CBHM Outpatient Authorization Requirement List (Outpatient behavioral health authorization requirements)
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Defines which outpatient mental health and substance abuse procedure codes require prior authorization, are not covered, or do not require authorization for HAP members; applies to contracted behavioral providers and billing for outpatient services.
No material clinical or coverage changes in this revision.
Coverage and Code-Level Authorization Status
Coverage by procedure code
Authorization status by code as listed (examples below); the list explicitly marks whether authorization is required, not required, or Not Covered for each procedure code.
See list entries for per-code designation.
Authorization required status is shown per code and may vary by product line; obtain authorization when the list indicates 'Yes'.
Coverage exclusions are product-line dependent; check the product line column and BAM/subscriber documents.
The policy explicitly lists multiple services as Not Covered. Examples called out in the list include CPT codes 90876 (individual psychophysiological therapy incorporating biofeedback), 90882 (environmental intervention for medical management purposes), 90885 (psychiatric evaluation of hospital records), and 90889 (preparation of report of patient's psychiatric status). Several HCPCS/G-codes are also shown as not covered for specified product lines (see other sections below). When a code is designated Not Covered for a product line, claims for that service will be denied if billed for members in that product line.
The document marks multiple G-codes as Not Covered for specified product lines. Notable examples include G0137 (intensive outpatient weekly bundle) designated Not Covered for some product lines, G0411 (interactive group psychotherapy in a partial hospitalization) and several take‑home nalmefene/naloxone codes such as G1028 and G0532 when product-line exclusions apply. The list indicates coverage varies by product line (e.g., ALL, MED, MCWRAP)—verify the product-line column before billing.
Several additional G-codes and related HCPCS entries are explicitly listed as Not Covered for certain product lines. Examples from the list include G0533, G0534, G0535, G0536, G0539, G0546–G0549, G0550–G0552, G0560, and take‑home naloxone/nalmefene entries such as G1028 and G2215/G2216 where the listing shows Not Covered for specific product lines. Providers must consult the per-code product-line designation in the list to determine coverage.
The policy identifies additional codes across H- and G-code series as Not Covered. Examples include naloxone-related codes G2215 and G2216 (take‑home supply) noted as Not Covered for many product lines, and multiple H-codes such as H0021, H0023, H0024, and prevention/education H-codes listed as Not Covered. Several social support and housing related H-codes (for example H0042–H0045) are also shown as Not Covered in the list.
In the CBHM listing a series of behavioral health H-codes are explicitly labeled Not Covered for all or specified product lines. Examples include H2018 and multiple community/CBHM codes such as H2021–H2026, H2030–H2034, and H2037. When these entries show Not Covered for a product line, the service is excluded and claims will deny if submitted for members in that product line.
Code Tables and Groupings
| 90785 | Interactive complexity (List separately in addition to the code for primary procedure). |
| 90791 | Psychiatric diagnostic evaluation. |
| 90792 | Psychiatric diagnostic evaluation with medical services. |
| 90832 | Psychotherapy, 30 minutes with patient and/or family member. |
| 90833 | Psychotherapy, 30 minutes with patient and/or family member when performed (add-on). |
| 90834 | Psychotherapy, 45 minutes with patient and/or family member. |
| 90836 | Psychotherapy, 45 minutes with patient and/or family member when performed (add-on). |
| 90837 | Psychotherapy, 60 minutes with patient and/or family member. |
| 90838 | Psychotherapy, 60 minutes with patient and/or family member when performed (add-on). |
| 90839 | Psychotherapy for crisis; first 60 minutes. |
| 90867 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial. |
| 90868 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent. |
