Prior authorization requirements summary

Eight of nine carriers had prior authorization requirements during the Period of Review; five carriers limited prior authorization to behavioral health (BH) providers only, one carrier applied requirements to both medical and BH non-employee providers, and two carriers did not specify provider types. Prior authorization was applied across code groups including psychotherapy, psychological testing, evaluation and management (new and established patients), and prolonged office visits, with effective years commonly 2015–2018 (some items limited to 2015 or 2015–2017).

• 8 of 9 carriers had prior authorization requirements (carriers 1,2,3,4,6,7,9,11).
• 5 carriers (2,6,7,9,11) applied PA to BH providers only; Carrier 1 applied to both Medical and BH non-employees; Carriers 3 and 4 did not specify provider types.
• Codes/groups subject to PA varied and included psychotherapy, psychological testing, E/M (new & established), and prolonged office visits.

Carrier-level prior authorization detail

Carriers applied prior authorization to different code groups and plans: Carrier 1 required PA for psychotherapy, psychological testing, and E/M (new and established); Carrier 2 required PA for psychotherapy and psychological testing (90837 PA was later waived for network providers as of Dec 2018); Carrier 4 applied PA to prolonged office visits; Carrier 6 and 7 had psychotherapy/testing requirements; Carrier 9 had PA for certain years (e.g., testing and biofeedback in 2015–2017); Carrier 11 required PA for psychotherapy. Effective years frequently spanned 2015–2018.

• Carrier 1: psychotherapy, psychological testing, evaluation & management (new and established) (chunk 4).
• Carrier 2: psychotherapy and psychological testing; CPT 90837 prior authorization (waived for network providers Dec 2018) (chunks 14, 34).
• Carrier 4: prolonged office visits (chunk 4).
• Carrier 6 & 7: psychotherapy/testing requirements (chunks 4, 14).
• Carrier 9: PA applied in limited years (testing 2015, testing 2015–2017; biofeedback 2015) (chunks 4, 14, 59–60).
• Carrier 11: psychotherapy (chunks 4, 14).

Utilization management actions and selected CPTs

Carriers used a mix of prior authorization, concurrent review, retrospective review and outlier management. Notably, Carrier 2 required prior authorization for CPT 90837 (later waived for network providers) and Carrier 3 required prior authorization for CPTs 90875 and 90876 for specified medical diagnoses while treating other indications as investigational.

• Utilization management transactions used variably: prior authorization, concurrent review, retrospective review, outlier management (chunk 21).
• Carrier 2: prior authorization for 90837 (waived for network providers Dec 2018) (chunks 34, 13).
• Carrier 3: prior authorization required for 90875 and 90876 for Dyssynergia-type constipation in adults; other indications considered investigational (chunk 37).

Triage and appointment access

Carrier 1 operates a Mental Health triage and appointment access protocol: licensed mental health clinicians triage member requests (most during business hours), are available 24/7 for urgent/emergent needs, and primary care referral is not required for mental health services; new outpatient members are screened by a licensed therapist.

• UR 14C Mental Health Protocols: licensed mental health clinicians available 24/7 for urgent/emergent needs and most requests triaged through a MH appointment line.
• Primary care referral not required; new members screened by a licensed therapist to assess urgency and appropriate care setting.

Prior authorization for biofeedback/neurofeedback (Carrier 3)

Carrier 3 requires prior authorization for CPT 90875 and CPT 90876 only when used for specific medical diagnoses (Dyssynergia-type constipation in adults); neurofeedback/biofeedback for other indications is considered investigational.

• PA required for 90875 and 90876 for diagnoses of Dyssynergia-type constipation in adults.
• Neurofeedback and biofeedback for other indications (including behavioral health diagnoses) considered investigational; neither code was processed to pay in the data (90875 received 122 submissions; 90876 received 26).

Concurrent review after 20 sessions (Carrier 5 historical)

Carrier 5 historically required a treatment plan (concurrent) review after 20 outpatient sessions for listed codes in 2015; that concurrent review requirement was retired in January 2016 and concurrent/retrospective oversight for outpatient MH/SUD was not performed from 2016–2018.

