Behavioral health prior authorization requirements for Complete Care members (AZ)
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Lists behavioral health services and revenue/CPT codes that require prior authorization for UnitedHealthcare Community Plan of Arizona Complete Care Medicaid members (includes CRS-designated members; excludes CRS Only).
No material clinical or coverage changes in this revision.
Prior Authorization Required Services
Prior authorization required services
The following revenue and procedure codes require prior authorization before services are provided. Some community-based outpatient services are generally not subject to prior authorization except for outlier cases identified via claims data that will be subject to clinical review.
Inpatient room/board and administratively necessary day services
- Revenue 114 — Psychiatric room and board, private room
- Revenue 116 — Detoxification, private room
- Revenue 118 — Rehabilitation, private room
- Revenue 124 — Psychiatric room and board, semi-private 2 beds
- Revenue 126 — Detoxification, semi-private room
- Revenue 128 — Rehabilitation, 2 beds
- Revenue 134 — Psychiatric room and board, semi-private 3 and 4 beds
- Revenue 136 — Detoxification, 3 and 4 beds
- Revenue 144 — Private (Deluxe) - Psychiatric
- Revenue 146 — Private (Deluxe) - Detoxification
- Revenue 148 — Private (Deluxe) - Rehabilitation
- Revenue 154 — Room/board, ward - Psychiatric
- Revenue 156 — Detoxification, ward room
- Revenue 158 — Rehabilitation, ward room
- Revenue 160, 169 — Inpatient mental health administratively necessary day services
Additional inpatient and treatment revenue codes
- Revenue 183 — Home pass
- Revenue 189 — Bed hold
- Revenue 204 — Intensive Care - Psychiatric
- Revenue 900 — Psychiatric/Psychological treatments (must be billed with an appropriate CPT; if the CPT requires authorization, the revenue code also requires authorization)
Outpatient, community, in-home therapy and testing
- Revenue 902 — Milieu therapy (must be billed with an appropriate CPT; if the CPT requires authorization, the revenue code also requires authorization)
- Revenue 903 — Play therapy (must be billed with an appropriate CPT; if the CPT requires authorization, the revenue code also requires authorization)
- Revenue 904 — Activity therapy (must be billed with an appropriate CPT; if the CPT requires authorization, the revenue code also requires authorization)
- Revenue 907 — Community behavioral health program - day treatment
- Revenue 911 — Psychiatric/Psychological services - Rehabilitation (must be billed with an appropriate CPT; if the CPT requires authorization, the revenue code also requires authorization)
- Revenue 914 — Individual therapy (must be billed with an appropriate CPT; if the CPT requires authorization, the revenue code also requires authorization)
- Revenue 915 — Group therapy (must be billed with an appropriate CPT; if the CPT requires authorization, the revenue code also requires authorization)
- Revenue 916 — Family therapy (must be billed with an appropriate CPT; if the CPT requires authorization, the revenue code also requires authorization)
- Revenue 917 — Biofeedback (must be billed with an appropriate CPT; if the CPT requires authorization, the revenue code also requires authorization)
- Revenue 918 — Testing (must be billed with an appropriate CPT; if the CPT requires authorization, the revenue code also requires authorization)
- Revenue 97153-97158 — Adaptive behavior treatment and related codes
- Revenue 90867-90869 — Therapeutic repetitive TMS treatment (planning, subsequent delivery and management, motor threshold redetermination)
- Revenue H0018 — Behavioral health short-term residential, without room and board
- Revenue S5140 — Therapeutic foster care, adult per diem
- Revenue S5145 — Therapeutic foster care, child per diem
Community-based outpatient service codes (generally not subject to PA; outliers subject to clinical review)
- H0004 — Group behavioral health counseling and therapy
- H0038 — Self-help/Peer services; per 15 minutes
- H2014 — Skills training and development; per 15 minutes
- H2017 — Psychosocial rehabilitation living skills training services; per 15 minutes
- H2027 — Psychoeducational service; per 15 minutes
- S5110 — Home care training family
Out-of-network (non-participating) providers must obtain prior authorization before providing behavioral health services; emergency services are exempt from prior authorization.
