CurrentOptumPolicy N/A

North Carolina Prior Authorization Requirements for UnitedHealthcare Exchange Plans - Behavioral Health

Lists behavioral health services and procedure codes that require prior authorization for UnitedHealthcare Exchange Plans members in North Carolina; applies to participating behavioral health providers.

Policy Summary

PayerOptum

PolicyNorth Carolina Prior Authorization Requirements for UnitedHealthcare Exchange Plans - Behavioral Health

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCProvider.com.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~90+procedure codes and revenue codes listed for prior authorization

NCgeographic applicability

2024-01-01effective date

Prior Authorization Requirements

Prior Authorization Required

Covered when ALL of the following are met:

Policy Summary

PayerOptum

PolicyNorth Carolina Prior Authorization Requirements for UnitedHealthcare Exchange Plans - Behavioral Health

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCProvider.com.

SourceLink

On This Page

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.

Procedure and Revenue Codes Requiring Prior Authorization

Inpatient Mental Health - Revenue CodesmixedCovered

Rev 114	Inpatient Mental Health (revenue codes)
Rev 124	Inpatient Mental Health (revenue codes)
Rev 134	Inpatient Mental Health (revenue codes)
Rev 144	Inpatient Mental Health (revenue codes)
Rev 154	Inpatient Mental Health (revenue codes)
Rev 204	Inpatient Mental Health (revenue codes)

Inpatient SUD Detoxification - Revenue CodesmixedCovered

Rev 116	Inpatient Substance Use Detoxification (hospital based) - Revenue Codes
Rev 126	Inpatient Substance Use Detoxification (hospital based) - Revenue Codes
Rev 136	Inpatient Substance Use Detoxification (hospital based) - Revenue Codes
Rev 146	Inpatient Substance Use Detoxification (hospital based) - Revenue Codes
Rev 156	Inpatient Substance Use Detoxification (hospital based) - Revenue Codes

SUD Rehabilitation - Revenue CodesmixedCovered

Rev 118	Substance Use Rehabilitation (hospital based) - Revenue Codes
Rev 128	Substance Use Rehabilitation (hospital based) - Revenue Codes
Rev 138	Substance Use Rehabilitation (hospital based) - Revenue Codes
Rev 148	Substance Use Rehabilitation (hospital based) - Revenue Codes
Rev 158	Substance Use Rehabilitation (hospital based) - Revenue Codes

Clinic / Treatment Room - Revenue CodesmixedCovered

Rev 513	Psychiatric Clinic - Revenue Code
Rev 761	Treatment Room - Revenue Code

OP Intensive/Partial - Revenue CodesmixedCovered

Rev 900	Evaluation/Initial-BH Treatments/Services - Revenue Code
Rev 905	MH Intensive Outpatient - Revenue Code
Rev 906	SUD Intensive Outpatient - Revenue Code
Rev 912	MH/SUD Partial Hospitalization - Revenue Codes
Rev 913	MH/SUD Partial Hospitalization - Revenue Codes

TMS, Biofeedback, Unlisted Psychiatry - CPTCPTCovered

90867	Therapeutic Repetitive Transcranial magnetic stimulation treatment; planning 1 VISIT
90868	Therapeutic Repetitive Transcranial magnetic stimulation treatment; delivery and management, per session 1 VISIT
90869	Therapeutic Repetitive Transcranial Magnetic Stimulation; subsequent motor threshold re-determination with delivery and management
90875	Individual psychophysiological therapy incorporating biofeedback training with psychotherapy (20-30 min)
90876	Individual psychophysiological therapy incorporating biofeedback training with psychotherapy (45-50 min)
90899	Unlisted psychiatric service or procedure

Psychological Testing - CPTCPTCovered

96130	Psychological testing evaluation
96131	Psychological testing evaluation (additional)
96136	Psych test admin & scoring by physician or QHP, two or more tests, first 30 minutes (auth required only if submitted with 96130/96131)
96137	Each additional 30 minutes for 96136
96138	Psych test admin & scoring by technician, two or more tests, first 30 minutes (auth required only if submitted with 96130/96131)
96139	Each additional 30 minutes for 96138
96146	Psych test admin with single automated standardized instrument via electronic platform

Behavioral/ABA-related Codes - CPT/HCPCSCPTCovered

97151	Behavior ID Assessment by PHYS/QHP EA 15 min
97152	Behavior ID Support Assessment by 1 Tech EA 15 min
97153	Adaptive Behavior Treatment by Protocol Tech EA 15 min
97154	Group Adaptive Behavior Treatment by Protocol Tech EA 15 min
97155	Adaptive Behavior Treatment Protocol Modification PHYS/QHP EA 15 min
97156	Family Adaptive Behavior Treatment Guidance PHYS/QHP EA 15 min
97157	Multiple Family Group Behavior Treatment Guidance PHYS/QHP EA 15 min
97158	Group Adaptive Behavior Protocol Modification PHYS/QHP EA 15 min
0362T	Behavior ID support assessment EA 15 min tech time
0373T	Adaptive behavior treatment protocol modification EA 15 min tech time

