Behavioral health prior authorization for Nebraska Heritage Health / UnitedHealthcare Community Plan
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Lists behavioral health services and specific revenue/CPT/J-code items that require prior authorization for members of the Nebraska Heritage Health / UnitedHealthcare Community Plan; applies to in-network and out-of-network non-emergency providers serving plan members in Nebraska.
No material clinical or coverage changes in this revision.
Services Requiring Prior Authorization
Listed services requiring prior authorization
The following listed services and codes require prior authorization for Nebraska members:
ALL of the following
Psychiatric inpatient
- Private room - Revenue code 114
- Semi-private room - Revenue code 124
- Subacute - Revenue code 190
- Intensive care psychiatric - Revenue code 204
ASAM levels / SUD and related services
- ASAM Level 1 - Adult community support - Revenue code H2015
- ASAM Level 2.1 - Adult SUD intensive outpatient; per hour - Revenue code H0015
- ASAM Level 3.1 - Adult halfway house - Revenue code H2034
- ASAM Level 3.2 - Adult SUD social detoxification; per diem - Revenue code H0012
- ASAM Level 3.3 - Adult intermediate therapeutic residential co-occurring capable; per diem - Revenue code H0019
- ASAM Level 3.3 - Adult therapeutic community; per diem - Revenue code H0019 (modifier TT)
- ASAM Level 3.5 - Short-term residential (co-occurring capable) - Revenue code H0018 (modifier HH)
Community, outpatient, and intensive services
- Community treatment aide (CTA); per 15 minutes - Revenue code H0036
- Assertive community treatment (ACT) - Revenue code H0040 (alternative ACT modifier 52)
- Partial hospitalization and day treatment for adults only - Revenue code H2012; minimum 6 units per hour, maximum 3 units noted in some entries
- Day treatment SUD (per hour) - Revenue code H2012 (modifier HF)
- PRTF hospital-based; per diem - Revenue code H2013
- PRTF community-based non-specialty - Revenue code T2048
- Intensive outpatient (IOP) - Direct care staff; per 15 minutes - Revenue code H2014
- Adult IOP mental health; per diem - Revenue code S9480
- Community support services (MRO), mental health; per 15 minutes - Revenue code H2015 (modifier HE)
- Therapeutic group home (including co-occurring mental health/SUD, sexual offense) - Revenue code H2020
- Day treatment - Direct care staff; per 15 minutes - Revenue code H2027
- Multi systemic therapy (MST); per 15 minutes - Revenue code H2033
Psychological and behavioral testing and assessment
Injections
- Injection - Aripiprazole 0.25 mg - Revenue code J0400
- Injection - Fluphenazine Decanoate up to 25 mg (Prolixin Decanoate) - Revenue code J2680
- Injection - Haloperidol up to 5 mg (Haldol) - Revenue code J1630
- Injection - Haloperidol Decanoate 50 mg (Haldol Decanoate) - Revenue code J1631
- Injection - Risperidone 0.5 mg (Risperdal Consta) - Revenue code J2794
Codes, Units, and Billing Requirements
| 114 | Psychiatric inpatient - private room |
| 124 | Psychiatric inpatient - semi-private room |
| 190 | Psychiatric inpatient - subacute |
| 204 | Psychiatric inpatient - intensive care psychiatric |
| H2015 | ASAM Level 1 - Adult community support; community support services (MRO) per 15 minutes |
| H0015 | ASAM Level 2.1 - Adult SUD intensive outpatient; per hour |
| H2034 | ASAM Level 3.1 - Adult halfway house |
| H0012 | ASAM Level 3.2 - Adult SUD social detoxification; per diem |
| H0019 | ASAM Level 3.3 - Adult intermediate therapeutic residential / therapeutic community; per diem; psychiatric residential rehabilitation services (MRO) - mental health; per diem |
| H0018 | SUD Level 3.5 - Short-term residential (co-occurring capable) |
Authorization Requirements and Submission
Prior authorization required; emergency services exception
Prior authorization is required for the listed behavioral health services for Nebraska Heritage Health / UnitedHealthcare Community Plan 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.
Where to submit authorizations and who to contact
Providers should consult the Prior authorization submission instructions, the Optum Behavioral Health National Network Manual, and the UnitedHealthcare Community Plan of Nebraska Care Provider Manual (Chapter 7) for submission details and processes. For questions, contact the Customer Service number on the back of the member's ID card.
Key Terms and Code Notes
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