Currentharvard pilgrim health carePolicy N/A

Behavioral Health Prior Authorization and Notification Grid

Governs prior authorization (PA), notification, and medical necessity review processes for behavioral health services for Tufts Health One Care providers (in-network and out-of-network) as detailed for inpatient, diversionary (24- and non-24-hour), and outpatient behavioral health services.

Policy Summary

Payerharvard pilgrim health care

PolicyBehavioral Health Prior Authorization and Notification Grid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIn-network providers must fax 857-304-6304 or call 855-393-3154 to request prior authorization, notification, or medical necessity review for behavioral health services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

72 hoursadmission notification timeframe

days 1-14notification window (24‑hr diversionary/SUD)

up to 14dbilling after timely notification (some services)

up to 90dResidential Rehab billing allowance

up to 180dCSP-JI / Peer Recovery Coach billing window

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~30behavioral health service lines listed

Service-level Coverage and Authorization Rules

Coverage criteria by service

Service-specific prior authorization (PA), notification, and continuing-stay medical necessity rules summarized by service type and setting.

Inpatient Mental Health: Admitting facility/ESP must notify THPP; prior authorization is not required for urgent admission; admitting facility faxes Notification form and BH assessment to THPP; facility must contact THP within 72 hours of admission to request continuing stay medical necessity review.

Inpatient Substance Use Disorder (Level 4): Prior authorization not required for urgent admission; notification required days 1-14 with admitting facility contacting THPP within 72 hours of admission; medical necessity review required for days 15+ and facility calls THPP on last covered day to request continuing stay review; provider may bill up to 14 days following timely notification.

Observation/Holding beds: Prior authorization not required for urgent admission; ESP and admitting facility required to notify THPP (ESP faxes ESP Notification Form and BH assessment); admitting facility contacts THPP for PA/continuing stay medical necessity review within the specified timeframe (72 hours, deferred to next business day if on weekend/holiday).

24-hour Diversionary Services (e.g., Community Crisis Stabilization Services, ATS Level 3.7): Notification required for days 1-14 with medical necessity review for days 15+; admitting facility contacts THP within 72 hours of admission to notify and request continuing-stay review; facility calls THPP to request continuing-stay medical necessity review for days 15+.

Non-24-hour Diversionary Services (e.g., Community Support Program, CSP variants, PHP, IOP, PACT, Peer Recovery Coach, Recovery Support Navigator): Authorization stance varies by program: some (e.g., CSP) have no PA/notification for the first specified period (CSP: first 6 months) with medical necessity review thereafter; where notification is required, providers follow the service-specific process (provider calls THPP); continued authorization requests handled by provider/facility contacting THPP.

Outpatient Behavioral Health Services (therapy, DBT, diagnostic evaluation, medication visits, family/case consultation, group/individual treatment): No PA or notification required; providers may bill per usual outpatient rules; notification and medical necessity review processes are N/A for these services.

Behavioral Health Services Authorization Criteria

Service-specific PA/notification and process notes.

Diagnostic Evaluation: PA/notification: None. Notification process: N/A. PA/medical necessity review process: N/A. Continued authorization: N/A.

Dialectical Behavioral Therapy (DBT): PA/notification: None. Notification process: N/A. PA/medical necessity review process: N/A. Continued authorization: N/A.

Medication Visit: PA/notification: None. Notification process: N/A. PA/medical necessity review process: N/A. Continued authorization: N/A.

Individual/Group/Couples/Family Treatment: PA/notification: None. Notification process: N/A. PA/medical necessity review process: N/A. Continued authorization: N/A.

Coding, Billing Limits, and Submission Methods

No codes provided in this portionmixed

No CPT/HCPCS/ICD codes listed in this partmixed

Billing limits after notification

Community Support Program (CSP)No PA/notification required for certain CSP services during the first 6 months; providers may bill directly for that period.

CSP for Individuals with Justice Involvement (CSP-JI)Upon timely notification (Peer Recovery Coach-style process), providers may bill up to 180 days.

