CurrentColorado Rocky Mountain Health PlansPolicy N/A

New Jersey Prior Authorization Requirements for UnitedHealthcare Exchange Plans (Behavioral Health)

Lists behavioral health services and procedure codes that require prior authorization for participating providers for UnitedHealthcare Exchange Plan members in New Jersey, effective January 1, 2024. Applies to inpatient and outpatient behavioral health services; emergency/urgent care is excluded.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyNew Jersey Prior Authorization Requirements for UnitedHealthcare Exchange Plans (Behavioral Health)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionPrior authorization must be obtained for the listed behavioral health services for Exchange Plan members in New Jersey via the Prior Authorization and Notification tool on UHCProvider.com; emergency and urgent care do not require prior authorization.

POLICY UPDATE CHANGES

No material clinical/coverage changes — policy remains a list of behavioral health services requiring prior authorization for UnitedHealthcare Exchange Plan members in New Jersey.

~60Listed Procedure Codes Requiring PA

Inpatient & OutpatientApplies to

New JerseyGeography

Policy Summary

Prior Authorization Requirement

Prior authorization is required for the listed behavioral health services for Exchange Plan members in New Jersey, except for emergency or urgent care and services outside the service area or out-of-network which are not covered:

Member enrollment: Member is enrolled in a UnitedHealthcare Exchange Plan in New Jersey
Service is listed behavioral health: Service is a listed inpatient or outpatient behavioral health service (see procedure codes in code_groups)
See source for full code list
Submission pathway: Prior authorization request is submitted via the Prior Authorization and Notification tool on UHCProvider.com
Access via Sign In on UHCProvider.com
Emergency/Urgent care: Prior authorization is not required for emergency or urgent care
Members have no non-emergent out-of-network coverage and no coverage outside of the service area for these plans

Prior Authorization

Prior authorization required

Prior authorization must be obtained for the listed behavioral health services for Exchange Plan members in New Jersey via the Prior Authorization and Notification tool on UHCProvider.com; emergency and urgent care do not require prior authorization.

Submit via the Prior Authorization and Notification tool on UHCProvider.com (Sign In > Prior Authorization and Notification).
Emergency and urgent care services are excluded from prior authorization.

Documentation Required

Reference member specific benefit plan

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

Coverage/adjudication requires reference to the member-specific benefit plan document because terms vary by state and plan.

Codes Requiring Prior Authorization

Inpatient Mental Health (Revenue codes)RevenueCovered

114	Rev 114
124	Rev 124
134	Rev 134
144	Rev 144
154	Rev 154
204	Rev 204

Inpatient Substance Use Detoxification (hospital based) (Revenue codes)RevenueCovered

116	Rev 116
126	Rev 126
136	Rev 136
146	Rev 146
156	Rev 156

Substance Use Rehabilitation (hospital based) (Revenue codes)RevenueCovered

118	Rev 118
128	Rev 128
138	Rev 138
148	Rev 148
158	Rev 158

Psychiatric Clinic / Treatment Room / Evaluation / Intensive Outpatient / Partial Hospitalization (Revenue codes)RevenueCovered

513	Psychiatric Clinic Rev 513
761	Treatment Room Rev 761
900	Evaluation/Initial-BH Treatments/Services Rev 900
905	MH Intensive Outpatient Rev 905
906	SUD Intensive Outpatient Rev 906
912	MH/SUD Partial Hospitalization Rev 912
913	MH/SUD Partial Hospitalization Rev 913

Outpatient Behavioral Health Testing / Other Treatment Services (Revenue codes)RevenueCovered

918	OP Services- Behavioral Health Testing Rev 918
919	OP Services- Other Behavioral Health Treatment/Services Rev 919

Drug/Alcohol/Combined Rehabilitation / Psychiatric / Residential Treatment (Revenue codes)RevenueCovered

944	Drug Rehabilitation Rev 944
945	Alcohol Rehabilitation Rev 945
953	Combined drug and alcohol rehabilitation Rev 953
961	Psychiatric Rev 961
1001	Residential Treatment- Psychiatric Rev 1001
1002	Residential Treatment- Chem Dep Rev 1002

Therapeutic Repetitive Transcranial Magnetic Stimulation (CPT)CPTCovered

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

Unlisted / Unspecified Evaluation (CPT)CPTCovered

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

Psychological Testing and Test Administration / Scoring (CPT)CPTCovered

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

Behavior Identification and Adaptive Behavior Treatment Codes (CPT/HCPCS)mixedCovered

97151	Behavior ID Assessment by PHYS/QHP EA 15 min
97152	Behavior ID Support Assessment by 1 tech ea 15 min
97153	Adaptive Behavior Tx by protocol tech ea 15 min
97154	Group Adaptive Behavior Tx by protocol tech ea 15 min
97155	Adaptive Behavior Tx PHYS/QHP ea 15 min
97156	Family Adaptive Behavior Tx guidance PHYS/QHP ea 15 min
97157	Multiple Family Group Behavior Tx 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
0373T	Adaptive Behavior Tx protocol modification ea 15 min tech time

Qualified Nonphysician Health Care Professional Online Digital Assessment and Management (CPT-like)CPTCovered

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

Billing & Submission Actions

Prior Authorization

Obtain prior authorization

To obtain authorization, submit a prior authorization request online using the Prior Authorization and Notification tool on UHCProvider.com. This requirement applies to the listed inpatient and outpatient behavioral health services below; prior authorization is not required for emergency or urgent care.

Submission pathway: Prior Authorization and Notification tool on UHCProvider.com (access via Sign In).
Affected services: inpatient and outpatient behavioral health (examples include Inpatient Mental Health, Inpatient Substance Use Detoxification, Substance Use Rehabilitation, Psychiatric Clinic, Intensive Outpatient, Partial Hospitalization, Outpatient Behavioral Health Testing/Other Treatment, Drug/Alcohol Rehabilitation, Residential Treatment, TMS, Psychological Testing, Behavior ID/Adaptive Behavior treatment codes).
Emergency and urgent care do not require prior authorization.

Operational note: members enrolled in these Exchange Plans have no non-emergent out-of-network coverage and no coverage outside the service area; providers should verify the member’s in-network status and review the member-specific benefit plan when determining coverage and submitting prior authorization requests.

OpenPayer

New Jersey Prior Authorization Requirements for UnitedHealthcare Exchange Plans (Behavioral Health)

Policy Summary

Prior Authorization Requirement

Codes Requiring Prior Authorization

Billing & Submission Actions

Policy Background

Document History