Prior Authorization Applicability and Emergency Exception

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; however, emergency admissions require timely notification to Optum/UnitedHealthcare per the member's plan instructions. For questions, reference the Optum Behavioral Health National Network Manual (pages 38-43) and the UnitedHealthcare Community Plan of Nebraska Care Provider Manual (Chapter 7), or call the Customer Service number on the member's ID card.

• Out-of-network providers: prior authorization required before service.
• Emergency services: prior authorization not required but notification required for emergency admissions.
• See Optum Behavioral Health National Network Manual (pp.38-43) and UnitedHealthcare Community Plan of Nebraska Care Provider Manual (Chapter 7) for details.

Services and Codes Requiring Prior Authorization

The following behavioral health services and associated revenue/CPT/HCPCS codes require prior authorization before services are rendered.

• Psychiatric inpatient – private room: Revenue 114
• Psychiatric inpatient – semi-private room: Revenue 124
• Psychiatric inpatient – subacute: Revenue 190
• Psychiatric inpatient – intensive care psychiatric: Revenue 204
• ASAM Level 1 – Adult community support: HCPCS H2015 (modifier HF)
• ASAM Level 2.1 – SUD intensive outpatient, per hour: HCPCS H0015
• ASAM Level 3.1 – Adult halfway house: HCPCS H2034
• ASAM Level 3.2 – SUD social detoxification, per diem: HCPCS H0012
• ASAM Level 3.3 – Intermediate therapeutic residential/co-occurring capable, per diem: HCPCS H0019
• ASAM Level 3.3 – Therapeutic community, per diem: HCPCS H0019 (modifier TT)
• Psychiatric residential rehabilitation services (MRO) – mental health, per diem: HCPCS H0019 (modifier HE)
• ASAM Level 3.7 – Medically monitored residential – withdrawal management: HCPCS H0010
• SUD Level 3.5 – Dual-disorder residential (co-occurring enhanced): HCPCS H0018 (modifier HF)
• SUD Level 3.5 – Short-term residential (co-occurring capable): HCPCS H0018 (modifier HH)
• Community treatment aide (CTA), per 15 min: HCPCS H0036
• Assertive community treatment (ACT): HCPCS H0040 (Alternative ACT modifier 52)
• Partial hospitalization / day treatment (adults) – H2012 (minimum 6 units per hour)
• Day treatment (SUD), H2012 (modifier HF)
• Partial hospitalization/day treatment (adults) – H2012 (maximum 3 units per hour, modifier 52)
• PRTF hospital-based, per diem: HCPCS H2013
• PRTF specialty, per day: Revenue T2033
• PRTF community-based non-specialty: Revenue T2048
• Intensive outpatient (IOP) – direct care staff, per 15 min: HCPCS H2014
• Adult IOP mental health, per diem: HCPCS S9480
• Day rehabilitation services (MRO), min 12 units per 15 min: HCPCS H2017
• Day rehabilitation services full day (MRO), per diem: HCPCS H2018
• Secure residential rehabilitation services (MRO), per diem: HCPCS H2018 (modifier HK)
• Community support services (MRO), mental health, per 15 min: HCPCS H2015 (modifier HE)
• Therapeutic group home (includes co-occurring MH/SUD, sexual offense): HCPCS H2020
• Day treatment – direct care staff, per 15 min: HCPCS H2027
• Multi-systemic therapy (MST), per 15 min: HCPCS H2033
• Psychological testing evaluation – first hour: CPT 96130
• Psychological testing evaluation – each additional hour: CPT 96131
• Psychological/neuropsych testing administration/scoring by physician/QHP two+ tests, first 30 min: CPT 96136 (auth required only if submitted with 96130/96131)
• Psychological/neuropsych testing administration/scoring by physician/QHP, each additional 30 min: CPT 96137 (auth required only if submitted with 96130/96131)
• Psychological/neuropsych testing administration/scoring by technician two+ tests, first 30 min: CPT 96138 (auth required only if submitted with 96130/96131)
• Psychological/neuropsych testing administration/scoring by technician, each additional 30 min: CPT 96139 (auth required only if submitted with 96130/96131)
• Behavior identification assessment by doctor/other, per 15 min: CPT 97151
• Behavior identification supporting assessment by tech under direction, per 15 min: CPT 97152
• Adaptive behavior treatment by protocol – technician, per 15 min: CPT 97153
• Group adaptive behavior treatment by protocol – technician, per 15 min: CPT 97154
• Adaptive behavior treatment by protocol – doctor/QHP, per 15 min: CPT 97155
• Family adaptive behavior treatment guidance – doctor/QHP, per 15 min: CPT 97156
• Adaptive behavior treatment social skills group – doctor/QHP, per 15 min: CPT 97158
• Medication injections (selected J-codes): J0400 (aripiprazole 0.25 mg), J2680 (fluphenazine decanoate up to 25 mg), J1630 (haloperidol up to 5 mg), J1631 (haloperidol decanoate 50 mg), J2794 (risperidone 0.5 mg)