CurrentOptumPolicy N/A

Treatment Review & Authorization Request — Medicaid Rehab Option (MRO) form

This document is a treatment authorization request and review template used by managed care organizations for Medicaid Rehab Option services in Nebraska; it governs prior authorization, re-authorization, and clinical information collection for providers submitting MRO service requests.

Policy Summary

PayerOptum

PolicyTreatment Review & Authorization Request — Medicaid Rehab Option (MRO) form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIndicate Initial or Re-Authorization and designate Routine (up to 14 days) or Urgent (within 72 hours) when submitting the form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14 daysRoutine request turnaround window

72 hoursUrgent request turnaround window

NebraskaState governed

H0040,H2015,H2017,H2018Common service codes referenced

Authorization and Coverage Criteria

MRO service authorization criteria

Service-specific prior authorization expectations and required fields to complete on the MRO Treatment Request form:

ALL of the following

ALL of the following
- Service code: H0040 (or H0040-52 if applicable).
- Number of units requested.
- Frequency and number of weeks requested.
- Note: Prior Authorization and Concurrent Request are required by all MCOs for ACT.

Policy Summary

PayerOptum

PolicyTreatment Review & Authorization Request — Medicaid Rehab Option (MRO) form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIndicate Initial or Re-Authorization and designate Routine (up to 14 days) or Urgent (within 72 hours) when submitting the form.

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.

Service Codes and Units

Referenced service codesmixed

H0040	Assertive Community Treatment (ACT)
H0040-52	Assertive Community Treatment (ACT) - modifier 52
H2017	Psychosocial Rehabilitation Services
H2018	Psychosocial Rehabilitation Services (alternate)
H2015-HE	Community Support - HE
H2015-HF	Community Support - HF

Authorization units and frequency

Required request fieldsProviders must specify number of units, frequency, and weeks requested per service code on the form.

Example field: Assertive Community Treatment (ACT)Service code H0040 (or H0040-52), plus Number of Units, Frequency and Weeks must be entered.

Example field: Psychosocial Rehabilitation ServicesService code H2017 or H2018, plus Number of Units, Frequency and Weeks must be entered.

Example field: Community SupportService codes H2015-HE or H2015-HF, plus Number of Units, Frequency and Weeks must be entered.

Submission Requirements and Timing

Prior Authorization

Request type and timing

Indicate whether the request is an Initial Authorization/Initial Clinical Assessment/Plan of Care or a Re-Authorization/Plan of Care; mark Routine (up to 14 days) or Urgent (within 72 hours) and provide the admission date and the date of request.

Documentation Required

Submission and MCO requirements

Specify the Managed Care Organization for the member and submit the form using the MCO-specific fax numbers listed on the form (UnitedHealthcare Community Plan, Nebraska Total Care, WellCare).

UnitedHealthcare Community Plan Fax: 1-844-881-4926
Nebraska Total Care Fax: 1-866-593-1955
WellCare Outpatient Fax: 1-855-279-3683; Inpatient Fax: 1-877-849-5071
Note: Some services (e.g., ACT and Psychiatric Residential Rehab) require prior authorization and concurrent requests by all MCOs; prior authorization requirements for Psychosocial Rehabilitation and Community Support vary by MCO (UHCCP and NTC: no prior auth; WellCare: prior auth).

Documentation Required

Re-authorization documentation

When requesting a re-authorization, complete the Treatment Review section documenting number of appointments attended since the last authorization, the types of services and units/encounters used from the last authorization, and include the treating provider signature and date.

Document appointments attended since last authorization.
List units used by service (e.g., ACT, Psych Res Rehab, PRS, Peer Support, Community Support).
Include Treating Provider Signature and Date.

Request Type Definitions

Urgent Request

DefinitionUrgent Request: Services needed to stabilize the patient and prevent deterioration; client needs significant and immediate supportive interventions.

Turnaround timeframeDecision timeframe: within 72 hours.

When to useSelect when services are needed immediately to prevent deterioration as indicated on the form.

Routine Request

DefinitionRoutine Request: standard authorization request processed under the routine timeframe.

Turnaround timeframeDecision timeframe: up to 14 days.

When to useSelect for non-urgent authorizations that do not require immediate intervention.