Medicare Prior Authorization Codes
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Lists behavioral health services and procedure codes that require prior authorization for Medicare Advantage members and notes special rules for OTPs, PHP/IOP, TMS, and psychological testing. Affects providers delivering behavioral health services to Optum Medicare Advantage plan members.
No material clinical or coverage changes in this revision.
Prior authorization and coverage rules
Prior authorization coverage criteria and exceptions
Prior authorization is required for the behavioral health services and codes listed below; some services are exceptions or have additional notification and delivery requirements.
ALL of the following
- Psychiatric - private: 114
- Detoxification - private: 116
- Rehabilitation - private: 118
- Psychiatric - semi-private: 124
- Detoxification - semi-private: 126
- Rehabilitation - semi-private: 128
- Psychiatric - 3-4 bed: 134
- Detoxification - 3-4 bed: 136
- Rehabilitation - 3-4 bed: 138
- Psychiatric - ward: 154
- Detoxification - ward: 156
- Rehabilitation - ward: 158
- Intensive Care - Psychiatric: 204
- Substance Use Disorder - Drug rehabilitation: 944
- Substance Use Disorder - Alcohol rehabilitation: 945
ALL of the following
- PHP billed with condition code 41; IOP billed with condition code 92.
- PHP and IOP services cannot be delivered via telehealth.
- IOP minimum intensity: minimum of 9 services over a 7-contiguous day period (may include individual and group therapy and other qualified services).
- Relevant procedure/billing codes include: individual therapy 914; group therapy 915; family therapy 916; behavioral health testing 918; FQHC/RHC only intensive OP services 905; PHP primary procedure code G0137 (when applicable).
OTP exception
Procedure and billing codes
| 114 | Psychiatric inpatient/private |
| 116 | Detoxification inpatient/private |
| 118 | Rehabilitation inpatient/private |
| 124 | Psychiatric semi-private |
| 126 | Detoxification semi-private |
| 128 | Rehabilitation semi-private |
| 134 | Psychiatric 3-4 bed |
| 136 | Detoxification 3-4 bed |
| 138 | Rehabilitation 3-4 bed |
| 154 | Psychiatric ward |
| 914 | Individual therapy |
| 915 | Group therapy |
| 916 | Family therapy |
| 918 | Behavioral health testing |
| 905 | Intensive OP Services - Psychiatric (FQHC/RHC only) |
| G0137 | Partial Hospitalization Program service |
| 90867 | TMS planning |
| 90868 | TMS delivery and management per session |
| 90869 | TMS motor threshold redetermination |
| 96130 | Psychological testing evaluation, physician or qualified professional |
| 90832 | Outlier psychotherapy services (listed examples) |
| 90834 | Outlier psychotherapy services (listed examples) |
| 90837 | Outlier psychotherapy services (listed examples) |
| 90845 | Outlier psychotherapy services (listed examples) |
| 90846 | Outlier psychotherapy services (listed examples) |
| 90847 | Outlier psychotherapy services (listed examples) |
| 90849 | Outlier psychotherapy services (listed examples) |
| 90853 | Outlier psychotherapy services (listed examples) |
| 90833 | Outlier psychotherapy services (listed examples) |
| 90880 | Hypnotherapy |
What providers must do
Prior authorization notification and where to get more information
Please check listed requirements before providing services to Medicare Advantage members. Additional information about prior authorization for behavioral health services can be found in the Optum Behavioral Health National Network Manual (pages 38-43). If you have questions, call the Customer Service number on the back of the member's ID card. Out-of-network providers should call the number on the back of the member ID card for information on prior authorization requirements that apply to non-contracted (non-participating) clinicians.
OTP advance notification requirement
Medication-Assisted Treatment (MAT) provided by Medicare-certified Opioid Treatment Programs (OTPs) is not subject to prior authorization. However, network (contracted) OTPs must provide advance notification prior to rendering services so claims can be reimbursed according to negotiated bundled rates. Failure to provide advance notification may result in claim denials.
- Weekly bundle including dispensing/administration, substance use counseling, individual and group therapy, and toxicology testing (if performed): G2067 (methadone), G2068 (buprenorphine oral), G2073 (naltrexone)
- Advance notification required for network OTPs to be reimbursed; MAT itself is exempt from PA
PHP/IOP prior authorization and service requirements
Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) require prior authorization and must meet minimum intensity and service requirements. PHP/IOP services cannot be delivered via telehealth.
- PHP billed with condition code 41; IOP billed with condition code 92
- PHP/IOP cannot be delivered virtually (telehealth)
- Minimum IOP intensity: at least 9 services over a 7-contiguous day period (may include individual and group therapy provided by physicians, psychologists, or other authorized mental health professionals)
- Covered service types include individual therapy (914), group therapy (915), family therapy (916), behavioral health testing (918), and FQHC/RHC intensive OP psychiatric services (905)
- PHP services may include occupational therapy, social workers, psychiatric nursing, drugs and biologicals for therapeutic purposes (excluding FDA‑approved opioid agonist/antagonist medications for OUD and opioid antagonists for emergency overdose treatment), individualized activity therapies (non-recreational), family counseling focused on the member's condition, patient training and education related to care, and diagnostic services (excluding toxicology testing unless part of OTP billing)
- Medicare-enrolled Opioid Treatment Program services should be listed separately in addition to the primary procedure code when applicable (G0137)
Program and term definitions
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