| 90869 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent. |
| 90870 | Electroconvulsive therapy (includes necessary monitoring). |
| 90885 | Psychiatric evaluation of hospital records, other psychiatric services (not covered). |
| 90889 | Preparation of report of patient's psychiatric status, history (not covered). |
| 96116 | Neurobehavioral status exam (clinical assessment of thinking). |
| 96121 | Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgement). |
| 96130 | Psychological testing evaluation services by physician or other qualified health professional. |
| 96131 | Psychological testing evaluation services by physician or other qualified health professional. |
| 96132 | Neuropsychological testing evaluation services by physician or other qualified health professional. |
| 96133 | Neuropsychological testing evaluation services by physician or other qualified health professional. |
| 96136 | Psychological or neuropsychological test administration and scoring by physician or other qualified health professional. |
| 96137 | Psychological or neuropsychological test administration and scoring by physician or other qualified health professional. |
| 97151 | Behavior identification assessment, administered by a physician or other qualified health professional. |
| 97152 | Behavior identification-supporting assessment, administered by one technician. |
| 97153 | Adaptive behavior treatment by protocol, administered by technician under the direction of a BCBA. |
| 97154 | Group adaptive behavior treatment by protocol, administered by technician. |
| 97155 | Adaptive behavior treatment with protocol modification, administered by physician or other qualified health professional. |
| 97156 | Family adaptive behavior treatment guidance, administered by physician or other qualified health professional. |
| 97157 | Multiple-family group adaptive behavior treatment guidance. |
| 97158 | Group adaptive behavior treatment with protocol modification. |
| 99212 | Office or other outpatient visit for the evaluation and management of an established patient (low level). |
| 99213 | Office or other outpatient visit for the evaluation and management of an established patient (expanded problem-focused). |
| 99214 | Office or other outpatient visit for the evaluation and management of an established patient (detailed). |
| 99215 | Office or other outpatient visit for the evaluation and management of an established patient (comprehensive). |
| 99441 | Telephone evaluation and management service provided by a physician or other qualified health care professional, 5-10 minutes. |
| 99442 | Telephone evaluation and management service provided by a physician or other qualified health care professional, 11-20 minutes. |
| 99443 | Telephone evaluation and management service provided by a physician or other qualified health care professional, 21-30 minutes. |
| 99492 | Initial psychiatric collaborative care management, first 70 minutes in the first calendar month. |
| 99493 | Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month. |
| 99494 | Initial or subsequent psychiatric collaborative care management, each additional 30 minutes. |
| C7900 | Service for diagnosis, evaluation, or treatment of a mental health or substance use condition. |
| C7901 | Service for diagnosis, evaluation, or treatment of a mental health or substance use condition. |
| C7902 | Service for diagnosis, evaluation, or treatment of a mental health or substance use condition. |
| G0137 | Intensive outpatient services; weekly bundle, minimum of 9 services over a 7 consecutive day period. |
| G0176 | Activity therapy, such as music, dance, art or play therapies. |
| G0177 | Training and educational services related to the care and treatment. |
| G0409 | Social work and psychological services, directly relating to patient care (not covered). |
| G0410 | Group psychotherapy other than of a multiple-family group. |
| G0411 | Interactive group psychotherapy, in a partial hospitalization setting. |
| G0532 | Take-home supply of nasal nalmefene hydrochloride; one carton of two, 2.7 mg. |
| G1028 | Take-home supply of nasal naloxone; 2-pack of 8mg per 0.1 ml nasal spray. |
| G2215 | Take-home supply of nasal naloxone (provision of the services by a medicare-e). |
| G2216 | Take-home supply of injectable naloxone (provision of the services by a medica). |