• In 2015, concurrent review required after 20 outpatient visits for codes such as 90823, 90833, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 90863 (carrier notified providers and requested current treatment plan).
• Requirement retired 1/2016; no routine review of outpatient behavioral health services 2016–2018.

Prior authorization list (Carrier 7)

Carrier 7 applied prior authorization/NQTLs to selected psychological and neuropsychological testing and behavioral intervention codes (96101, 96102, 96116, 96118, 96152) and listed specific codes subject to outlier management; outpatient psychiatry and medication management were not subject to PA or concurrent/retrospective review.

• PA applied to: 96101, 96102, 96116, 96118, 96152 (chunks 54–55).
• Outlier management applied to psychotherapy/family/health & behavior codes including 90832–90840, 90846–90847, 90863, 90875–90876, 96150–96151 (chunk 56).
• Carrier 7 asserted NQTL processes conducted equitably across medical/surgical and MH/SUD benefits and outpatient psychiatry/medication management did not require PA or reviews (chunks 54–56).

Prior authorization and outlier management practices (Carrier 7)

Carrier 7 listed specific outpatient psychological testing and ABA codes as subject to prior authorization and identified a set of psychotherapy, family therapy, pharmacologic management, psychophysiological therapy, and health & behavior assessment codes as subject to outlier management; the carrier stated these NQTLs were applied equitably and that outpatient psychiatry/medication management were not subject to PA or reviews.

• PA codes include: 96101, 96102, 96116, 96118, 96152 (chunk 55).
• Outlier-managed codes include: 90832–90840, 90846–90847, 90863, 90875–90876, 96150–96151 (chunk 56).
• Carrier 7 noted no comparable outlier management for medical outpatient visits and stated prior authorization requests from medical/surgical providers for psychological testing would be redirected to the carrier's third-party behavioral health entity (chunk 56).

No-authentication approach for routine outpatient BH services (Carriers 8 and 10)

Carriers 8 and 10 did not require prior authorization, concurrent review, retrospective review, or outlier management for routine outpatient office-based behavioral health services during the Period of Review; Carrier 10 explicitly stated 'No Auth. required - objective is to remove barriers to care.'

• Carrier 8: no medical necessity review, PA, concurrent/retrospective review, or outlier management for the 35 outpatient codes (chunk 57).
• Carrier 10: no authorization required for in-network outpatient services; stated goal to remove barriers to care and no outlier management for outpatient services (chunk 63).

Historical precertification changes (Carrier 9)

Carrier 9 historically required precertification for psychological/neuropsychological testing (96101, 96102, 96118) and for psychophysiological therapy with biofeedback (90875, 90876) during parts of the Period of Review; the carrier removed the precertification requirement for testing (recommended for removal July 9, 2018) and removed the biofeedback precertification after 2016.

• Precertification required 2015–2017 for testing codes (96101, 96102, 96118) and for biofeedback codes in 2015 (chunks 59–60).
• Carrier reviewed national precertification list and removed testing precertification recommended July 9, 2018; biofeedback precertification removed after 2016 (chunks 59–60).

Outlier management triggers (Carrier 11)

Carrier 11's outlier management algorithm included visit-frequency triggers such as 12+ visits in six weeks with the same clinician, 21+ visits with a single provider in six months, and other diagnosis- or service-based numeric thresholds; these triggers could prompt further review or outreach.

• 12+ outpatient visits in six weeks with the same clinician (last session within 45 days).
• 21+ outpatient services with a single provider by Tax ID within past 6 months (last session within 45 days).
• >48 health & behavior services in past 6 months (last session within 45 days).

Outlier trigger for high outpatient visit volume

Carriers' prior authorization and outlier triggers included a high-volume outpatient visit threshold: patients with 31 or more outpatient or EAP visits with a single preferred network clinician within the past six months (with at least one session in the past 45 days) were flagged.

• Trigger defined as 31+ outpatient or EAP visits with a single preferred network clinician within 6 months, with at least one session within past 45 days.
• Codes used to define services for this trigger are listed in the carrier's chart (e.g., selected E/M and psychotherapy codes) (chunk 72).