CurrentOptumPolicy N/A

Prior authorization requirements for New Jersey FamilyCare behavioral health services

This document lists behavioral health procedure and revenue codes that require prior authorization for UnitedHealthcare Community Plan members in New Jersey FamilyCare and notes key authorization policies for providers affected by the plan.

Policy Summary

PayerOptum / UnitedHealthcare Community Plan (New Jersey FamilyCare)

PolicyPrior authorization requirements for New Jersey FamilyCare behavioral health services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionProviders must check the listed services and obtain prior authorization before providing behavioral health services to UnitedHealthcare Community Plan members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

dozensbehavioral health codes listed that require prior authorization

NJapplies to

yesemergency exemption

yesOON requires auth

Services Requiring Prior Authorization

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Services requiring prior authorization

Prior authorization is required for the following categories and specific codes:

Inpatient and partial hospital

Mental health (MH) - Inpatient, Revenue Codes: 100, 114, 124, 134, 144, 154, 204 (prior authorization required).
Substance use disorder (SUD) - Inpatient withdrawal management (ASAM 4.0), Revenue Codes: 116, 126, 136, 146, 156 (prior authorization required).
SUD - Intensive outpatient, Revenue Code: 906 / H0015 (prior authorization required).
Mental health - Partial hospital / Acute partial hospital (adult and under 18) Revenue Codes: 912, 913 (prior authorization required).

Outpatient SUD, TMS, and psychological testing

Outpatient SUD Partial Care (ASAM 2.5), Procedure Code: H2036 (prior authorization required).
Outpatient SUD Ambulatory withdrawal management (ASAM 2.0-WM), Procedure Codes: 944, 945 / H0014 (prior authorization required).
Mental health - Partial care, Procedure Code: H0035 (prior authorization required).
Therapeutic repetitive transcranial magnetic stimulation (TMS) — initial and subsequent: Procedure Codes: 90867, 90868, 90869 (prior authorization required).
Psychological testing evaluation, Procedure Codes: 96130, 96131 (prior authorization required).

Psychological, neuropsychological testing administration/scoring

Testing administration/scoring, Procedure Codes: 96136, 96137, 96138, 96139 (prior authorization required only when submitted with psychological testing evaluation codes 96130 or 96131; no authorization required if submitted with neuropsychological testing evaluation codes 96132 or 96133).
Auth condition depends on associated evaluation codes as specified.

Health behavior interventions and supervision

Initial assessment/reassessment and treatment plan development; supervision (including EP and modifier 26 references), Procedure Code: 96156 EP (prior authorization required).
Health behavior intervention — individual/group/family codes and add-ons, Procedure Codes: 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171 (prior authorization required).

Behavior identification assessments and adaptive behavior treatment

Behavior identification assessment and supporting assessment, Procedure Codes: 97151, 97152 (prior authorization required).
Adaptive behavior treatment by protocol and related codes administered by technician or QHP, Procedure Codes: 97153, 97154, 97155, 97156, 97157, 97158 (prior authorization required).
Behavior identification supporting assessment and adaptive behavior treatment technician time, Procedure Codes: 0362T, 0373T (prior authorization required when meeting specified components).
0373T/0362T require components such as QHP on site, assistance of two or more technicians, patient exhibiting destructive behavior, and a customized environment.

Provider authorization reminders

All providers must check the listed services and obtain prior authorization before providing behavioral health services to UnitedHealthcare Community Plan members in New Jersey FamilyCare.
All out-of-network (non-participating) providers must obtain prior authorization approval prior to providing behavioral health services.
Emergency services do not require prior authorization; however emergency admissions require notification to the plan.

Procedure and Revenue Codes

Inpatient and Partial Hospital Revenue Codes (Prior Authorization Required)RevenueCovered

100	Mental health - Inpatient
114	Mental health - Inpatient
124	Mental health - Inpatient
134	Mental health - Inpatient
144	Mental health - Inpatient
154	Mental health - Inpatient
204	Mental health - Inpatient
116	SUD - Inpatient withdrawal management (ASAM 4.0)
126	SUD - Inpatient withdrawal management (ASAM 4.0)
136	SUD - Inpatient withdrawal management (ASAM 4.0)

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Outpatient SUD and TMS/Testing Codes (Prior Authorization Required)mixedCovered

906	SUD - Intensive outpatient
H0015	SUD - Intensive outpatient (HCPCS)
944	Outpatient SUD - Ambulatory withdrawal management (ASAM 2.0-WM)
945	Outpatient SUD - Ambulatory withdrawal management (ASAM 2.0-WM) / H0014 (HCPCS)
H0014	Outpatient SUD - Ambulatory withdrawal management (HCPCS)
90867	TMS initial with cortical mapping, motor threshold determination, delivery and management
90868	TMS subsequent delivery and management, per session
90869	Transcranial magnetic stimulation
96130	Psychological testing evaluation, first hour
96131	Psychological testing evaluation, each additional hour

Behavioral, Testing, and Adaptive Behavior Treatment Codes (Prior Authorization Required)CPTCovered

96158	Health behavior intervention, individual, initial 30 minutes
96159	Health behavior intervention, individual, each additional 15 minutes
96164	Health behavior intervention, group initial 30 minutes
96165	Health behavior intervention, group each additional 15 minutes
96167	Health behavior intervention, family (with patient present) initial 30 minutes
96168	Health behavior intervention, family (with patient present) each additional 15 minutes
96170	Health behavior intervention, family (without patient) initial 30 minutes
96171	Health behavior intervention, family (without patient) each additional 15 minutes
96136	Psychological and neuropsychological testing administration/scoring
96137	Psychological and neuropsychological testing administration/scoring

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inv-05: Auth required condition for test admin/scoring — only when 96136-96139 billed with 96130/96131; other details

ConditionAuth Required - Only if the admin/scoring codes (96136-96139) are submitted with psychological testing evaluation codes 96130 and 96131. No Auth Required - If the admin/scoring codes are submitted with neuropsychological testing evaluation codes 96132 and 96133.

Prior Authorization Requirements and Exceptions — Provider Responsibilities

Prior Authorization

Prior authorization requirements and exceptions

Providers must verify the services listed in this policy and obtain prior authorization from UnitedHealthcare Community Plan before delivering behavioral health services to New Jersey FamilyCare members. Out-of-network (non-participating) providers are required to secure prior authorization approval prior to providing behavioral health services. Prior authorization is not required for emergency services; however, emergency admissions still require notification to the plan.

Check the listed services and codes in this policy prior to providing care.
Out-of-network providers must obtain authorization before rendering services.
Emergency services are exempt from prior authorization, but emergency admissions require notification.

Key Definitions and Exceptions

Out-of-network provider prior authorization requirement

Out-of-network provider requirementAll out-of-network (non-participating) providers must obtain prior authorization approval before providing behavioral health services.

ScopeApplies to behavioral health services for UnitedHealthcare Community Plan members under New Jersey FamilyCare as listed in this notice.

TimingAuthorization must be obtained prior to providing the service; do not render services expecting retroactive approval for OON providers.

Emergency services and admission notification

Emergency services exceptionPrior authorization is not required when rendering emergency services.

Emergency admissions notificationEmergency admissions require notification to the plan despite the authorization exemption.

Provider actionProvide necessary emergency care without prior authorization and notify the plan per admission notification requirements.