CurrentColorado Rocky Mountain Health PlansPolicy N/A

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

Lists behavioral health services and revenue/procedure codes that require prior authorization for UnitedHealthcare Exchange plan members in New Jersey, effective January 1, 2025; applies to inpatient and outpatient behavioral health providers. Excludes emergency/urgent care and notes members have no non-emergent out-of-network or out-of-service-area coverage.

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, 2025

Next Review Date

Key ActionProviders must submit prior authorization requests for the listed services via the Prior Authorization and Notification tool on UHCProvider.com for New Jersey Exchange plan members effective January 1, 2025.

POLICY UPDATE CHANGES

No material changes to clinical coverage or requirements were identified.

~50Listed CPT/Revenue/HCPCS codes requiring PA

2025-01-01Effective Date

Policy Summary & Scope

This policy lists behavioral health services and the associated revenue/CPT/HCPCS codes that require prior authorization for UnitedHealthcare Exchange plan members in New Jersey, effective January 1, 2025. It applies to inpatient and outpatient behavioral health providers and enumerates specific revenue and procedure codes (see policy code list). Emergency and urgent care services are excluded from prior authorization requirements. Members in these Exchange plans have no non-emergent out-of-network coverage and no coverage outside the service area.

Prior Authorization Requirement

Prior authorization is required for the services listed below for members enrolled in the UnitedHealthcare Exchange New Jersey plan.

ALL of the following

Member is enrolled in the UnitedHealthcare Exchange New Jersey plan (NJ).
Service requested is one of the services requiring prior authorization as listed in the plan's code groups (see code group links for Rev codes, CPT codes, and other procedure codes).
Service lists include inpatient mental health, inpatient SUD detoxification, SUD rehabilitation, psychiatric clinic services, intensive outpatient programs, partial hospitalization, outpatient behavioral health testing and other behavioral health treatments, residential treatments, supervised living, TMS procedures, psychological testing and related admin/scoring codes, behavior services (97151–97158), and other listed codes.
Prior authorization request has been submitted via the Prior Authorization and Notification tool on UHCProvider.com (access via Sign In).
Use the Prior Authorization and Notification tool — do not submit via fax or paper for these requests.
The request is not for emergency or urgent care (prior authorization is not required for emergency or urgent care).

Prior Authorization

Prior Authorization Required

Providers must submit prior authorization requests for New Jersey UnitedHealthcare Exchange plan members through the Prior Authorization and Notification tool on UHCProvider.com. Do not submit requests by alternate portals. Effective date: 2025-01-01.

Submit all PA requests via the Prior Authorization and Notification tool accessible from the Sign In function on UHCProvider.com.
Effective for services on or after 2025-01-01.

Documentation Required

Reference Member-Specific Benefit Plan

Always verify the member-specific benefit plan document before rendering services or submitting authorizations. Coverage terms, prior authorization requirements, benefit limits, and network rules vary by state and by the member's specific plan.

Reference the member-specific benefit plan (Evidence of Coverage/benefit booklet) for eligibility, covered benefits, and any state-specific variations.
Checking member-specific documents can prevent denials and ensure correct authorization requirements are followed.

Denial Risk

No Coverage Out-of-Network or Out-of-Area

Members in these Exchange plans have no non-emergent out-of-network coverage and no coverage outside the service area. Claims may be denied if services are provided out-of-network or outside the service area for non-emergent care.

No non-emergent out-of-network coverage is available for these plans.
No coverage exists outside the plan's service area; out-of-area claims may be denied.

Codes Requiring Prior Authorization

Inpatient Mental Health - Revenue CodesRevenueCovered

114	Inpatient Mental Health (Rev 114)
124	Inpatient Mental Health (Rev 124)
134	Inpatient Mental Health (Rev 134)
144	Inpatient Mental Health (Rev 144)
154	Inpatient Mental Health (Rev 154)
204	Inpatient Mental Health (Rev 204)

Inpatient Substance Use Detoxification (hospital based) - Revenue CodesRevenueCovered

116	Substance Use Detoxification (Rev 116)
126	Substance Use Detoxification (Rev 126)
136	Substance Use Detoxification (Rev 136)
146	Substance Use Detoxification (Rev 146)
156	Substance Use Detoxification (Rev 156)