| G0533 | Medication assisted treatment, buprenorphine (injectable) administered on a we. |
| G0534 | Coordinated care and/or referral services, such as to adequate and accessible. |
| G0535 | Patient navigational services, provided directly or by referral; including helping t. |
| G0536 | Peer recovery support services, provided directly or by referral; including levera. |
| G0539 | Caregiver training in behavior management/modification for caregiver(s) of pati. |
| G0540 | Caregiver training in behavior management/modification for parent(s)/guardian(. |
| G0544 | Post discharge telephonic follow-up contacts performed in conjunction with a di. |
| G0546 | Interprofessional telephone/internet/electronic health record assessment and m. |
| G0547 | Interprofessional telephone/internet/electronic health record assessment and m. |
| G0548 | Interprofessional telephone/internet/electronic health record assessment and m. |
| G2067 | Medication assisted treatment, methadone; weekly bundle including dispensing and/or a. |
| G2068 | Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing. |
| G2069 | Medication assisted treatment, buprenorphine (injectable); weekly bundle including dispe. |
| G2070 | Medication assisted treatment, buprenorphine (implant insertion); weekly bundle includin. |
| G2071 | Medication assisted treatment, buprenorphine (implant removal); weekly bundle including. |
| G2072 | Medication assisted treatment, buprenorphine (implant insertion and removal); weekly bu. |
| G2073 | Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or ad. |
| G2074 | Medication assisted treatment, weekly bundle not including the drug, including substance. |
| G2075 | Medication assisted treatment, medication not otherwise specified; weekly bundle includi. |
| G2076 | Intake activities, including initial medical examination that is a complete, fully documented. |
| H0001 | ALCOHOL AND/OR DRUG ASSESSMENT |
| H0002 | ALCOHOL AND/OR DRUG SCREENING TO DETERMINE ELIGIBILITY |
| H0003 | ALCOHOL AND/OR DRUG SCREENING; LABORATORY ANALYSIS |
| H0004 | BEHAVIORAL HEALTH COUNSELING AND THERAPY, PER 15 MINUTES |
| H0005 | ALCOHOL AND/OR DRUG SERVICES; GROUP COUNSELING |
| H0006 | ALCOHOL AND/OR DRUG SERVICES; CASE MANAGEMENT |
| H0007 | ALCOHOL AND/OR DRUG SERVICES; CRISIS INTERVENTION (OUTPATIENT) |
| H0008 | ALCOHOL AND/OR DRUG SERVICES; SUB-ACUTE DETOXIFICATION (HOSPITAL) |
| H0009 | ALCOHOL AND/OR DRUG SERVICES; ACUTE DETOXIFICATION (HOSPITAL) |
| H0010 | ALCOHOL AND/OR DRUG SERVICES; SUB-ACUTE DETOXIFICATION (RESIDENTIAL) |
| H2031 | MENTAL HEALTH CLUBHOUSE SERVICES, PER DIEM |
| H2032 | ACTIVITY THERAPY, PER 15 MINUTES |
| H2033 | MULTISYSTEMIC THERAPY FOR JUVENILES, PER 15 MINUTES |
| H2034 | ALCOHOL AND/OR DRUG ABUSE HALFWAY HOUSE SERVICES, PER DIE |
| H2035 | ALCOHOL AND/OR OTHER DRUG TREATMENT PROGRAM, PER HOUR |
| H2036 | ALCOHOL AND/OR OTHER DRUG TREATMENT PROGRAM, PER DIEM |
| S0201 | PARTIAL HOSPITALIZATION SERVICES. LESS THAN 24 HRS, PER DIEM |
| S5111 | Home care training, family; per session |
| S9475 | AMBULATORY SETTING SUBSTANCE ABUSE TREATMENT OR DETOXIFIC |
| S9480 | INTENSIVE OUTPATIENT PSYCHIATRIC SERVICES, PER DIEM |
| S9484 | CRISIS INTERVENTION MENTAL HEALTH SERVICES, PER HOUR |
| S9485 | CRISIS INTERVENTION MENTAL HEALTH SERVICES, PER DIEM |
Authorization, Verification, and Billing Actions for Providers
Authorization, Verification, and Billing Overview
Prior authorization is required for a subset of behavioral health and substance use service codes. Providers must verify eligibility and benefit coverage using HAP's Member Eligibility Application (MEA) and the Benefit Administration Manual (BAM) before rendering services. Claims may be denied if benefit limits are exceeded or if authorization is required but not obtained.
- Verify member eligibility and benefit limits (MEA, BAM) prior to service to avoid denial.
- Claims are not reimbursable if benefit limits for mental health and behavioral services are exceeded.
- Services billed with place of service 11 or 22 are eligible under this program.
Prior Authorization Required for Select Codes (TMS, ECT)
Prior authorization is required for select codes including neurostimulation and ECT. Obtain authorization before delivering these services to avoid denial.
