Prior Authorization Requirements for New Jersey FamilyCare Behavioral Health Services
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This document lists behavioral health services and procedure codes that require prior authorization for New Jersey FamilyCare (UnitedHealthcare Community Plan of NJ) members and provides notes on exceptions and where to find additional guidance. It affects participating and non-participating behavioral health providers serving NJ FamilyCare members.
No material clinical or coverage changes in this revision.
Services Requiring Prior Authorization
Prior authorization required services
Prior authorization is required for the behavioral health services and procedure/revenue codes listed below. Exceptions: out-of-network (non‑participating) providers must obtain prior authorization before providing services; emergency services do not require prior authorization (emergency admissions require notification).
Inpatient services
- Mental health (MH) - Inpatient: Revenue codes 100, 114, 124, 134, 144, 154, 204.
- Substance use disorder (SUD) - Inpatient withdrawal management (ASAM 4.0): Revenue codes 116, 126, 136, 146, 156.
Partial hospital / Intensive services
- SUD - Intensive Outpatient: Revenue code 906 / Procedure Code H0015.
- Mental health - Partial hospital (Adult): Revenue code 912.
- Mental health - Acute partial hospital (Adult): Revenue code 913.
- Mental health - Partial hospital (Under 18): Revenue code 913.
Outpatient SUD and related procedures
Outpatient mental health procedures
- Mental health - Partial care: Procedure Code H0035.
Psychological and neuropsychological testing
- Psychological and neuropsychological test administration/scoring: Procedure Codes 96136, 96137, 96138, 96139. Note: authorizaton required for admin/scoring codes only if submitted with psychological testing evaluation codes 96130 and 96131; no authorization required for admin/scoring when submitted with neuropsychological testing evaluation codes 96132 and 96133.
Health behavior intervention and related assessment codes
- Initial assessment, treatment planning, reassessment and progress reporting / supervision codes: Procedure Code 96156 EP (including supervision when billed with modifier 26; must be face-to-face).
ABA / Behavior identification and adaptive behavior treatment codes
- Behavior identification assessment (physician or other QHP), each 15 minutes: Procedure Code 97151.
- Behavior identification supporting assessment by one technician under direction of QHP: Procedure Code 97152.
- Adaptive behavior treatment with protocol modification (physician or other QHP), face-to-face with one patient, every 15 minutes: Procedure Code 97155.
- Behavior identification supporting assessment by technicians, every 15 minutes requiring specified components: Procedure Codes 0362T and 0373T (components include physician or QHP on site, assistance of two or more technicians, patient exhibits destructive behavior, completed in a customized environment).
Procedure, Revenue, and Behavior Codes
| 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 |
| 146 | SUD - Inpatient withdrawal management - ASAM 4.0 |
| 156 | SUD - Inpatient withdrawal management - ASAM 4.0 |
| 96130 | Psychological testing evaluation - administered to the patient |
| 96131 | Psychological testing evaluation - administered to the patient (each additional) |
| 96136 | Psychological and neuropsychological testing administration/scoring by technician |
| 96137 | Psychological and neuropsychological testing administration/scoring by computer |
| 96138 | Psychological and neuropsychological testing administration/scoring with interpretation and report |
| 96139 | Psychological and neuropsychological testing administration/scoring with interpretation and report (each additional) |
| 90867 | TMS initial including mapping and motor threshold determination |
| 90868 | TMS subsequent delivery and management, per session |
| 90869 | Transcranial magnetic stimulation |
| H2036 | Outpatient SUD Partial Care: ASAM 2.5 |
| 97151 | Behavior identification assessment by physician/other qualified healthcare professional |
| 97152 | Behavior identification supporting assessment by technician |
| 97153 | Adaptive behavior treatment by protocol - technician, 15 min |
| 97154 | Group adaptive behavior treatment by protocol - technician, per group/15 min |
| 97155 | Adaptive behavior treatment with protocol modification by QHP, 15 min |
| 97156 | Family adaptive behavior treatment guidance by QHP, 15 min |
| 97157 | Multiple-family group adaptive behavior treatment guidance, 15 min |
| 97158 | Group adaptive behavior treatment with protocol modification, 15 min |
| 0362T | Behavior identification supporting assessment - intensive technician time, per 15 min (destructive behavior, multi-technician, QHP on site) |
| 0373T | Adaptive behavior treatment with protocol modification - intensive technician time, per 15 min (destructive behavior, multi-technician, QHP on site) |
Provider Requirements and Callouts
Prior Authorization Overview and Exceptions
All out-of-network (non-participating) providers must obtain prior authorization approval before providing behavioral health services. Prior authorization is not required when rendering emergency services; however, emergency admissions require notification. If you have questions, call the Customer Service number on the back of the member's ID card.
- Out-of-network providers: Prior authorization required before services.
- Emergency services: No prior authorization required, but emergency admissions require notification.
Codes Requiring Prior Authorization
The following procedure, CPT, HCPCS and revenue codes and service categories require prior authorization. Review this list before providing services.
- Inpatient Mental Health: Revenue codes 100, 114, 124, 134, 144, 154, 204.
- Inpatient SUD withdrawal management (ASAM 4.0): Revenue codes 116, 126, 136, 146, 156.
- SUD Intensive Outpatient: Revenue code 906 / HCPCS H0015.
- Partial Hospital / Acute Partial Hospital (Adult and Under 18): Revenue codes 912, 913.
- Outpatient SUD Partial Care (ASAM 2.5): Procedure code H2036.
- Outpatient SUD Ambulatory Withdrawal Management (ASAM 2.0-WM): Procedure codes 944, 945 / HCPCS H0014.
- Mental health Partial Care: Procedure code H0035.
- Therapeutic repetitive transcranial magnetic stimulation (TMS): Initial 90867; Subsequent 90868; 90869.
- Psychological testing evaluation: Procedure codes 96130, 96131 (authorization required).
- Psychological/neuropsych testing administration/scoring: Procedure codes 96136, 96137, 96138, 96139 — Auth required only when submitted with 96130/96131.
- No auth required for administration/scoring when submitted with neuropsych eval codes 96132 and 96133.
- Initial assessment / treatment plan & reassessment: Procedure code 96156 EP (includes supervision codes 26 when applicable).
- Health behavior intervention (individual/group/family) and add-on codes: 96158 EP, 96159 EP, 96164 EP, 96165 EP, 96167 EP, 96168 EP, 96170 EP, 96171 EP.
- Behavior identification assessment & related services: Procedure codes 97151, 97152, 0362T (supporting assessment), 97153, 97154, 97155, 97156, 97157, 97158, 0373T — prior authorization required for these behavior/ABA-related services as specified.
Program and ASAM Level References
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