CurrentColorado Rocky Mountain Health PlansPolicy N/A

Texas Prior Authorization Requirements for UnitedHealthcare Exchange Plans (Behavioral Health)

List of behavioral health services and revenue/CPT codes that require prior authorization for UnitedHealthcare Exchange Plans members in Texas, covering inpatient and outpatient behavioral health, residential, partial hospitalization, intensive outpatient, testing, TMS, and various therapy/procedure codes. Prior authorization requests must be submitted online and do not apply to emergency/urgent care.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTexas Prior Authorization Requirements for UnitedHealthcare Exchange Plans (Behavioral Health)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests for the listed behavioral health services via the Prior Authorization and Notification tool accessed through Sign In on UHCProvider.com.

POLICY UPDATE CHANGES

No material clinical or coverage changes.

~40Listed procedure/revenue/CPT codes requiring prior auth

TexasState scope

ExchangePlan type

Policy Summary

This policy lists behavioral health services and specific revenue/CPT codes that require prior authorization for participating behavioral health providers for UnitedHealthcare Exchange Plans members in Texas. Covered services include inpatient and outpatient behavioral health, residential treatment, partial hospitalization, intensive outpatient, behavioral testing, TMS, psychotherapy/biofeedback, psychological testing and administration/scoring, and adaptive behavior/ABA-related codes.

Prior Authorization Requirement

Prior Authorization Requirement for Exchange Plans in Texas

Prior authorization is required for the listed behavioral health services for participating behavioral health providers for Exchange Plans members in Texas unless emergency or urgent care.

Prior authorization required

Member enrollment: Member is enrolled in a UnitedHealthcare Exchange Plan for Texas.
Covered services/Codes: Service is one of the listed inpatient, outpatient, residential, partial hospitalization, intensive outpatient, testing, TMS, behavior identification/adaptive behavior treatment, biofeedback, unlisted psychiatric/E&M, or Qualified Nonphysician Health Care Professional online digital assessment & management procedure/CPT or revenue codes enumerated in this policy (examples: Rev 114,124,134,144,154,204; Rev 116,126,136,146,156; Rev 118,128,138,148,158; Rev 513; Rev 761; Rev 900; Rev 905; Rev 906; Rev 912,913; Rev 918; Rev 919; Rev 944,945,953; Rev 961; Rev 1001,1002; CPT 90867-90869; CPT 90875-90876; CPT 90899,99499; CPT 96130-96139,96146; CPT 97151-97158,0362T,0373T; CPT 98966-98968).
Exact codes and grouping listed in source chunks 2-4.
Submission method: Prior authorization request must be submitted online using the Prior Authorization and Notification tool accessed via Sign In on UHCProvider.com.
Emergency/Urgent care exemption: Not emergency or urgent care — prior authorization is not required for emergency or urgent care encounters.

Documentation Required

Emergency/Urgent Care Exemption

Do not submit prior authorization for emergency or urgent care encounters — these do not require prior authorization.

Emergency and urgent care are exempt from prior authorization.

Codes Requiring Prior Authorization

Inpatient Mental Health - Revenue CodesRevenue

114	Inpatient Mental Health
124	Inpatient Mental Health
134	Inpatient Mental Health
144	Inpatient Mental Health
154	Inpatient Mental Health
204	Inpatient Mental Health

Inpatient Substance Use Detoxification (hospital based) - Revenue CodesRevenue

116	Substance Use Detoxification (hospital based)
126	Substance Use Detoxification (hospital based)
136	Substance Use Detoxification (hospital based)
146	Substance Use Detoxification (hospital based)
156	Substance Use Detoxification (hospital based)

Substance Use Rehabilitation (hospital based) - Revenue CodesRevenue

118	Substance Use Rehabilitation (hospital based)
128	Substance Use Rehabilitation (hospital based)
138	Substance Use Rehabilitation (hospital based)
148	Substance Use Rehabilitation (hospital based)
158	Substance Use Rehabilitation (hospital based)

Psychiatric Clinic - Revenue CodeRevenue

513	Psychiatric Clinic

Treatment Room - Revenue CodeRevenue

761	Treatment Room

Evaluation/Initial Behavioral Health Treatments/Services - Revenue CodeRevenue

900	Evaluation/Initial Behavioral Health Treatments/Services

Mental Health Intensive Outpatient - Revenue CodeRevenue

905	MH Intensive Outpatient

Substance Use Disorder Intensive Outpatient - Revenue CodeRevenue

906	SUD Intensive Outpatient

Partial Hospitalization - Revenue CodesRevenue

912	MH/SUD Partial Hospitalization
913	MH/SUD Partial Hospitalization

Outpatient Services - Behavioral Health Testing - Revenue CodeRevenue

918	OP Services- Behavioral Health Testing

Outpatient Services - Other Behavioral Health Treatment/Services - Revenue CodeRevenue

