Prior authorization for behavioral health services
Customize your policy alerts
Sign up for all Optum policy alerts
Know when Optum releases new policies or updates existing guidance.
Monitor payer policy activity
This document lists behavioral health services and procedure codes that require prior authorization for UnitedHealthcare Community Plan members in the Washington Integrated Medicaid Managed Care contract, and applies to participating and non-participating providers delivering these services in Washington state.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
Prior authorization coverage stance
Prior authorization required for the listed behavioral health service codes. See Care Provider Manual Chapter 7 for further authorization process and criteria.
Procedure codes requiring prior authorization
- 114 — Inpatient psychiatric / private room
- 116 — Inpatient detoxification / private room
- 124 — Inpatient psychiatric / semiprivate room
- 126 — Inpatient detoxification / semiprivate room
- 134 — Inpatient psychiatric / 3-4 beds room
- 144 — Inpatient psychiatric / private deluxe room
- 154 — Inpatient psychiatric / ward room
- 169 — Administratively necessary day services
- 191 — Administratively necessary day services
- 204 — Inpatient hospital intensive care - Psychiatric
- 907 — Community behavioral health program, day treatment
- 912 — Partial hospital care
- 1001 — Residential treatment - Psychiatric
- 1002 — Residential treatment - Chemical dependency
- 90867 — Transcranial magnetic stimulation (TMS)
- 90868 — Therapeutic repetitive TMS treatment; subsequent delivery and management, per session
- 90869 — Therapeutic repetitive TMS treatment; subsequent motor threshold re-determination with delivery and management
- 97153 — Adaptive behavioral treatment by protocol technician; 15 minutes
- 97154 — Group adaptive behavioral treatment by protocol technician; 15 minutes
- H0010 — Alcohol and/or drug sub-acute detoxification: residential addiction program inpatient
- H0011 — Alcohol and/or drug acute detoxification: residential addiction program inpatient
- H0017 — Behavioral health; residential (hospital residential treatment program), without room and board, per diem
- H0018 — Short term residential nonhospital residential program, without room and board
- H0019 — Behavioral health long-term residential
- H0035 — Mental health partial hospitalization, treatment; less than 24 hours
- H2012 — Behavioral health day treatment; per hour
- H2020 — Therapeutic behavioral services; per diem
- H2022 — Community-based wrap-around services, per diem
- S5126 — Attendant care services
- T2048 — Behavioral health: long-term care residential (non-acute care in a residential treatment program where stay is typically longer than 30 days)
Behavioral Health Procedure Codes
| 114 | Inpatient psychiatric / private room |
| 116 | Inpatient detoxification / private room |
| 124 | Inpatient psychiatric / semiprivate room |
| 126 | Inpatient detoxification / semiprivate room |
| 134 | Inpatient psychiatric / 3-4 beds room |
| 144 | Inpatient psychiatric / private deluxe room |
| 154 | Inpatient psychiatric / ward room |
| 169 | Administratively necessary day services |
| 191 | Administratively necessary day services |
| 204 | Inpatient hospital intensive care - Psychiatric |
Provider Requirements and Action Items
Prior authorization requirement overview
Providers must check the listed behavioral health services before providing care to UnitedHealthcare Community Plan members. 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. For additional authorization details, see the UnitedHealthcare Community Plan of Washington Care Provider Manual (Chapter 7) or call the Customer Service number on the member's ID card.
- Check the listed services prior to providing care.
- Out-of-network providers: obtain prior authorization before providing behavioral health services.
- Emergency services: prior authorization not required.
Procedure codes requiring prior authorization
The following procedure codes require prior authorization under this contract. Providers must obtain authorization for these services before delivery (except in emergencies).
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.