization

Services and Codes Requiring Prior Authorization

The following services and associated procedure/revenue/CPT codes require prior authorization for behavioral health (inpatient and outpatient) services.

Inpatient Mental Health — Revenue codes: 0114, 0124, 0134, 0144, 0154 (listed as Rev 114, 124, 134, 144, 154).
Inpatient Substance Use Detoxification (hospital based) — Revenue codes: 0116, 0126, 0136, 0146, 0156 (Rev 116, 126, 136, 146, 156).
Substance Use Rehabilitation (hospital based) — Revenue codes: 0118, 0128, 0138, 0148, 0158 (Rev 118, 128, 138, 148, 158).
Psychiatric Clinic — Revenue code: 0513 (Rev 513).
Treatment Room — Revenue code: 0761 (Rev 761).
Evaluation/Initial Behavioral Health Treatments/Services — Revenue code: 0900 (Rev 900).
Mental Health Intensive Outpatient — Revenue code: 0905 (Rev 905).
Substance Use Disorder Intensive Outpatient — Revenue code: 0906 (Rev 906).
MH/SUD Partial Hospitalization — Revenue codes: 0912, 0913 (Rev 912, 913).
Outpatient Services - Behavioral Health Testing — Revenue code: 0918 (Rev 918).
Outpatient Services - Other Behavioral Health Treatment/Services — Revenue code: 0919 (Rev 919).
Drug Rehabilitation — Revenue code: 0944 (Rev 944).
Alcohol Rehabilitation — Revenue code: 0945 (Rev 945).
Combined Drug and Alcohol Rehabilitation — Revenue code: 0953 (Rev 953).
Psychiatric — Revenue code: 0961 (Rev 961).
Residential Treatment - Psychiatric — Revenue code: 1001 (Rev 1001).
Residential Treatment - Chemical Dependency — Revenue code: 1002 (Rev 1002).
Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS) — CPT codes: 90867 (planning, 1 visit), 90868 (delivery and management, per session), 90869 (subsequent motor threshold re-determination with delivery and management).
Unlisted psychiatric service or procedure — CPT 90899.
Psychological testing evaluation — CPT codes 96130, 96131.
Psychological or neuropsychological test administration & scoring by physician or qualified health care professional, two or more tests, first 30 minutes — CPT 96136 (auth required only if submitted with 96130/96131).
Psychological or neuropsychological test admin & scoring by physician or qualified health care professional, two or more tests, each additional 30 minutes — CPT 96137 (auth required only if submitted with 96130/96131).
Psychological or neuropsychological test admin & scoring by technician, two or more tests, first 30 minutes — CPT 96138 (auth required only if submitted with 96130/96131).
Psychological or neuropsychological test admin & scoring by technician, two or more tests, each additional 30 minutes — CPT 96139 (auth required only if submitted with 96130/96131).
Computer-based psychological/neuropsychological testing — CPT 96146.
Behavior Identification Assessment by physician/qualified health professional, each 15 min — CPT 97151.
Behavior ID support assessment by one technician, each 15 min — CPT 97152.
Adaptive behavior treatment by protocol, technician, each 15 min — CPT 97153.
Group adaptive behavior treatment by protocol, technician, each 15 min — CPT 97154.
Adaptive behavior treatment by protocol modification by physician/qualified health professional, each 15 min — CPT 97155.
Family adaptive behavior treatment guidance, physician/qualified health professional, each 15 min — CPT 97156.
Multiple-family group behavior treatment guidance, physician/qualified health professional, each 15 min — CPT 97157.
Group adaptive behavior protocol modification by physician/qualified health professional, each 15 min — CPT 97158.
Behavior ID support assessment, technician time, each 15 min — CPT 0362T.
Adaptive behavior treatment protocol modification, technician time, each 15 min — CPT 0373T.
Qualified nonphysician health care professional online digital assessment and management for an established patient (up to 7 days cumulative): 5-10 minutes — CPT 98966; 11-20 minutes — CPT 98967; 21+ minutes — CPT 98968.
Unlisted evaluation and management service — CPT 99499.

OpenPayer

Florida Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Authorization and Coverage Criteria

Behavioral Health Service Codes

Provider Submission Requirements & Service Lists

Key Definitions

114	Inpatient Mental Health
124	Inpatient Mental Health
134	Inpatient Mental Health
144	Inpatient Mental Health
154	Inpatient Mental Health
204	Inpatient Mental Health
116	Inpatient Substance Use Detoxification (hospital based)
126	Inpatient Substance Use Detoxification (hospital based)
136	Inpatient Substance Use Detoxification (hospital based)
146	Inpatient Substance Use Detoxification (hospital based)