Optum Behavioral Health Prior Auth Policy Update | OpenPayer
CurrentOptumPolicy N/A
New York Mainstream Medicaid Under 21 In Foster Care — Behavioral Health Prior Authorization Requirements
Lists behavioral health services and procedure/revenue codes that require prior authorization for UnitedHealthcare Community Plan members in New York who are under 21 and in foster care. Applies to in-network and out-of-network providers (out-of-network must obtain prior authorization); emergency services are excluded.
Policy Summary
PayerOptum
PolicyBehavioral health prior authorization requirements for New York Mainstream Medicaid under‑21 in foster care
Policy CodePolicy N/A
Change TypeNo material change
Effective DateOct 1, 2023
Next Review DateN/A
Key ActionObtain prior authorization before providing behavioral health services listed in the table; out-of-network providers must secure authorization prior to service delivery.
No material clinical or coverage changes in this revision.
multipleprocedure and revenue codes requiring prior authorization
ECT ended 11/1/2023procedure removed from prior authorization requirement
ASAM 3.7substance use inpatient levels referenced
includedcommunity and respite services requiring authorization
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Services Requiring Prior Authorization
Services requiring prior authorization
Services and specific procedure/revenue codes that continue to require prior authorization include (non-exhaustive examples from the table):
ALL of the following
Inpatient and facility revenue codes
All-inclusive room and board plus ancillary — Revenue code 100
Administration/scoring — Procedure codes 96136, 96137, 96138, 96139 (auth required only if submitted with 96130/96131; not required if submitted with 96132/96133)
OASAS Residential Programs (Stabilization and Rehabilitation) — Procedure code H2036 with TG/HF modifiers as specified
Planned and Crisis Respite (per 15 minutes and per diem) — Procedure codes S5150 (under 4 hrs) and S5151 (per diem), with applicable modifiers
Notes: This list contains non-exhaustive examples from the table; prior authorization is required as specified by the code/revenue and modifiers in the table. Emergency services are excluded from prior authorization requirements.
Selected Procedure and Revenue Codes
Selected inpatient/revenue codesRevenueCovered
0114, 0124, 0134
Inpatient psychiatric revenue codes
100
All-inclusive room and board plus ancillary revenue code
158
Medically Monitored Intensive Inpatient Services, ASAM 3.7 revenue code
Selected outpatient and assessment codesCPT|HCPCS|mixedCovered
96130, 96131, 96132, 96133, 96136-96139
Psychological and neuropsychological testing evaluation and administration/scoring
97151-97158
Behavior identification assessments and adaptive behavior treatment codes
H0035, H2012, H2014, H2015, H2023
Partial hospitalization, continuing day treatment, caregiver/family advocacy, supported employment and related codes
Prior Authorization Instructions and Provider Notices
Prior Authorization
Prior Authorization Required
Prior authorization is required for the behavioral health services listed below. 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 information, see the Optum Behavioral Health National Network Manual (pages 38-40) or call the Customer Service number on the back of the member's ID card.
Applies to the New York Mainstream Medicaid Under 21 In Foster Care contract
Out-of-network providers must obtain prior authorization prior to providing services
Emergency services are excluded from prior authorization requirements
Note
ECT Prior Authorization Removal
Effective Nov 1, 2023, prior authorization requirement is removed for electroconvulsive therapy (ECT) when billed with Procedure Code 90870 (ECT, single seizure and multiple seizure per day).
Procedure Code: 90870 — ECT, single seizure and multiple seizure per day
Prior authorization requirement ends 2023-11-01
Prior Authorization
Codes Continuing to Require Prior Authorization
The following procedure and revenue codes continue to require prior authorization. This list includes inpatient, outpatient, partial hospitalization, community/respite, ASAM substance use services, habilitation, ABA/adaptive behavior services, psychological testing and related administration/scoring codes, palliative care services, and a range of HCBS and day/continuing treatment services. Providers must obtain authorization before rendering these services.
All-inclusive room and board plus ancillary — Revenue Code: 100
Psychological & Neuropsychological testing administration/scoring — Procedure Codes: 96136, 96137, 96138, 96139 (Auth required only when submitted with 96130/96131; not required when submitted with 96132/96133)
Key Definitions
inv-07: Prior authorization — definition and scope
DefinitionPrior authorization is the approval providers must obtain before delivering certain behavioral health services (not required for emergency services).
ScopeApplies to behavioral health services for New York Mainstream Medicaid members under 21 in foster care as listed in the policy table.
Out-of-network providersAll out-of-network (non-participating) providers must obtain prior authorization approval before providing behavioral health services.
Emergency servicesPrior authorization is not required when rendering emergency services.
ReferenceSee the Optum Behavioral Health National Network Manual (pages 38-40) for additional information and instructions.
Policy Summary
PayerOptum
PolicyBehavioral health prior authorization requirements for New York Mainstream Medicaid under‑21 in foster care
Policy CodePolicy N/A
Change TypeNo material change
Effective DateOct 1, 2023
Next Review DateN/A
Key ActionObtain prior authorization before providing behavioral health services listed in the table; out-of-network providers must secure authorization prior to service delivery.
Family adaptive behavior treatment guidance — Procedure Code: 97156
Group adaptive behavior treatment with protocol modification — Procedure Code: 97158
Palliative Care Pain and Symptom — Procedure Code: 99347 (modifier TJ noted)
Partial Hospitalization services — Procedure Code: H0035 with unit modifiers U4+UA, U5+UA, U6+UA, U7+UA and collateral modifiers U1/HR/HS as applicable
Continuing Day Treatment (various durations) — Procedure Code: H2012 with unit modifiers U1, U2, U3, U5, U8, U9, UK as applicable
Intensive Psychiatric Rehabilitation Treatment Programs (1–5 hours) — Procedure Code: H2012 with modifiers HK + U1–U5 or H2012 alone as applicable
Caregiver/Family Advocacy and Support Services (L1, L2; individual/group) — Procedure Code: H2012 mapped to H2014/H2015 with modifiers (UK + HQ, HA, UN, UP) as indicated
Community HCBS Habilitation (per 15 minutes; individual/group) — Procedure Code: H2012 mapped to H2014 with modifiers HA, UP, UN as applicable
Supported Employment (15 minutes) — Procedure Code: H2023 with modifier HA
OASAS Residential Programs (Stabilization, Rehabilitation) — Procedure Code: H2036 with modifiers TG (w/ or w/o HF) or HF
Planned and Crisis Respite (per 15 minutes and per diem options) — Procedure Codes: S5150 (under 4 hours) and S5151 (per diem) with modifiers HA, HQ, ET, HK as applicable
Prevocational Services (individual/group) — Procedure Code: T2015 with modifiers HA, UN, UP as indicated
Day HCBS Habilitation (per 15 minutes; individual/group) — Procedure Code: T2020 with modifiers HA, UN, UP as applicable
Partial Hospital Collateral and Group Collateral services — Procedure Code: H0035 with collateral modifiers U1, U2, HQ, HR, HS as applicable
Intensive Psychiatric Rehabilitation and Continuing Day Treatment program mappings — H2012 with UK/HR/HQ/UK modifiers mapping to HK and other modifier combinations as specified