CurrentOptumPolicy N/A

Prior authorization requirements for behavioral health services (Pennsylvania CHIP)

Defines which behavioral health services and specific procedure/revenue codes require prior authorization for Pennsylvania Children's Health Insurance Program (CHIP) members and notes network/emergency exceptions; applies to providers serving UnitedHealthcare Community Plan members in Pennsylvania.

Policy Summary

PayerOptum

PolicyPrior authorization requirements for behavioral health services (Pennsylvania CHIP)

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateJun 1, 2025

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Inpatient & outpatient servicessettings listed

ManyABA codes

RequiredOut-of-network auth

Not requiredEmergency exception

Prior Authorization Required Services

Policy Summary

PayerOptum

PolicyPrior authorization requirements for behavioral health services (Pennsylvania CHIP)

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateJun 1, 2025

Next Review DateN/A

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

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

Inpatient mental health revenue codes: 114, 124, 134, 144, 154, 204.
Inpatient substance use disorder detoxification (non-hospital based) revenue codes: 116, 126, 136, 146, 156.
Substance use disorder - Residential treatment revenue codes: 128, 1001, 1002.
Mental health/substance use disorder - Intensive outpatient revenue codes: 0905, 0906.
Mental health/substance use disorder - Partial hospitalization revenue codes: 0912, 0913.

ALL of the following

Psychological testing evaluation (procedure codes): 96130, 96131.
Psychological and neuropsychological testing administration/scoring (procedure codes): 96136, 96137, 96138, 96139. Note: authorization is required only if these administration/scoring codes are submitted with psychological testing evaluation codes 96130 or 96131; no authorization is required if they are not submitted with 96130/96131.
Behavior identification assessment (Applied Behavioral Analysis/ABA) (procedure code): 97151.
Behavior identification-supporting assessment by technician (procedure code): 97152.
Adaptive behavior treatment by protocol, technician (procedure code): 97153.
Group adaptive behavior treatment by protocol (procedure code): 97154.
Adaptive behavior treatment with protocol modification (procedure code): 97155.
Family adaptive behavior treatment guidance (procedure code): 97156.
Group adaptive behavior treatment with protocol modification (procedure code): 97158.
Intensive outpatient procedure codes: H0015, S9480 (bill revenue codes 0905 and 0906).
Partial hospitalization procedure codes: H0035, S0201 (bill revenue codes 0912 and 0913).

ALL of the following

When billing intensive outpatient or partial hospitalization procedure codes, also bill the corresponding revenue codes as indicated (intensive outpatient: revenue 0905/0906; partial hospitalization: revenue 0912/0913).
Psychological testing administration/scoring codes (96136–96139) require authorization only when submitted with evaluation codes 96130 or 96131.

ALL of the following

These prior authorization requirements apply to behavioral health services for Pennsylvania Children's Health Insurance Program (CHIP) members. Exceptions such as emergency services and specific network rules are addressed in the program manuals.

Behavioral Health Codes Requiring Authorization

Inpatient mental health - Revenue codesRevenueCovered

114	Inpatient mental health
124	Inpatient mental health
134	Inpatient mental health
144	Inpatient mental health
154	Inpatient mental health
204	Inpatient mental health

Inpatient substance use disorder detoxification (non-hospital) - Revenue codesRevenueCovered

116	Inpatient SUD detoxification (non-hospital based)
126	Inpatient SUD detoxification (non-hospital based)
136	Inpatient SUD detoxification (non-hospital based)
146	Inpatient SUD detoxification (non-hospital based)
156	Inpatient SUD detoxification (non-hospital based)

Substance use disorder - Residential treatment Revenue codesRevenueCovered

128	Residential treatment
1001	Residential treatment
1002	Residential treatment

Intensive outpatient - Revenue codesRevenueCovered

0905	Intensive outpatient
0906	Intensive outpatient

Partial hospitalization - Revenue codesRevenueCovered

0912	Partial hospitalization
0913	Partial hospitalization

Psychological testing evaluation - CPTCPTCovered

96130	Psychological testing evaluation by physician or qualified health care professional; administration
96131	Psychological testing evaluation by physician or qualified health care professional; scoring and interpretation

Psychological and neuropsychological testing administration/scoring - CPTCPTCovered