Peer Recovery CoachFacility must fax the Peer Recovery Coach Notification Form within 14 days of service start; providers may bill up to 180 days upon timely notification.

Recovery Support NavigatorFacility notifies THPP by fax within one week of service start; providers may bill up to 90 days or 360 units upon timely notification.

Program of Assertive Community Treatment (PACT)PA/notification = None — providers bill for this service directly.

Provider Notification, Prior Authorization, and Review Actions

Note

How to request PA/notification

In-network providers must fax 857-304-6304 or call 855-393-3154 for prior authorization (PA), notification, or medical necessity review for behavioral health services as outlined in the charts on the subsequent pages. Out-of-network providers are required to request PA before initiating services. Refer to the following sections for PA and/or notification instructions for a particular service: Inpatient Services; Diversionary Services; Outpatient Behavioral Health Services; Other Behavioral Health Services.

Note

Inpatient notification and continuing stay review

For inpatient admissions (mental health, SUD, observation/holding), the admitting facility or ESP must notify THPP within 72 hours of admission. If 72 hours falls on a weekend or holiday, notification is deferred to the next business day. Facilities request continuing-stay medical necessity review by calling THPP; continued authorization requests are completed via telephone.

Note

24-hour diversionary notification/medical necessity

24-hour diversionary services (e.g., ATS, Clinical Support Services, Residential Rehabilitation) generally require notification for days 1–14 with medical necessity review beginning on day 15 (timing may vary by service). Admitting facilities must notify THPP within the specified timeframes (commonly within 72 hours or per service-specific instructions) and call THPP to request continuing-stay reviews and authorizations.

Key Definitions

Inpatient Services

DefinitionInpatient Services are 24-hour services that provide clinical intervention for acute mental health or substance abuse diagnoses.

Notification requirementESP and admitting facility must notify THPP; admitting facility contacts THP within 72 hours of admission to request continuing stay medical necessity review.

PA for urgent admissionsPA not required for urgent admission, but continuing stay review is required per the 72-hour notification process.

Diversionary Services

DefinitionDiversionary Services are mental health or SUD services provided as alternatives to inpatient care, delivered in 24-hour or non-24-hour settings to support community return or intensive community support.

24-hour diversionary services

Policy Summary

Payerharvard pilgrim health care

PolicyBehavioral Health Prior Authorization and Notification Grid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIn-network providers must fax 857-304-6304 or call 855-393-3154 to request prior authorization, notification, or medical necessity review for behavioral health services.

SourceLink

On This Page

Inpatient-Outpatient Bridge visit: PA/notification: None. Notification process: N/A. PA/medical necessity review process: N/A. Continued authorization: N/A.

Collateral Contact (under 21): PA/notification: None; provider can bill in conjunction with outpatient therapy visits. Notification process: N/A. PA/medical necessity review process: N/A. Continued authorization: N/A.

Psychological/Neuropsychological Testing: PA/notification: PA required. Notification process: N/A. PA/medical necessity review process: Fax Psychological and Neuropsychological Assessment Supplemental form. Note: Most treatment facilities have an all-inclusive per diem that covers testing; individual provider reimbursement may not be made for testing during an inpatient stay.

Electro‑Convulsive Therapy (ECT): PA/notification: None. Notification process: N/A. PA/medical necessity review process: N/A. Continued authorization: N/A. Note: Refer to Outpatient Electroconvulsive Therapy (ECT) Performance Specifications.

Specialing: PA/notification: PA required. Notification process: N/A. PA/medical necessity review process: ESP or inpatient facility calls THPP to discuss this service. Continued authorization: Inpatient facility discusses authorization during medical necessity reviews.

Repetitive Transcranial Magnetic Stimulation (rTMS): PA/notification: PA required. Notification process: N/A. PA/medical necessity review process: Fax Repetitive Transcranial Magnetic Stimulation Request Form for initial and continued authorization. Continued authorization: Fax Repetitive Transcranial Magnetic Stimulation Request Form.

Authorization submission method

Psychological/Neuropsychological TestingAuthorization submission: Fax the Psychological and Neuropsychological Assessment Supplemental form for PA and medical necessity review.