Substance Use Rehabilitation (hospital based) - Revenue CodesRevenueCovered

118	Substance Use Rehabilitation (Rev 118)
128	Substance Use Rehabilitation (Rev 128)
138	Substance Use Rehabilitation (Rev 138)
148	Substance Use Rehabilitation (Rev 148)
158	Substance Use Rehabilitation (Rev 158)

Psychiatric Clinic - Revenue CodeRevenueCovered

513	Psychiatric Clinic (Rev 513)

Evaluation/Initial-BH Treatments/Services - Revenue CodeRevenueCovered

900	Evaluation/Initial Behavioral Health Treatments/Services (Rev 900)

MH Intensive Outpatient - Revenue CodeRevenueCovered

905	MH Intensive Outpatient (Rev 905)

SUD Intensive Outpatient - Revenue CodeRevenueCovered

906	SUD Intensive Outpatient (Rev 906)

Community Behavioral Health Program, Day Treatment - Revenue CodeRevenueCovered

907	Community Behavioral Health Program, Day Treatment (Rev 907)

MH/SUD Partial Hospitalization - Revenue CodesRevenueCovered

912	MH/SUD Partial Hospitalization (Rev 912)
913	MH/SUD Partial Hospitalization (Rev 913)

OP Services - Behavioral Health Testing - Revenue CodeRevenueCovered

918	Outpatient Behavioral Health Testing (Rev 918)

OP Services - Other Behavioral Health Treatment/Services - Revenue CodeRevenueCovered

919	Other Outpatient Behavioral Health Treatment/Services (Rev 919)

Drug Rehabilitation - Revenue CodeRevenueCovered

944	Drug Rehabilitation (Rev 944)

Alcohol Rehabilitation - Revenue CodeRevenueCovered

945	Alcohol Rehabilitation (Rev 945)

Combined Drug and Alcohol Rehabilitation - Revenue CodeRevenueCovered

953	Combined Drug and Alcohol Rehabilitation (Rev 953)

Psychiatric - Revenue CodeRevenueCovered

961	Psychiatric (Rev 961)

Behavioral Health Accommodations - Revenue CodeRevenueCovered

1000	Behavioral Health Accommodations (Rev 1000)

Residential Treatment - Psychiatric/Chem Dep/Supervised Living - Revenue CodesRevenueCovered

1001	Residential Treatment - Psychiatric (Rev 1001)
1002	Residential Treatment - Chemical Dependency (Rev 1002)
1003	Supervised Living (Rev 1003)

TMS and Related CPT CodesCPTCovered

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

Unlisted Psychiatric ServiceCPTCovered

90899

Unlisted psychiatric service or procedure

Psychological Testing and Admin/Scoring - CPT CodesCPTCovered

96130	Psychological testing evaluation
96131	Psychological testing evaluation
96136	Test administration & scoring by physician/QHP, two or more tests, first 30 minutes (Auth required only if submitted with 96130/96131)
96137	Each additional 30 minutes (Auth required only if submitted with 96130/96131)
96138	Test administration & scoring by technician, first 30 minutes (Auth required only if submitted with 96130/96131)
96139	Each additional 30 minutes by technician (Auth required only if submitted with 96130/96131)
96146	Computer based psychological/neuropsychological testing

Behavioral Assessment and Adaptive Behavior Treatment CodesmixedCovered

97151	Behavior ID Assessment by PHYS/QHP, each 15 min
97152	Behavior ID Support Assessment by 1 tech, each 15 min
97153	Adaptive behavior treatment by protocol, technician, each 15 min
97154	Group adaptive behavior treatment by protocol, technician, each 15 min
97155	Adaptive behavior treatment protocol modification, PHYS/QHP, each 15 min
97156	Family adaptive behavior treatment guidance, PHYS/QHP, each 15 min
97157	Multiple-family group behavior treatment guidance, PHYS/QHP, each 15 min
97158	Group adaptive behavior protocol modification, PHYS/QHP, each 15 min
0362T	Behavior ID support assessment, technician time, each 15 min
0373T	Adaptive behavior treatment protocol modification, technician time, each 15 min

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

Policy Summary & Scope

Prior Authorization Requirement

Codes Requiring Prior Authorization

Billing & Submission Actions

Definitions & Terms

Policy Dates & Changes