Prior authorization for behavioral health services
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This document lists behavioral health services that require prior authorization for UnitedHealthcare Community Plan of Wisconsin Medicaid Managed Care members and explains exceptions (emergency services and in-network rules). It affects participating and out-of-network behavioral health providers serving Wisconsin Medicaid Managed Care members.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
Prior authorization coverage criteria
Prior authorization is required for the listed behavioral health services and codes. Emergency services are excluded; community-based adult day treatment codes are generally not prior authorized unless the provider is identified as an outlier and subject to clinical review.
Services requiring prior authorization
- Psychiatric inpatient mental health; private room (Revenue Code 114).
- Inpatient detoxification; private room (Revenue Code 116).
- Psychiatric inpatient mental health; semi-private room (Revenue Code 124).
- Inpatient substance use detoxification; semi-private room (Revenue Code 126).
- Psychiatric inpatient mental health; 3-4 beds (Revenue Code 134).
- Inpatient substance use detoxification; 3-4 beds (Revenue Code 136).
- Psychiatric inpatient mental health; ward (Revenue Code 154).
- Psychiatric inpatient mental health intensive care (Revenue Code 204).
- Intensive psychiatric outpatient services requiring HCPCS S9480 (Revenue Code 905).
- Intensive SUD outpatient services requiring HCPCS H0015 (Revenue Code 906).
- Day treatment for children and adolescents (H2012 with HA modifier).
- Intensive Outpatient (IOP) — mental health (non-hospital/non-psych hospital) (H2019).
- Intensive Outpatient (IOP) — SUD (non-hospital/non-psych hospital) (H2019).
- Psychological testing evaluation; first hour (96130).
- Psychological testing evaluation; each additional hour (96131).
- Therapeutic repetitive transcranial magnetic stimulation (TMS) — planning; 1 visit (90867).
- Therapeutic repetitive TMS treatment — delivery and management; per session (90868).
- Unlisted psychiatric service (90899).
Exceptions
- Emergency services do not require prior authorization.
- Out-of-network (non-participating) providers must obtain prior authorization approval before providing behavioral health services (emergencies excluded).
Codes generally not subject to prior authorization (but subject to outlier review)
- Adult Day treatment; mental health (H2012 with HE modifier) — generally not subject to prior authorization but may be clinically reviewed if provider is an outlier.
- Adult Day treatment; SUD (H2012 with HF modifier) — generally not subject to prior authorization but may be clinically reviewed if provider is an outlier.
Providers identified as utilization outliers by claims data may be subject to clinical review to assess whether continued care is medically necessary.
Revenue, CPT/HCPCS and Other Codes
| 114 | Revenue Code – Psychiatric inpatient mental health; private room |
| 116 | Revenue Code – Inpatient detoxification; private room |
| 124 | Revenue Code – Psychiatric inpatient mental health; semi-private room |
| 126 | Revenue Code – Inpatient substance use detoxification; semi-private room |
| 134 | Revenue Code – Psychiatric inpatient mental health; 3-4 beds |
| 136 | Revenue Code – Inpatient substance use detoxification; 3-4 beds |
| 154 | Revenue Code – Psychiatric inpatient mental health; ward |
| 204 | Revenue Code – Psychiatric inpatient mental health intensive care |
| 905 | Revenue Code – Intensive psychiatric outpatient services (HCPCS S9480) |
| 906 | Revenue Code – Intensive SUD outpatient services (HCPCS H0015) |
Provider Requirements and Authorization Process
General prior authorization requirements
Providers must check the listed services before providing care. All out-of-network (non‑participating) providers must obtain prior authorization approval before providing behavioral health services. Prior authorization is not required for emergency services. For additional guidance, see the Optum Behavioral Health National Network Manual, the UnitedHealthcare Community Plan of Wisconsin Care Provider Manual (Chapter 7), and prior authorization submission instructions. If you have questions, call the Customer Service number on the back of the member's ID card.
Codes requiring prior authorization
The following revenue, HCPCS and CPT codes require prior authorization for behavioral health services: inpatient psychiatric and detox services (various room types and levels of care), intensive outpatient and day treatment programs, psychological and neuropsychological testing codes, therapeutic repetitive transcranial magnetic stimulation (TMS) codes, and unlisted psychiatric services. Providers must obtain prior authorization before billing these codes.
- Revenue Code 114 — Psychiatric inpatient mental health; private room
- Revenue Code 116 — Inpatient detoxification; private room
- Revenue Code 124 — Psychiatric inpatient mental health; semi‑private room
- Revenue Code 126 — Inpatient substance use detoxification; semi‑private room
- Revenue Code 134 — Psychiatric inpatient mental health; 3‑4 beds
- Revenue Code 136 — Inpatient substance use detoxification; 3‑4 beds
- Revenue Code 154 — Psychiatric inpatient mental health; ward
- Revenue Code 204 — Psychiatric inpatient mental health intensive care
- HCPCS S9480 — Intensive psychiatric outpatient services (Revenue Code 905)
- HCPCS H0015 — Intensive substance use disorder outpatient services (Revenue Code 906)
- H2012 with HA modifier — Day treatment for children and adolescents
- H2019 — Intensive Outpatient (IOP); mental health (non‑hospital or non‑psych hospital)
- H2019 — Intensive Outpatient (IOP); SUD (non‑hospital or non‑psych hospital)
- CPT 96130 — Psychological testing evaluation; first hour
- CPT 96131 — Psychological testing evaluation; each additional hour
- CPT 96136 — Psychological and neuropsychological testing administration/scoring (when billed with 96130 or 96131)
- CPT 96137 — Psychological and neuropsychological testing administration/scoring (when billed with 96130 or 96131)
- CPT 96138 — Psychological and neuropsychological testing administration/scoring (when billed with 96130 or 96131)
- CPT 96139 — Psychological and neuropsychological testing administration/scoring (when billed with 96130 or 96131)
- CPT 90867 — Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; planning; 1 visit
- CPT 90868 — Therapeutic repetitive TMS treatment; delivery and management; per session; 1 visit
- CPT 90899 — Unlisted psychiatric service
Outlier clinical review
Certain community‑based outpatient services are generally not subject to prior authorization but may be clinically reviewed if a provider is identified as an outlier based on higher utilization determined from claims data. Outlier review assesses whether continued care is medically necessary.
Key Definitions
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