CurrentOptumPolicy N/A

Behavioral health telehealth, claims, and prescribing guidance after COVID-19 public health emergency

Governs changes to telehealth, timely filing, prescribing controlled substances, and related billing/authorization practices for Optum behavioral health providers following the end of the COVID-19 public health emergency; applies to providers under Optum networks (state variations may apply).

Policy Summary

PayerOptum

PolicyBehavioral health telehealth, claims, and prescribing guidance after COVID-19 public health emergency

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain authorization for Intensive Outpatient Program (IOP) and Partial Hospitalization (PHP) when delivered virtually per Optum Clinical Guidelines and Criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

May 11, 2023end of national PHE

Aug. 9, 2023HIPAA transition end

Dec. 31, 2024Medicare flexibilities through

Audio-onlyAudio-only allowed

State-specificState rules may supersede

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.

Telehealth Coverage Criteria

Telehealth and related coverage criteria

Covered when meeting applicable plan, state, and federal requirements; modality and prescribing flexibilities are subject to DEA, SAMHSA, CMS, and state law and may vary by program.

Telehealth services are reimbursed per the member's benefit plan and applicable state and federal requirements; state mandates and plan requirements take precedence.

See state-specific Medicaid guidance where applicable.

Providers must use HIPAA-compliant telehealth platforms beginning Aug. 10, 2023; a transition period from May 12–Aug. 9, 2023 allowed use of non-HIPAA platforms for good-faith provision without financial penalty.

ALL of the following

Outpatient services
- Outpatient therapy: audio/visual and telephonic (audio)
- Medication management / Outpatient E&M: audio/visual and telephonic (audio)
Inpatient and specialty services
- Inpatient E&M: audio/visual only
- Applied Behavior Analysis (ABA): limited to supervision of behavior technicians and family training; audio/visual only
- Intensive Outpatient Program (IOP): audio/visual only; authorization required per Optum Clinical Guidelines and Criteria
  Authorization required for virtual IOP.
- Partial Hospitalization (PHP): audio/visual only; authorization required per Optum Clinical Guidelines and Criteria
  Optum will continue to authorize Virtual PHP despite limited evidence of efficacy to ensure access while providers develop efficacy metrics.
- Virtual psychological testing and outpatient ECT & TMS: not permitted (no demonstrated effectiveness)

Medicare telehealth flexibilities: the vast majority remain in place through Dec. 31, 2024, including access from any geographic area and home-based visits; certain visits may be delivered audio-only per HHS guidance.

Controlled-substance prescribing via telemedicine (temporary DEA/SAMHSA extension effective Nov. 11, 2023–Dec. 31, 2024): practitioners may prescribe schedule II–V controlled medications via audio-video telemedicine; schedule III–V narcotics for OUD maintenance/withdrawal may be prescribed via audio-only where allowed; all prescribing must comply with DEA guidance, DEA regulations, and applicable federal and state laws.

Timely filing and claims: timely filing requirements for commercial plans resumed in 2023; Medicare Advantage follows standard timely filing; Medicaid follows state rules.

Provider directory and attestation: providers may deliver virtual services without attestation but must complete Provider Express attestation to be listed in the provider directory as offering virtual visits.

Service Modalities, Codes, and Timely Filing

Intensive Outpatient Program (IOP)mixedCovered

IOP	Permitted via audio/visual only

Timely filing resumption (inv-03)

Commercial timely filingTimely claim filing requirements for commercial health plans will resume in 2023 as outlined in the IRS/DOL regulation related to the national emergency period; Optum will provide additional implementation details when finalized.

Medicare Advantage timely filingOptum Behavioral Health Solutions is following standard timely filing requirements for Medicare Advantage plans.

Medicaid timely filingMedicaid follows state-specific rules and other state requirements; providers should refer to their state-specific website for details.

Timely filing pause contextDuring the public health emergency the IRS/DOL regulation paused the timely filing clock for commercial claims; that pause extended 60 days after the national emergency ended per IRS/DOL guidance.

Authorization and Provider Requirements

Prior Authorization

Prior Authorization Required for Virtual IOP and PHP

Authorization required for Intensive Outpatient Program (IOP) and Partial Hospitalization (PHP) when delivered virtually. Providers must obtain prior authorization before initiating Virtual IOP or Virtual PHP services to ensure coverage and clinical appropriateness.

Applies to Virtual IOP and Virtual PHP (audio/visual delivery)
State regulations and health plan requirements may take precedence; check applicable Medicaid state rules

Note

Virtual Partial Hospitalization Authorization Guidance

Optum will continue to authorize Virtual Partial Hospitalization (PHP) despite limited evidence demonstrating efficacy to ensure access to care and to allow providers time to develop metrics demonstrating effectiveness. Authorization does not imply clinical equivalence to in-person PHP and documentation should support the medical necessity of virtual delivery.

Virtual PHP authorized for audio/visual delivery only
Providers should document rationale and outcomes metrics to support continued authorization

Regulatory Transition Notes

HIPAA enforcement discretion (inv-06)

Transition period datesThe HIPAA enforcement discretion for non‑HIPAA-compliant telehealth platforms ended May 11, 2023; a transition period runs May 12, 2023 through 11:59 pm Aug. 9, 2023.

Penalty policy during transitionFinancial penalties for non‑compliance will not be imposed during the transition period in connection with the good‑faith provision of telehealth services.

Requirement after transitionBeginning Aug. 10, 2023, providers must use a HIPAA‑compliant communications platform to conduct telehealth visits; failure to do so may result in financial penalties.

Platform options and attestationProviders are not required to use Optum Virtual Visits; any HIPAA‑compliant platform may be used, and providers must complete a Provider Express attestation to be listed in provider directories as offering virtual visits.

Telemedicine flexibilities for controlled substances (inv-07)