Revenue, CPT and Service Code Groups
| Revenue 114 | Psychiatric room and board, private room |
| Revenue 116 | Detoxification, private room |
| Revenue 118 | Rehabilitation, private room |
| Revenue 124 | Psychiatric room and board, semi-private 2 beds |
| Revenue 126 | Detoxification, semi-private room |
| Revenue 128 | Rehabilitation, 2 beds |
| Revenue 134 | Psychiatric room and board, semi-private 3 and 4 beds |
| Revenue 136 | Detoxification, 3 and 4 beds |
| Revenue 144 | Private (Deluxe) - Psychiatric |
| Revenue 146 | Private (Deluxe) - Detoxification |
| Revenue 183 | Home pass |
| Revenue 189 | Bed hold |
| Revenue 204 | Intensive Care - Psychiatric |
| Revenue 900 | Psychiatric/Psychological treatments (must be billed with an appropriate CPT code) |
| Revenue 902 | Milieu therapy (must be billed with an appropriate CPT code) |
| Revenue 903 | Play therapy (must be billed with an appropriate CPT code) |
| Revenue 904 | Psychiatric/Psychological treatments - activity therapy (must be billed with an appropriate CPT code) |
| Revenue 907 | Community behavioral health program - day treatment |
| Revenue 911 | Psychiatric/Psychological services - Rehabilitation (must be billed with an appropriate CPT code) |
| Revenue 914 | Individual therapy (must be billed with an appropriate CPT code) |
| Revenue 915 | Group therapy (must be billed with an appropriate CPT code) |
| Revenue 916 | Family therapy (must be billed with an appropriate CPT code) |
| Revenue 97153 | Adaptive behavior treatment by protocol technician; each 15 minutes |
| Revenue 97154 | Group adaptive behavior treatment by protocol technician; each 15 minutes |
| H0004 | Group behavioral health counseling and therapy |
| H0038 | Self-help/Peer services; per 15 minutes |
| H2014 | Skills training and development; per 15 minutes |
| H2017 | Psychosocial rehabilitation living skills training services; per 15 minutes |
| H2027 | Psychoeducational service; per 15 minutes |
| S5110 | Home care training family |
Provider Responsibilities and Highlighted Requirements
Prior authorization overview and provider responsibilities
Providers must check the listed behavioral health services that require prior authorization before providing services to UnitedHealthcare Community Plan of Arizona Complete Care members. All out-of-network (non‑participating) providers must obtain prior authorization approval before providing behavioral health services. Prior authorization is not required when rendering emergency services. For additional guidance see the Optum Behavioral Health National Network Manual and the UnitedHealthcare Community Plan of Arizona Care Provider Manual or call the Customer Service number on the member's ID card.
- Check this PA list before providing services to UnitedHealthcare Community Plan members.
- Out-of-network (non-participating) providers must obtain prior authorization.
- Emergency services are exempt from prior authorization.
- Refer to the Optum Behavioral Health National Network Manual (pages 38–43) and the UnitedHealthcare Community Plan of Arizona Care Provider Manual (Chapter 9) for more information.
Services and revenue/CPT codes that require prior authorization
The specific revenue codes, CPT codes and service descriptions listed in this document require prior authorization before services are provided. Several revenue codes must be billed with an appropriate CPT code; when that CPT code requires prior authorization, the associated revenue code also requires authorization.
- Inpatient room/board and administratively necessary day services: Revenue codes 114, 116, 118, 124, 126, 128, 134, 136, 144, 146, 148, 154, 156, 158, 160, 169 (psychiatric/detox/rehab and administratively necessary day services).
- Additional inpatient/treatment and facility codes: Revenue codes 183, 189, 204, 900 (home pass, bed hold, intensive care psychiatric; 900 must be billed with an appropriate CPT).
- Outpatient/community/in‑home therapy, TMS, testing and adaptive behavior: Revenue codes 902–918, 97153–97158, 90867–90869, 96130–96139, H0018, S5140, S5145 (milieu, play therapy, adaptive behavior treatment, TMS, psychological testing, short‑term residential, therapeutic foster care).
- Community‑based outpatient service codes (generally not subject to PA except outliers): H0004, H0038, H2014, H2017, H2027, S5110 (group counseling, peer services, skills training, psychosocial rehab, psychoeducational services, home care family training); outlier cases identified by claims data may be subject to clinical review.
Scope and Member / Provider Definitions
Revision History and Background
Policy becomes effective for UnitedHealthcare Community Plan of Arizona Complete Care members (includes CRS-designated members; excludes CRS Only).
Clarified that out-of-network providers must obtain prior authorization and that emergency services are exempt from prior authorization.
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