Optum behavioral health Prior Auth update | OpenPayer
CurrentOptumPolicy N/A
Prior authorization requirements for behavioral health services (NY Adult HARP)
Defines which behavioral health services require prior authorization for UnitedHealthcare Community Plan members under the New York Adult Health and Recovery Plans (HARP) contract; affects participating and out-of-network behavioral health providers delivering services to HARP members in New York.
Policy Summary
PayerOptum
PolicyPrior authorization requirements for behavioral health services (NY Adult HARP)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateOct 1, 2023
Next Review DateN/A
Key ActionProviders must check the listed services and obtain prior authorization for listed behavioral health services before providing them to UnitedHealthcare Community Plan members; out-of-network providers must obtain prior authorization.
Behavioral Health Day Treatment, Procedure Code H2012: prior authorization required.
Psychological and neuropsychological testing (evaluation, administration/scoring)
Psychological testing evaluation services, Procedure Codes 96130 (first hour) and 96131 (each additional hour): prior authorization required when billed as listed.
Test administration and scoring by a clinician, Procedure Codes 96136 (first 30 minutes) and 96137 (each additional 30 minutes): prior authorization required ONLY when these Admin & Scoring codes are submitted with Psychological Testing Evaluation Codes 96130 or 96131; No prior authorization required when the Admin & Scoring codes are submitted with Neuropsychological Testing Evaluation Codes 96132 or 96133.
Psychological & Neuropsychological testing administration/scoring, Procedure Codes 96138 and 96139: prior authorization required ONLY when submitted with Psychological Testing Eval Codes 96130 or 96131; No prior authorization required when submitted with Neuropsychological Testing Eval Codes 96132 or 96133.
Mental health assessment and service planning
Mental health assessment by non-physician, per hour, Procedure Code H0031: prior authorization required.
Mental health service plan development by non-physician, Procedure Code H0032: prior authorization required.
HARP HCBS services
HARP HCBS Psychosocial Rehab - individual - per diem, Procedure Code H2018: prior authorization required.
HARP HCBS Intensive Supported Employment, Procedure Codes H2019 and H2023: prior authorization required.
HARP HCBS On-going Supported Employment, Procedure Codes H2019 and H2025: prior authorization required.
HARP HCBS Education Support Services, Procedure Code T2013: prior authorization required.
HARP HCBS Pre-vocational, Procedure Code T2015: prior authorization required.
Mental Health intensive outpatient (note: NOT State Plan)
906
Intensive OP Services - Psychiatric
0912
Mental Health partial hospitalization
0913
Mental Health partial hospitalization
Auth requirement conditional on code combinations — admin & scoring codes (96136/96137/96138/96139) require auth only when submitted with Psychological Testing Eval Codes 96130/96131; no auth otherwise.
Auth requirement conditional on code combinationsAdministration & scoring codes 96136/96137 and 96138/96139 require prior authorization ONLY when submitted with Psychological Testing Evaluation codes 96130/96131. No prior authorization required when these admin/scoring codes are submitted with Neuropsychological Testing Evaluation codes 96132/96133.
Provider Instructions and Authorization Notices
Prior Authorization
General prior authorization instructions
Please check this list before you provide services to 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. 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 New York Adult - Health and Recovery Plans (HARP) contract
Emergency services are exempt from prior authorization
Note
Authorization ending — Nov. 1, 2023
Prior authorization requirement ending on Nov. 1, 2023 for the following outpatient procedure: OP ECT Electroconvulsive therapy (with monitoring).
Procedure Code: 90870
Service: OP ECT Electroconvulsive therapy (w/monitoring)
Prior authorization no longer required effective 2023-11-01
Prior Authorization
Services continuing to require authorization
The following inpatient, residential, partial hospitalization, intensive outpatient, testing, and HARP HCBS services continue to require prior authorization.
All-inclusive room and board plus ancillary — Revenue Code: 100
Testing administration and scoring (physician/qualified health professional) — Procedure Codes: 96136, 96137
Applicability and Service Definitions
Prior authorization applicability
Out-of-network providersAll out-of-network (non-participating) providers must obtain prior authorization approval before providing behavioral health services
Check before providing servicesProviders should check the listed services before providing services to UnitedHealthcare Community Plan members
Emergency services exceptionPrior authorization is not required when rendering emergency services
Where to get more infoAdditional information available in the Optum Behavioral Health National Network Manual (pages 38-40) or via Customer Service on the member's ID card
OP ECT (90870)
DefinitionOutpatient electroconvulsive therapy with monitoring (OP ECT)
Procedure codeCPT/Procedure code 90870
Authorization notePrior authorization requirement for 90870 ends on Nov. 1, 2023 (per document)
Policy Summary
PayerOptum
PolicyPrior authorization requirements for behavioral health services (NY Adult HARP)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateOct 1, 2023
Next Review DateN/A
Key ActionProviders must check the listed services and obtain prior authorization for listed behavioral health services before providing them to UnitedHealthcare Community Plan members; out-of-network providers must obtain prior authorization.