Digital Assessment / Unlisted E/M - CPTCPTCovered

98966	Qualified nonphysician health care professional online digital assessment and management, established patient, up to 7 days; 5-10 minutes
98967	Qualified nonphysician health care professional online digital assessment and management, established patient, up to 7 days; 11-20 minutes
98968	Qualified nonphysician health care professional online digital assessment and management, established patient, up to 7 days; 21 or more minutes
99499	Unlisted evaluation and management service

What Providers Must Do

Prior Authorization

Services requiring prior authorization

Prior authorization is required for the inpatient and outpatient behavioral health services and procedure/revenue codes listed in this policy for Exchange Plans members in North Carolina. Prior authorization is not required for emergency or urgent care.

Services include: inpatient mental health, inpatient SUD detoxification (hospital based), substance use rehabilitation (hospital based), psychiatric clinic, treatment room, evaluation/initial BH treatments/services, MH intensive outpatient, SUD intensive outpatient, MH/SUD partial hospitalization, outpatient behavioral health testing, other outpatient behavioral health treatments/services, drug/alcohol/combined rehabilitation, psychiatric, residential psychiatric treatment, residential chemical dependency treatment, therapeutic TMS services, psychological testing and test administration/scoring codes, behavior identification and adaptive behavior treatment codes, qualified nonphysician online digital assessment & management codes, and certain unlisted codes (see code lists).

Note

Exceptions & benefit limits

Do not require prior authorization for emergency or urgent behavioral health care; members may have no non-emergent out-of-network coverage or coverage outside the service area under these plans—verify the member's plan benefits.

Note

Submission route

Submit all prior authorization requests online using the Prior Authorization and Notification tool accessed via the Sign In function on UHCProvider.com.

Online submission required via Prior Authorization and Notification tool

Prior Authorization

Prior authorization requirement

Prior authorization must be obtained for the listed inpatient and outpatient behavioral health services and corresponding procedure/revenue codes before non-emergent services are provided; reference the member-specific benefit plan when making coverage determinations.

Provider must confirm member-specific benefits and service area restrictions
Prior auth not required for emergency or urgent care
A comprehensive list of affected procedure and revenue codes is included in the policy (e.g., Revenue codes: 114,124,134,144,154,204; 116,126,136,146,156; 118,128,138,148,158; 513; 761; 900; 905; 906; 912,913; 918; 919; 944; 945; 953; 961; 1001; 1002; CPT examples: 90867-90869, 90875-90876, 90899, 96130-96131, 96136-96139, 96146, 97151-97158, 0362T, 0373T, 98966-98968, 99499

Levels of Care Covered

Inpatient, Residential, PHP, IOP, Outpatient (as listed by service type)

Level-of-care services listed below require prior authorization when provided to Exchange Plans members in North Carolina.

Inpatient/Residential/PHP/IOP/Outpatient (by service type): Inpatient Mental Health (Rev 114, 124, 134, 144, 154, 204); Inpatient Substance Use Detoxification (hospital based) (Rev 116, 126, 136, 146, 156); Substance Use Rehabilitation (hospital based) (Rev 118, 128, 138, 148, 158); Psychiatric Clinic (Rev 513); Treatment Room (Rev 761); Evaluation/Initial-BH Treatments/Services (Rev 900); MH Intensive Outpatient (Rev 905); SUD Intensive Outpatient (Rev 906); MH/SUD Partial Hospitalization (Rev 912, 913); OP Services - Behavioral Health Testing (Rev 918); OP Services - Other Behavioral Health Treatment/Services (Rev 919); Drug Rehabilitation (Rev 944); Alcohol Rehabilitation (Rev 945); Combined Drug and Alcohol Rehabilitation (Rev 953); Psychiatric (Rev 961); Residential Treatment - Psychiatric (Rev 1001); Residential Treatment - Chemical Dependency (Rev 1002)

Prior authorization required prior to non-emergent care.

Specific Treatment Modalities

TMS

Therapeutic transcranial magnetic stimulation (TMS) services require prior authorization for Exchange Plans members in North Carolina.

TMS: Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS) codes 90867 (treatment planning), 90868 (delivery and management, per session), and 90869 (subsequent motor threshold re‑determination with delivery and management) require prior authorization when provided to Exchange Plans members in North Carolina.

Authorization must be obtained prior to non-emergent treatment.

Psychological Testing

Psychological and neuropsychological testing services require prior authorization for Exchange Plans members in North Carolina.

Psychological Testing: Psychological testing evaluation codes 96130 and 96131 require prior authorization. Test administration and scoring codes 96136-96139 and single-instrument automated code 96146 also require prior authorization; note that admin & scoring codes (96136-96139) require authorization only when submitted with 96130 or 96131.

Authorization required prior to non-emergent testing; admin/scoring codes require auth only if billed with 96130/96131 as specified.

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