CurrentOptumPolicy N/A

Kansas Prior Authorization Requirements for UnitedHealthcare Exchange Plans (Behavioral Health)

Lists behavioral health services and procedure/revenue/CPT codes that require prior authorization for participating behavioral health providers for UnitedHealthcare Exchange Plans in Kansas (inpatient and outpatient). Applies to non-emergent services and notes member-specific benefit plan terms vary by state.

Policy Summary

PayerOptum

PolicyKansas Prior Authorization Requirements for UnitedHealthcare Exchange Plans (Behavioral Health)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review Date

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCProvider.com for the listed behavioral health services for Exchange Plans members in Kansas.

POLICY UPDATE CHANGES

No material clinical/coverage changes

~50Listed Codes Requiring PA

KansasState Scope

Policy Summary

This policy lists behavioral health services and specific procedure/revenue/CPT codes that require prior authorization for UnitedHealthcare Exchange Plans members in Kansas. Effective January 1, 2024, it applies to the inpatient and outpatient services enumerated in the code lists and is current. The rule requires prior authorization for the listed behavioral health services for Exchange Plans members in Kansas, except for emergency or urgent care. Members have no non-emergent out-of-network coverage and no coverage outside of the service area, and coverage decisions remain subject to the member-specific benefit plan terms.

Codes: Services Requiring Prior Authorization

Inpatient Mental Health - Revenue CodesRevenue

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

Inpatient Substance Use Detoxification (hospital based) - Revenue CodesRevenue

116	Substance Use Detox (Rev 116)
126	Substance Use Detox (Rev 126)
136	Substance Use Detox (Rev 136)
146	Substance Use Detox (Rev 146)
156	Substance Use Detox (Rev 156)

Substance Use Rehabilitation (hospital based) - Revenue CodesRevenue

118	SUD Rehab (Rev 118)
128	SUD Rehab (Rev 128)
138	SUD Rehab (Rev 138)
148	SUD Rehab (Rev 148)
158	SUD Rehab (Rev 158)

Psychiatric Clinic / Treatment Room / Evaluation - Revenue CodesRevenue

513	Psychiatric Clinic (Rev 513)
761	Treatment Room (Rev 761)
900	Evaluation/Initial BH Treatments/Services (Rev 900)

Intensive Outpatient / Partial Hospitalization - Revenue CodesRevenue

905	MH Intensive Outpatient (Rev 905)
906	SUD Intensive Outpatient (Rev 906)
912	MH/SUD Partial Hospitalization (Rev 912)
913	MH/SUD Partial Hospitalization (Rev 913)

Outpatient Behavioral Health Testing / Other BH Treatment - Revenue CodesRevenue

918	OP Services - Behavioral Health Testing (Rev 918)
919	OP Services - Other Behavioral Health Treatment/Services (Rev 919)

Rehabilitation / Residential Treatment - Revenue CodesRevenue

944	Drug Rehabilitation (Rev 944)
945	Alcohol Rehabilitation (Rev 945)
953	Combined Drug and Alcohol Rehabilitation (Rev 953)
961	Psychiatric (Rev 961)
1001	Residential Treatment - Psychiatric (Rev 1001)
1002	Residential Treatment - Chemical Dependency (Rev 1002)

Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS) - CPTCPT

90867	TMS treatment; planning, 1 visit
90868	TMS treatment; delivery and management, per session, 1 visit
90869	TMS treatment; subsequent motor threshold re-determination with delivery and management, 1 visit

Unlisted Psychiatric / E/M - CPTCPT

90899	Unlisted psychiatric service or procedure
99499	Unlisted evaluation and management service

Psychological Testing and Test Administration/Scoring - CPTCPT

96130	Psychological testing evaluation
96131	Psychological testing evaluation
96136	Psychological or neuropsych test admin & scoring by physician/QHP, two+ tests, first 30 minutes (Auth required only if submitted with 96130 & 96131)
96137	Each additional 30 minutes (Auth required only if submitted with 96130 & 96131)
96138	Test admin & scoring by technician, two+ tests, first 30 minutes (Auth required only if submitted with 96130 & 96131)
96139	Each additional 30 minutes by technician (Auth required only if submitted with 96130 & 96131)
96146	Computer based psychological/neuropsychological testing

Behavioral Health Adaptive / Behavior ID / Family / Group Therapy - CPT and Category IIImixed

97151	Behavior ID Assessment by PHYS/QHP EA 15 min
97152	Behavior ID Support Assessment by tech EA 15 min
97153	Adaptive behavior tx by protocol tech EA 15 min
97154	Group adaptive behavior tx by protocol tech EA 15 min
97155	Adaptive behavior tx protocol modification PHYS/QHP EA 15 min
97156	Family adaptive behavior tx guidance PHYS/QHP EA 15 min
97157	Multiple family group behavior tx 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 (Category III)
0373T	Adaptive behavior tx protocol modification EA 15 min tech time (Category III)

Qualified Nonphysician Online Digital Assessment and Management - CPTCPT

98966	QNHP online digital assessment & management, established patient, up to 7 days, 5-10 minutes
98967	QNHP online digital assessment & management, established patient, up to 7 days, 11-20 minutes
98968	QNHP online digital assessment & management, established patient, up to 7 days, 21+ minutes

What Providers Must Do

Prior Authorization

Submit prior authorization for listed services

Providers must submit prior authorization requests online via the Prior Authorization and Notification tool on UHCProvider.com for the listed behavioral health services for Exchange Plans members in Kansas.

Documentation Required

Reference member-specific benefit plan

When deciding coverage, providers must reference the member-specific benefit plan document because terms vary by state.

Denial Risk

No prior authorization for emergency/urgent care

Prior authorization is not required for emergency or urgent care; non-emergent out-of-network or out-of-area services are not covered for these benefit plans and may be denied.

Non-emergent out-of-network or out-of-area services may be denied.

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

OpenPayer

Kansas Prior Authorization Requirements for UnitedHealthcare Exchange Plans (Behavioral Health)

Policy Summary

Prior Authorization Requirement

Codes: Services Requiring Prior Authorization

What Providers Must Do

Key Definitions

Policy Revision History