CurrentColorado Rocky Mountain Health PlansPolicy N/A

South Carolina Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Lists behavioral health services and procedure and revenue codes that require prior authorization for participating providers for UnitedHealthcare Exchange Plans members in South Carolina; applies to inpatient and outpatient behavioral health services. Emergency/urgent care and member-specific benefit variations are noted.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySouth Carolina Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical or coverage changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCProvider.com.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~80+procedure codes and revenue codes listed for prior authorization

South Carolinastate-specific prior authorization list applies to

Onlineprior authorization submission method (UHCProvider.com)

Prior Authorization Coverage Criteria

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General prior authorization coverage criteria

Covered when prior authorization is obtained for listed services and codes.

Prior authorization requirement: Services listed in this document require prior authorization for participating behavioral health providers for UnitedHealthcare Exchange Plans members in South Carolina.

Submit requests online via the Prior Authorization and Notification tool on UHCProvider.com

Prior authorization is not required for emergency or urgent care. When determining coverage for non-emergent services, always refer to the member specific benefit plan because benefit terms vary by state. For the Exchange Plans covered by this list in South Carolina, members have no non-emergent out-of-network coverage and no coverage outside of the service area.

Codes Requiring Prior Authorization

Inpatient Mental Health (Revenue Codes)mixedCovered

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

Inpatient SUD Detox (Revenue Codes)mixedCovered

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

SUD Rehabilitation (Revenue Codes)mixedCovered

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

Other Revenue and Service CodesmixedCovered

Rev 513	Psychiatric Clinic
Rev 761	Treatment Room
Rev 900	Evaluation/Initial-BH Treatments/Services
Rev 905	MH Intensive Outpatient
Rev 906	SUD Intensive Outpatient
Rev 912	MH/SUD Partial Hospitalization
Rev 913	MH/SUD Partial Hospitalization
Rev 918	OP Services- Behavioral Health Testing
Rev 919	OP Services- Other Behavioral Health Treatment/Services
Rev 944	Drug Rehabilitation

1–10 of 15

1/2

TMS CPT CodesCPTCovered

90867	Therapeutic Repetitive Transcranial magnetic stimulation treatment; planning 1 VISIT
90868	Therapeutic Repetitive Transcranial magnetic stimulation treatment; delivery and management, per session 1 VISIT
90869	Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS) subsequent motor threshold Re-determination with delivery and management 1 VISIT

Unlisted PsychiatricCPTCovered

90899

Unlisted psychiatric service or procedure

Psychological Testing EvaluationCPTCovered

96130	Psychological testing evaluation
96131	Psychological testing evaluation

Psych Testing Admin & Scoring (Auth conditional)CPTCovered

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

Behavioral/ABA-related CodesCPTCovered

97151	Behavior ID Assessment by PHYS/QHP EA 15 min
97152	BEHAVIOR ID SUPPORT ASSMT BY 1 TECH EA 15 MIN
97153	ADAPTIVE BEHAVIOR TX BY PROTOCOL TECH EA 15 MIN
97154	GROUP ADAPTIVE BHV TX BY PROTOCOL TECH EA 15 MIN
97155	MODIFICAJ PHYS/QHP EA 15 MIN
97156	FAMILY ADAPT BHV TX GDN PHYS/QHP EA 15 MIN
97157	MULTIPLE FAM GROUP BHV TX GDN PHYS/QHP EA 15 MIN
97158	GRP ADAPT BHV PRTCL MODIFCAJ PHYS/QHP EA 15 MIN
0362T	BEHAVIOR ID SUPPORT ASSMT EA 15 MIN TECH TIME
0373T	ADAPT BHV TX PRTCL MODIFICAJ EA 15 MIN TECH TIME

Online digital assessment and management (Nonphysician)CPTCovered

98966	Qualified nonphysician health care professional online digital assessment and management, established patient, up to 7 days; 5-10 minutes
98967	Qualified nonphysician HC professional online digital assessment and management, established patient, up to 7 days; 11-20 minutes
98968	Qualified nonphysician HC professional online digital assessment and management, established patient, up to 7 days; 21+ minutes

Unlisted E/MCPTCovered

99499

Unlisted evaluation and management service

Provider Requirements and Submission

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed inpatient and outpatient behavioral health services and procedure/revenue codes. Participating behavioral health providers must obtain prior authorization before rendering services except in emergency or urgent care situations.

Inpatient and outpatient behavioral health services listed in this policy require prior authorization.
Members have no non-emergent out-of-network coverage and no coverage outside the service area for these benefit plans.

Note

Provider Impact

Participating behavioral health providers should obtain prior authorization through the required online process and verify member benefits and coverage limitations before scheduling services.

Prior Authorization

Submission Method: Online Only

Prior authorization requests must be submitted online via the Prior Authorization and Notification tool on UHCProvider.com (access through Sign In).

Online: Use the Prior Authorization and Notification tool on UHCProvider.com to submit clinical transactions.

Note

Applicability and Member Plan Reference

This prior authorization requirement applies to participating behavioral health providers for Exchange plan members in South Carolina; always reference the member-specific benefit plan for coverage details.

Applies to Exchange Plans members in South Carolina.
Reference the member specific benefit plan document when deciding coverage.

Levels of Care Requiring Authorization

Inpatient, Residential, Partial Hospitalization, IOP, Outpatient — criteria group

Prior authorization is required for the following levels of care and associated procedure/revenue codes.

Service-level PA requirement: Inpatient Mental Health, Inpatient SUD Detoxification, SUD Rehabilitation, Psychiatric Clinic, MH/SUD Partial Hospitalization, Intensive Outpatient, Residential Treatment and other listed services require prior authorization as indicated by revenue/procedure codes.

See code lists in coding section (Rev and CPT codes).

Continued stay PA: Continued inpatient or residential stays are subject to prior authorization as required by the payer; specific utilization review criteria are not provided in this document.

Refer to payer utilization review/clinical policy for continued stay criteria.

Modality-specific Authorization Rules

TMS — criteria group for transcranial magnetic stimulation

TMS procedures require prior authorization when billed with the listed CPT codes.

TMS authorization: TMS procedures require prior authorization when billed with CPT codes 90867, 90868, or 90869.

See coding section for full TMS code descriptions.

Key Definitions and Submission Tools

Prior authorization submission

DefinitionPrior Authorization and Notification tool: online system accessed via the Sign In function on UHCProvider.com for submitting clinical transactions.

When to useUse this tool to submit prior authorization requests for the behavioral health services and procedure/revenue codes listed in this document.

AccessAccessible via Sign In on UHCProvider.com (Online).

ExceptionsPrior authorization is not required for emergency or urgent care.

Member plan noteReference the member-specific benefit plan document for coverage details because terms vary by state.

Policy Background

This document is an administrative list that specifies which behavioral health services require prior authorization for participating providers for UnitedHealthcare Exchange Plans members in South Carolina. It applies to inpatient and outpatient behavioral health services listed in the policy. To request prior authorization, providers must submit requests online via the Prior Authorization and Notification tool accessible through the Sign In function on UHCProvider.com.