CurrentOptumPolicy N/A

Behavioral Health Prior Authorization Code List — TennCare and CoverKids

Lists behavioral health services and billing codes that require prior authorization for Tennessee TennCare and CoverKids members served by UnitedHealthcare Community Plan; applies to inpatient stays, out-of-network providers, TMS, ABA, residential, and related services.

Policy Summary

PayerOptum

PolicyBehavioral Health Prior Authorization Code List — TennCare and CoverKids

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for the listed behavioral health codes and for all inpatient stays and out-of-network providers; emergency services are exempt.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+behavioral health service codes listed for prior authorization

All inpatient staysrequire prior authorization

Out-of-networknon-participating providers require authorization

Emergency servicesdo not require prior authorization

Coverage Criteria Summary

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing Codes Requiring Prior Authorization

Room and board / bed-related codesmixedCovered

114	Psychiatric, room and board - private room
116	Detoxification, room and board - private room
118	Rehabilitation, room and board - private room
120	Room and board - semi-private room
124	Psychiatric, room and board - semi-private room, two beds
126	Detoxification, room and board - semi-private room, two beds
128	Rehabilitation, room and board - semi-private room, two beds
134	Psychiatric, room and board - three and four beds
136	Detoxification, room and board - semi-private room, three and four beds
138	Rehabilitation, room and board - semi-private room, three and four beds

1–10 of 19

1/2

Subacute and intensive caremixedCovered

190	Subacute care - General
191	Subacute care - Level 1
192	Subacute care - Level 2
193	Subacute care - Level 3
194	Subacute care - Level 4
199	Other subacute care
203	Intensive care-Pediatric
204	Intensive care-Psychiatric

Behavioral health accommodations / residentialmixedCovered

1001	Behavioral health accommodations - Residential treatment, Psychiatric
1002	Behavioral health accommodations - Residential treatment, Chemical dependency
1003	Behavioral health accommodations - Supervised living
1004	Halfway house
1005	Group home

TMS codesCPTCovered

90867	Therapeutic repetitive transcranial magnetic stimulation (TMS) planning, 1 visit
90868	Therapeutic repetitive TMS; delivery and management, per session
90869	Therapeutic repetitive TMS; subsequent motor threshold re-determination with delivery and management

Applied Behavioral Analysis (ABA) codesCPTCovered

97151	ABA - Behavior identification assessment (physician or qualified professional), per 15 minutes
97152	ABA - Behavior identification supporting assessment (technician), per 15 minutes
97153	ABA - Adaptive behavior treatment by protocol (technician), per 15 minutes
97154	ABA - Group adaptive behavior treatment by protocol, per 15 minutes
97155	ABA - Adaptive behavior treatment with protocol modification (physician or qualified professional), per 15 minutes
97156	ABA - Family adaptive behavior treatment guidance, per 15 minutes
97157	ABA - Multiple-family group adaptive behavior treatment guidance, per 15 minutes
97158	ABA - Group adaptive behavior treatment with protocol modification
0362T	ABA - Behavior identification supporting assessment (technicians), per 15 minutes
0373T	ABA - Adaptive behavior treatment with protocol modification (technicians), per 15 minutes

Behavioral health HCPCS/H codes and other servicesmixedCovered

G9002	Coordinated care fee, maintenance rate
H0018	Behavioral health; short-term residential (nonhospital residential treatment program), without room and board, per diem
H0025	Alcohol and/or drug prevention
H0036	Community psychiatric supportive treatment, face-to-face, per 15 min
H0037	Community psychiatric supportive treatment program, per diem
H0043	Supported housing, per diem
H2015	Comprehensive community support services, per 15 minutes
T2048	Behavioral health; long-term care community based psychiatric residential treatment facility (non-acute care) in a residential program, per diem

inv-08: Authorization required for inpatient stays

Authorization requirementAll inpatient stays require prior authorization.

Applies toAll inpatient stays for TennCare and CoverKids members.

Out-of-network providersAll out-of-network (non-participating) providers require authorization.

What Providers Must Do

Prior Authorization

Prior Authorization Required for Listed Codes

The table below outlines the behavioral health services that require prior authorization for the Tennessee TennCare (Medicaid) and CoverKids contracts. Please check this list before you provide services to UnitedHealthcare Community Plan members. Additional information about prior authorization for behavioral health services can be found in the UnitedHealthcare Community Plan of Tennessee Care Provider Manual (Chapter 9). If you have additional questions, please call the Customer Service number on the back of the member's ID card. Note: Prior authorization is not required for emergency services.

All out-of-network (non-participating) providers require prior authorization.
All inpatient stays require prior authorization.
Prior authorization is not required when rendering emergency services.
Prior authorization is not required for IDD/ICF Bill Type 66x for certain room-and-board semi-private room services (see code list).

Prior Authorization

Prior authorization is required for the codes below

Prior authorization is required for the behavioral health codes listed in the policy code list (includes, but is not limited to: room and board psychiatric/detoxification/rehabilitation codes; supervised living, halfway house, group home; TMS codes 90867–90869; extensive Applied Behavior Analysis (ABA) codes 97151–97158, 0362T, 0373T; coordinated care fee G9002; short-term residential H0018; H0036/H0037/H0043/H2015/T2048; and others). Prior authorization is required for all inpatient stays and for services provided by out-of-network providers. Failure to obtain prior authorization for these services may result in claim denial or nonpayment.

Examples of codes that require prior authorization (not exhaustive): 114, 116, 118, 120, 124, 126, 128, 1003, 1004, 1005, 90867, 90868, 90869, 97151–97158, 0362T, 0373T, G9002, H0018, H0025, H0036, H0037, H0043, H2015, T2048.

Note

Provider resources

Providers should refer to the UnitedHealthcare Community Plan of Tennessee Care Provider Manual (Chapter 9) for detailed prior authorization procedures, submission instructions, and any service-specific documentation requirements. If you have questions about coverage or the authorization process, contact the plan's Customer Service number found on the member's ID card.

Check the UnitedHealthcare Community Plan of Tennessee Care Provider Manual (Chapter 9) for authorization procedures.
Call Customer Service on the member's ID card for questions.

Denial Risk

Prior authorization required — Denial Risk

Failure to obtain prior authorization for the listed behavioral health services — including all inpatient stays and services provided by out-of-network providers — may result in denial of the claim or nonpayment. Always verify authorization requirements before rendering non-emergency services.

Denial risk applies to inpatient stays and out-of-network provider services without prior authorization.
Confirm prior authorization and document authorization numbers on claims to reduce denial risk.

Definitions

inv-14: Psychiatric Residential Treatment Facility

TermPsychiatric Residential Treatment Facility (PRTF)

Related codesPRTF hospital leave day (Billing Code = 185); bed hold and therapeutic leave days are listed in room/board codes.

NotesPrior authorization is required for PRTF-related services unless otherwise noted (see IDD/ICF bill type exceptions in source).

inv-15: Applied Behavioral Analysis (ABA)

Included CPT/HCPCS codes97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T.

Assessment codes97151 (behavior identification assessment - physician/qualified professional), 97152 (supporting assessment - technician), 0362T (technician supporting assessment).

Treatment codes97153, 97154, 97155, 97156, 97157, 97158, 0373T (adaptive behavior treatment and protocol modification codes for professionals and technicians).

OpenPayer

Behavioral Health Prior Authorization Code List — TennCare and CoverKids

Coverage Criteria Summary

Billing Codes Requiring Prior Authorization

What Providers Must Do

Background and Scope

Definitions

Level of Care Mapping

ABA Prior Authorization Criteria

Treatment Modalities

Visit Limits and Quantity Rules