96136	Psychological test administration and scoring by qualified health care professional
96137	Psychological test administration and scoring by technician
96138	Neuropsychological test administration and scoring by qualified health care professional
96139	Neuropsychological test administration and scoring by technician

Behavior analytic / ABA assessment and treatment - CPTCPTCovered

97151	Behavior identification assessment by physician or qualified health care professional, each 15 minutes
97152	Behavior identification-supporting assessment by technician, each 15 minutes
97153	Adaptive behavior treatment by protocol by technician, each 15 minutes
97154	Group adaptive behavior treatment by protocol by technician, each 15 minutes
97155	Adaptive behavior treatment with protocol modification by physician or qualified health care professional, each 15 minutes
97156	Family adaptive behavior treatment guidance by physician or qualified health care professional, each 15 minutes
97158	Group adaptive behavior treatment with protocol modification, each 15 minutes

Intensive outpatient - HCPCS/CPTmixedCovered

H0015	Intensive outpatient services, SUD
S9480	Intensive outpatient, mental health

Partial hospitalization - HCPCS/CPTmixedCovered

H0035	Partial hospitalization services, SUD
S0201	Partial hospitalization, mental health

Authorization Applicability and Provider Requirements

Prior Authorization

Prior Authorization Applicability and Exceptions

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. Providers should check the Optum Behavioral Health National Network Manual (pages 38-43) and the UnitedHealthcare Community Plan of Pennsylvania Care Provider Manual (Chapter 7) for additional prior authorization guidance. If questions remain, call the Customer Service number on the back of the member's ID card.

Applies to UnitedHealthcare Community Plan (Pennsylvania CHIP) members.
Out-of-network providers: prior authorization always required except for emergency services.

Prior Authorization

Services and Codes Requiring Prior Authorization

The following services and codes require prior authorization. Consolidate billing appropriately (revenue codes for facility-level services; CPT/HCPCS for professional services).

Inpatient mental health — Revenue codes: 114, 124, 134, 144, 154, 204
Inpatient substance use detoxification (non‑hospital based) — Revenue codes: 116, 126, 136, 146, 156
Substance use disorder residential treatment — Revenue codes: 128, 1001, 1002
Intensive outpatient (mental health/substance use disorder) — Revenue codes: 0905, 0906; Procedure codes: H0015, S9480
Partial hospitalization (mental health/substance use disorder) — Revenue codes: 0912, 0913; Procedure codes: H0035, S0201
Psychological testing — Procedure codes: 96130, 96131 (evaluation)
Psychological/neuropsych testing administration/scoring — Procedure codes: 96136, 96137, 96138, 96139 (authorization required only when billed with 96130/96131)
Behavior analytic / ABA services — Procedure codes: 97151, 97152, 97153, 97154, 97155, 97156, 97158 (behavior identification assessment; technician-administered assessments; adaptive behavior treatment individual/group; behavior consultation/analytic services)
When billing ABA services, ensure correct pairing of evaluation, administration/scoring, technician vs professional codes and obtain authorization for covered ABA procedure codes.

Key Definitions

Out-of-network provider

DefinitionA non-participating (out-of-network) provider who must obtain prior authorization approval before providing behavioral health services to Pennsylvania CHIP members.

ExceptionPrior authorization is not required when rendering emergency services.

ApplicabilityApplies to behavioral health services provided to UnitedHealthcare Community Plan members under the Pennsylvania CHIP contract.

GuidanceProviders should check the Optum Behavioral Health National Network Manual and UnitedHealthcare Community Plan of Pennsylvania Care Provider Manual for additional details and call member ID customer service with questions.

Behavior identification assessment (97151)

DescriptionAssessment administered by a physician or other qualified health care professional including face-to-face time with patient and/or guardian(s)/caregiver(s) and non-face-to-face activities such as analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan.

Procedure code97151

Timing/unitsEach 15 minutes of the physician's or qualified professional's time (face-to-face and/or non-face-to-face activities).

ContextReferred to as Behavior Analytic/Behavior Consultation - Applied Behavioral Analysis (ABA).

Included activitiesFace-to-face administering assessment and discussing findings/recommendations; non-face-to-face analyzing data, scoring/interpreting, preparing report/treatment plan.