CurrentOptumPolicy N/A

Behavioral health services prior authorization requirements (Ohio Medicaid Managed Care)

Lists behavioral health services and procedure/revenue codes that require prior authorization for Ohio Medicaid Managed Care (UnitedHealthcare Community Plan) providers; applies to in-network and out-of-network providers serving Ohio Medicaid members.

Policy Summary

PayerOptum

PolicyBehavioral health services prior authorization requirements (Ohio Medicaid Managed Care)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2023

Next Review DateN/A

Key ActionOut-of-network providers must obtain prior authorization before providing behavioral health services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~70+behavioral health procedure and revenue code entries listed

Includes 96130-96139testing and assessment codes

Includes TMS codesadvanced treatment modalities

Requiredout-of-network prior auth

Prior Authorization Coverage Criteria

Policy Summary

PayerOptum

PolicyBehavioral health services prior authorization requirements (Ohio Medicaid Managed Care)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2023

Next Review DateN/A

Key ActionOut-of-network providers must obtain prior authorization before providing behavioral health services.

SourceLink

On This Page

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All listed behavioral health services and specified revenue and procedure codes require prior authorization for Ohio Medicaid Managed Care members, except emergency services.

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.

Psychological/neuropsychological testing administration/scoring rule

Procedure codes 96138 and 96139 (Psychological and Neuropsychological testing administration/scoring) require authorization only when submitted with psychological testing evaluation codes 96130 or 96131.
No authorization is required for codes 96138 and 96139 when they are submitted with neuropsychological testing.

Examples of inpatient/revenue codes that require prior authorization include (but are not limited to) Revenue Codes 114, 116, 118, 124, 126, 128, 134, 136, 138, 154, and 156.

Behavioral Health Procedure and Revenue Codes

Behavioral health prior-auth codesmixedCovered

Revenue 114	Inpatient Psychiatric/private
Revenue 116	Inpatient Detoxification/private
Revenue 118	Inpatient Rehabilitation/private
Revenue 124	Psychiatric Inpatient/semi-private
Revenue 204	Psychiatric Inpatient Intensive Care
90867	TMS planning
90868	TMS delivery and management per session
90869	TMS subsequent motor threshold re-determination
96138	Psychological and Neuropsychological testing administration/scoring
96139	Psychological and Neuropsychological testing administration/scoring

1–10 of 14

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Psych testing admin/scoring auth condition

96138 (admin/scoring)Prior authorization required only when submitted with psychological testing evaluation codes 96130 or 96131; no prior authorization required when submitted with neuropsychological testing.

96139 (admin/scoring)Prior authorization required only when submitted with psychological testing evaluation codes 96130 or 96131; no prior authorization required when submitted with neuropsychological testing.

Condition summaryAuth requirement is conditional — applies to administration/scoring codes only when paired with psychological testing eval codes (96130, 96131); otherwise exempt when paired with neuropsychological testing.

Provider Prior-Authorization & Billing Actions

Prior Authorization

Prior Authorization Required for Non-Participating Providers

Note: 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. Please check the Optum Behavioral Health National Network Manual (pages 38-40) for additional submission and timing details. For questions, contact the Customer Service number on the back of the member's ID card.

Billing Rule

Psychological/Neuropsychological Testing Authorization Rule

Administration/scoring codes 96138 and 96139 require prior authorization only when billed with Psychological Testing Evaluation codes 96130 or 96131. If 96138/96139 are submitted with Neuropsychological Testing codes (neuropsych testing), prior authorization is not required. Ensure claims/authorizations specify the accompanying evaluation/testing codes to avoid denial or delay.

Prior auth required when 96138 or 96139 billed with 96130 or 96131.
No prior auth required for 96138 or 96139 when submitted with neuropsychological testing codes.

Key Definitions

Prior authorization — definition & scope

Definition - Prior authorizationRequirement to obtain approval before providing non-emergency behavioral health services, particularly for out-of-network (non-participating) providers.

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 behavioral health services.

Where to checkProviders should check the listed services and refer to the Optum Behavioral Health National Network Manual (pages 38-40) or member ID card Customer Service number for questions.