Medicare Prior Authorization Codes
Lists behavioral health services and procedure/revenue codes that require prior authorization for members enrolled in Optum Medicare Advantage plans; applies to providers delivering behavioral health services to Medicare Advantage members.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
Coverage stance and requirements
Behavioral health services listed below require prior authorization for Medicare Advantage members; some services are exempt from prior authorization but require advance notification.
Services that require prior authorization
- Inpatient hospitalization (various bed types) using procedure/revenue codes 114,116,118,124,126,128,134,136,138,154,156,158 and intensive care-psychiatric code 204.
- Intensive Outpatient (IOP) services using procedure/revenue codes 905 (psychiatric) and 906 (chemical dependency).
- Partial Hospitalization Program (PHP) services using procedure/revenue codes 912 (less intensive) and 913 (intensive).
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