919	OP Services- Other Behavioral Health Treatment/Services

Drug/Alcohol/Combined Rehabilitation - Revenue CodesRevenue

944	Drug Rehabilitation
945	Alcohol Rehabilitation
953	Combined drug and alcohol rehabilitation

Psychiatric - Revenue CodeRevenue

961	Psychiatric

Residential Treatment - Revenue CodesRevenue

1001	Residential Treatment- Psychiatric
1002	Residential Treatment- Chem Dep

Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS) - CPTCPT

90867	TMS treatment; planning, 1 visit
90868	TMS treatment; delivery and management, per session
90869	TMS subsequent motor threshold re-determination with delivery and management

Psychotherapy with Biofeedback - CPTCPT

90875	Individual psychophysiological therapy incorporating biofeedback (20-30 min) with psychotherapy
90876	Individual psychophysiological therapy incorporating biofeedback (45-50 min) with psychotherapy

Unlisted Psychiatric / E/M - CPTCPT

90899	Unlisted psychiatric service or procedure
99499	Unlisted evaluation and management service

Psychological Testing / Test Administration & Scoring - CPTCPT

96130	Psychological testing evaluation
96131	Psychological testing evaluation
96136	Test admin & scoring by physician/QHP, two or more tests, first 30 minutes (Auth required if submitted with Psychological Testing Eval)
96137	Test admin & scoring by physician/QHP, each additional 30 minutes (Auth required if submitted with Psychological Testing Eval)
96138	Test admin & scoring by technician, two or more tests, first 30 minutes (Auth required if submitted with Psychological Testing Eval)
96139	Test admin & scoring by technician, each additional 30 minutes (Auth required if submitted with Psychological Testing Eval)
96146	Computer Based Psychological/Neuropsychological Testing

Behavior Identification and Adaptive Behavior Treatment Codes - CPT / Category IIICPT

97151	Behavior ID Assessment by PHYS/QHP EA 15 min
97152	Behavior ID Support Assessment by 1 Tech EA 15 min
97153	Adaptive Behavior Treatment by Protocol Tech EA 15 min
97154	Group Adaptive Behavior Treatment by Protocol Tech EA 15 min
97155	Adaptive Behavior Treatment Protocol Modification PHYS/QHP EA 15 min
97156	Family Adaptive Behavior Treatment Guidance PHYS/QHP EA 15 min
97157	Multiple Family Group Behavior Treatment Guidance PHYS/QHP EA 15 min
97158	Group Adaptive Behavior Protocol Modification PHYS/QHP EA 15 min
0362T	Behavior ID Support Assessment EA 15 min Tech Time (Category III)
0373T	Adaptive Behavior Treatment Protocol Modification EA 15 min Tech Time (Category III)

Qualified Nonphysician Health Care Professional Online Digital Assessment & Management - CPTCPT

98966	QNHP online digital assessment & management, established patient, up to 7 days; 5-10 minutes
98967	QNHP online digital assessment & management, established patient, up to 7 days; 11-20 minutes
98968	QNHP online digital assessment & management, established patient, up to 7 days; 21+ minutes

What Providers Must Do

Prior Authorization

Submit Prior Authorization Online

Submit prior authorization requests online using the Prior Authorization and Notification tool accessed via Sign In on UHCProvider.com.

Use the Prior Authorization and Notification tool on UHCProvider.com (Sign In).

Documentation Required

Reference Member Specific Benefit Plan

Always check the member’s specific benefit plan document when determining coverage — plan terms vary by state and benefits may differ.

Reference the member specific benefit plan document for coverage details.

Billing Rule

No Non-Emergent Out-of-Network Coverage

For these Exchange Plans in Texas there is no non‑emergent out‑of‑network coverage and no coverage outside the service area — billing must reflect in‑network authorization requirements.

Members have no non‑emergent out‑of‑network coverage and no coverage outside the service area.
Bill according to in‑network authorization requirements.

OpenPayer

Texas Prior Authorization Requirements for UnitedHealthcare Exchange Plans (Behavioral Health)

Policy Summary

Prior Authorization Requirement

Codes Requiring Prior Authorization

What Providers Must Do

Definitions & Terms

Policy Dates