Repetitive Transcranial Magnetic Stimulation (rTMS)Authorization submission: Fax the Repetitive Transcranial Magnetic Stimulation Request Form for initial and continued authorization.

General instructionForms/Resources for testing and rTMS are specified in the respective service entries and must be submitted by fax as noted.

Note

Non-24-hour diversionary authorization rules

Non-24-hour diversionary services (e.g., CSP, PHP, IOP, Peer Recovery Coach, Recovery Support Navigator, PACT) have service-specific prior authorization/notification rules: some require no PA for initial periods and notification for continuation, others require notification at admission or after a set number of days; providers should follow the notification/process described for each service and contact THPP for medical necessity reviews and continued authorization.

Note

Outpatient PA/notification stance

Most outpatient behavioral health services (family consultation, case consultation, diagnostic evaluation, DBT, medication visits, couples/family treatment, psychotherapy, acupuncture, opioid treatment, ambulatory detoxification, etc.) do not require prior authorization. Providers may bill per service-specific guidance; follow performance specifications where noted.

Prior Authorization

Psychological Testing/Neuropsychological Testing - PA

Psychological Testing and Neuropsychological Testing require prior authorization. Note: many treatment facilities operate under an all‑inclusive per diem that covers psychological and neuropsychological testing performed during an inpatient stay or at an acute treatment program; in those cases individual provider reimbursement for tests performed in that context is not typically provided. To request PA, fax the Psychological and Neuropsychological Assessment Supplemental form as part of the PA/medical necessity review process.

PA required
Most inpatient/acute program per diems may cover testing — individual test claims during those stays may not be reimbursed separately
Submit Psychological and Neuropsychological Assessment Supplemental form (fax) for PA/medical necessity review

Note

ECT, Specialing, and other miscellaneous services

Electroconvulsive Therapy (ECT) does not require prior authorization per this section; refer to the Outpatient Electroconvulsive Therapy performance specifications. Specialing requires prior authorization and is discussed with THPP during medical necessity review and continuing-stay authorization.

Includes community crisis stabilization and Residential Rehabilitation; generally require notification for initial days with medical necessity review thresholds (e.g., day 15 or day 90+ depending on service).

Non-24-hour diversionary servicesIncludes CSP, Peer Recovery Coach, Recovery Support Navigator, PACT; PA/notification requirements vary by service and may include specified notification windows and billing allowances.

Outpatient behavioral health services

DefinitionOutpatient behavioral health services provide clinical intervention for acute mental health or substance use diagnoses in an outpatient setting.

Common servicesIncludes diagnostic evaluation, DBT, medication visits, individual/group/family therapy, opioid replacement therapy, ambulatory detox — most do not require PA or notification.

Billing/authorization stanceProviders may bill per usual outpatient rules; PA/notification is generally not required for routine outpatient behavioral health services.

Diagnostic Evaluation

DefinitionDiagnostic Evaluation: An assessment of an Enrollee's level of functioning to diagnose and design a treatment plan.

PA/notificationPA or notification = None; notification process and medical necessity review process = N/A.

Continued authorizationContinued authorization process = N/A for diagnostic evaluation.

Opioid Replacement Therapy

DefinitionOpioid Replacement Therapy: Medically monitored administration of methadone, buprenorphine, or other FDA-approved medications to opiate-addicted individuals in conformance with FDA and DEA regulations.

PA/notificationPA or notification = None; notification and medical necessity review processes = N/A.

Continued authorizationContinued authorization process = N/A.

Repetitive Transcranial Magnetic Stimulation (rTMS)

DefinitionRepetitive Transcranial Magnetic Stimulation (rTMS): A non-invasive neurostimulation applying rapidly changing magnetic fields to the scalp via a coil connected to a magnetic stimulator.

PA requirementPA is required for rTMS; providers must fax the Repetitive Transcranial Magnetic Stimulation Request Form for PA and continued authorization.

Forms/ResourcesRefer to Transcranial Magnetic Stimulation (TMS) Medical Necessity Guidelines and use the specified fax request form.