Authorization Required for G2067 (Methadone MAT)
Authorization is required for medication assisted treatment (MAT) weekly bundles for certain product lines. Confirm product-line specific requirements when submitting prior authorization requests.
Multiple MAT and Related Service Codes Require Authorization per Product Line
Multiple MAT and related G-codes require authorization for some product lines. Check each code's product-line notes and obtain authorization when indicated.
- Affected G-codes include G2067–G2075, G2076–G2077, G2079–G2080 and others listed; many show 'Authorization Required = Yes' for ALL except MED and MCWRAP where indicated as 'No'.
- Examples: G2070–G2075 (various buprenorphine/naltrexone implants and bundles) — Authorization Required = Yes for ALL (Except MED, MCWRAP); MED and MCWRAP often show Authorization = No.
Codes Requiring Prior Authorization
A broad set of codes require prior authorization. Failure to obtain required authorization may result in claim denial. Document authorization numbers on claims.
- Behavioral health/substance use codes with Authorization Required = Yes include (not exhaustive): 97151–97156 (ABA assessments/therapy), H0006–H0019 (selected substance use services), H2011–H2014 (day treatment/crisis services), H2019–H2020 (Therapeutic Behavioral Services), H2028–H2029 (sexual offender treatment), H2035–H2036 (substance use treatment programs), S0201 (partial hospitalization <24 hrs), S9475 (ambulatory substance abuse treatment), S9484–S9485 (crisis intervention).
- Specific MAT/G-codes listed earlier also require prior authorization for applicable product lines.
Not Covered Services
Some services are explicitly marked Not Covered. Billing for these codes will result in denial. Verify coverage before rendering or billing these services.
Document and Confirm Authorization per Product Line
Document and confirm authorization status per product line and include authorization numbers and applicable service units when submitting prior authorization requests or claims.
- When product-line exceptions apply (e.g., MED or MCWRAP showing Authorization = No while ALL shows Yes), record the member's product line and the corresponding authorization requirement.
- Submit prior auth requests with the specific HCPCS/CPT-like code and the number of service units (for example, weekly bundles G2067–G2075 or per-15-minute codes like H2019) as required.
Authorization Status by Code
Authorization status is reported per code; providers must review each code's 'Authorization Required' flag and act accordingly. When in doubt, request HAP review.
- Codes explicitly listed with 'Authorization Required = Yes' (e.g., 90868–90870, 97151–97156, H0006–H0014, H0017–H0019, H2011–H2014, H2019–H2020, H2028–H2029, H2035–H2036, S0201, S9475, S9484–S9485) require prior authorization.
- Codes listed with 'Authorization Required = No' do not require prior authorization but still require benefit verification.
No Step Therapy Specified
No step therapy rules are specified in this authorization requirement list. Providers should follow other clinical policy documents if step therapy applies.
- This list does not define any step therapy protocols.
- If step therapy is required for a particular service or medication, providers will be informed via separate BAM policies or the member's benefit documents.
Policy Background
Background: The CBHM Outpatient Authorization Requirement List is a per‑procedure code listing of outpatient behavioral health services that indicates whether each code requires prior authorization, does not require authorization, or is not covered for specific product lines. It covers psychotherapy, assessment/testing, ABA, neuromodulation (TMS), ECT, medication‑assisted treatment (MAT) bundles and counseling minutes, naloxone/nalmefene take‑home supplies, HCPCS/G‑codes, and many H‑code community behavioral health services. Providers must verify member eligibility and product‑line rules using HAP’s Member Eligibility Application and the Benefit Administration Manual and obtain prior authorization when the list shows Authorization Required = Yes to avoid claim denials.
Definitions and Keys
Level-of-Care Groupings and Criteria
Applied Behavior Analysis (ABA) Requirements
ABA services
ABA-related CPT codes are specially keyed and require authorization; refer to the Benefit Administration Manual (BAM) for coverage criteria.
Product Lines: ALL.
Specific Treatment Modalities and Modality-Level Rules
TMS
Product Lines: ALL.
ECT
Product Lines: ALL.
ABA
Product Lines: ALL.
Visit Limits and Per-Unit Billing Notes
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