Prior authorization requirements for behavioral health services (Pennsylvania CHIP)
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Lists behavioral health services and specific procedure/revenue codes that require prior authorization for UnitedHealthcare Community Plan members under the Pennsylvania CHIP; applies to participating and out-of-network providers in Pennsylvania.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
Prior authorization coverage criteria
Prior authorization is required for the behavioral health services and codes listed below. Providers should verify member eligibility and follow applicable submission instructions in the referenced provider manuals.
ALL of the following
Inpatient and facility services
- Inpatient mental health revenue codes: 114, 124, 134, 144, 154, 204.
- Inpatient SUD detoxification (non-hospital based) revenue codes: 116, 126, 136, 146, 156.
- Substance use disorder — Residential treatment revenue codes: 128, 1001, 1002.
- Intensive outpatient revenue codes: 0905, 0906.
- Partial hospitalization revenue codes: 0912, 0913.
Psychological testing
- Psychological and neuropsychological testing administration/scoring procedure codes: 96136, 96137, 96138, 96139 — authorization required ONLY when these Admin/Scoring codes are submitted with psychological testing evaluation codes 96130 or 96131; if billed without 96130/96131, authorization is not required.
Auth required only when billed with 96130/96131; no auth if billed alone.
IOP and Partial Hospitalization procedures
Exceptions and provider responsibilities
- Emergency services are exempt from prior authorization requirements.
- Out-of-network (non-participating) providers must obtain prior authorization approval before providing behavioral health services.
Reference resources and contact Customer Service for additional information.
Facility, Procedure and Revenue Codes Requiring Prior Authorization
| 114 | Inpatient mental health |
| 124 | Inpatient mental health |
| 134 | Inpatient mental health |
| 144 | Inpatient mental health |
| 154 | Inpatient mental health |
| 204 | Inpatient mental health |
| 116 | Inpatient SUD detoxification (non-hospital based) |
| 126 | Inpatient SUD detoxification (non-hospital based) |
| 136 | Inpatient SUD detoxification (non-hospital based) |
| 146 | Inpatient SUD detoxification (non-hospital based) |
| 156 | Inpatient SUD detoxification (non-hospital based) |
| 128 | Residential treatment - SUD |
| 1001 | Residential treatment - SUD |
| 1002 | Residential treatment - SUD |
| 0905 | Intensive outpatient |
| 0906 | Intensive outpatient |
| 0912 | Partial hospitalization |
| 0913 | Partial hospitalization |
| 96136 | Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional |
| 96137 | Psychological or neuropsychological test administration and scoring by technician |
| 96138 | Psychological or neuropsychological test administration and scoring — add-on |
| 96139 | Psychological or neuropsychological test administration and scoring — add-on |
| 97151 | Behavior identification assessment by physician or other qualified health care professional |
| 97152 | Behavior identification-supporting assessment by technician, each 15 minutes |
| 97153 | Adaptive behavior treatment by protocol by technician, each 15 minutes |
| 97154 | Group adaptive behavior treatment by protocol, each 15 minutes |
| 97155 | Adaptive behavior treatment with protocol modification by physician or other qualified health care professional, each 15 minutes |
| 97156 | Family adaptive behavior treatment guidance, each 15 minutes |
| 97158 | Group adaptive behavior treatment with protocol modification, each 15 minutes |
| 96136-96139 | Authorization required only when billed in conjunction with evaluation codes 96130 or 96131; no authorization required if submitted without 96130/96131. |
| 0905, 0906 | Map to Intensive Outpatient — bill with procedure codes H0015 or S9480 as applicable. |
| 0912, 0913 | Map to Partial Hospitalization — bill with procedure codes H0035 or S0201 as applicable. |
Provider Requirements and Actionable Rules
Prior Authorization Required
All behavioral health services listed below require prior authorization before services are provided except for emergency services. All out-of-network (non-participating) providers must obtain prior authorization approval prior to delivering behavioral health services. For detailed policies, coding guidance, and the prior authorization process, refer to the Optum Behavioral Health National Network Manual (pages 38-43) and the UnitedHealthcare Community Plan of Pennsylvania Care Provider Manual (Chapter 7). If you have additional questions, call the Customer Service number on the back of the member's ID card.
- Prior authorization not required for emergency services
- Out-of-network providers: prior authorization always required before non-emergency services
- Check member ID/card for Customer Service contact for questions
Codes Requiring Prior Authorization
The following inpatient, residential, intensive outpatient (IOP), partial hospitalization (PHP), testing, and Applied Behavior Analysis (ABA) procedure and revenue codes require prior authorization. Bill the associated revenue codes where indicated for facility-based services.
- Inpatient mental health — Revenue Codes: 114, 124, 134, 144, 154, 204
- Inpatient SUD detoxification (non-hospital based) — Revenue Codes: 116, 126, 136, 146, 156
- SUD residential treatment — Revenue Codes: 128, 1001, 1002
- IOP (mental health/SUD) — Revenue Codes: 0905, 0906; Procedure Codes: H0015, S9480
- PHP (mental health/SUD) — Revenue Codes: 0912, 0913; Procedure Codes: H0035, S0201
- Psychological testing evaluation — CPT: 96130, 96131 (auth required)
- Psychological/neuropsych testing administration/scoring — CPT: 96136, 96137, 96138, 96139 (auth required when billed with 96130/96131)
- ABA Behavior identification assessment — CPT: 97151 (auth required)
- ABA Technician-administered assessment — CPT: 97152 (auth required)
- ABA Adaptive behavior treatment by protocol (one-on-one) — CPT: 97153 (auth required)
- ABA Group adaptive behavior treatment — CPT: 97154 (auth required)
- ABA Adaptive behavior treatment with protocol modification — CPT: 97155 (auth required)
- ABA Family adaptive behavior treatment guidance — CPT: 97156 (auth required)
- ABA Group adaptive behavior treatment with protocol modification — CPT: 97158 (auth required)
Definitions and Scope Notes
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