CurrentOptumPolicy N/A

Treatment Review & Authorization Request — Medicaid Rehab Option (MRO) Authorization Form

This document is an authorization request and review form used by Medicaid managed care organizations for behavioral health rehabilitation services (e.g., ACT, Psychosocial Rehabilitation/Day Rehab, Community Support, Psychiatric Residential Rehab) in Nebraska; it guides providers on information required for initial and re-authorization requests.

Policy Summary

PayerOptum

PolicyTreatment Review & Authorization Request — Medicaid Rehab Option (MRO) Authorization Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization and required clinical documentation when requesting Assertive Community Treatment (ACT) or Psychiatric Residential Rehabilitation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

H0040, H2017/H2018, H2015, H0019service codes listed for authorization requests

Nebraskagoverning state

Routine 14d / Urgent 72hrequest turnaround

ACT & PRRprior auth required

Authorization Clinical Criteria

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Clinical information required for authorization

Authorization requests should include the following clinical content to support medical necessity:

Required clinical elements: Provide current psychiatric and medical diagnoses; current medications (name, dose, frequency, prescriber); justification for authorization/why now (attach treatment history and current clinical documentation); expectation for improvement on treatment plan goals; discharge/transition plan; inpatient admissions in the last 90 days; date of last assessment/authorization; significant changes since last assessment; level of engagement/motivation and supports (family/caregiver involvement); referral to clinical care coordination when applicable.

Form includes checkboxes and fields prompting for these elements for initial and re-authorization requests.

In-scope behavioral health services (ACT, Psychosocial Rehab/Day Rehab, Community Support, Psychiatric Residential Rehab)

Services listed on the form and the MCO prior authorization expectations:

In-scope services: Assertive Community Treatment (ACT); Psychosocial Rehabilitation Services (Day Rehab); Community Support Services; Psychiatric Residential Rehabilitation.

Providers must specify service code, number of units, frequency, and weeks being requested; re-authorization requires completion of the 'Treatment Review' section documenting units used and appointments attended since last authorization.

Prior authorization notes: ACT and Psychiatric Residential Rehab require prior authorization and concurrent request by all MCOs. Psychosocial Rehabilitation and Community Support may require prior authorization depending on the MCO (WellCare requires prior auth; UHCCP and Nebraska Total Care may not).

Service-specific codes are listed on the form and must be used when requesting authorization.

ACT, Psychosocial Rehabilitation (Day Rehab), Community Support, Psychiatric Residential Rehab

When requesting these services, complete the service-specific fields on the form:

Service request fields: Specify service code, number of units, frequency, and weeks being requested; use the service codes shown for each modality (ACT: H0040 or H0040-52; Psychosocial Rehab: H2017 or H2018; Community Support: H2015 variants; Psychiatric Residential Rehab: H0019-HE).

Form contains blank fields for units and frequency; no fixed visit limits are specified.

Re-authorization requirements: For re-authorizations complete the 'Treatment Review' section: document number of appointments attended since last authorization, types of services and units/encounters used (including ACT, Psych Res Rehab, PRS/Day Rehab, Peer Support, Community Support), and treating provider signature and date.

This information supports continued medical necessity review.

Submission, Documentation, and Prior Authorization

Note

Administrative / Member / Provider Information

Provider(s) Information Program/Facility/Contact Person: __________ Phone #: __________ Rendering Provider: __________ NPI#: __________ Facility Information Name: __________ Medicaid Provider #: __________ NPI: __________ Member Information Name: __________ Date of Birth: __________ Nebraska Medicaid #: __________ Address: __________ Mobile Phone #: __________ Home Phone #: __________ Additional Contact: __________ Relationship: __________ Phone #: __________

Complete provider, facility, and member identifying information on all submissions.
Include Rendering Provider NPI and Medicaid Provider number to avoid processing delays.
Provide at least one member contact phone number and an alternate contact when available.

Documentation Required

Required Clinical Documentation

Current Diagnoses (psychiatric, substance use, medical), current medications (name, dose, frequency, prescriber), justification for authorization, treatment goals/expectations, discharge/transition plan, recent inpatient admissions, date of last assessment/authorization, and any significant life changes.

Attach treatment history and current clinical documentation to support the authorization request.
List all current medications with prescriber and dosing; if none, indicate 'None'.
Document expectation for improvement and discharge/transition planning.

Prior Authorization

Prior Authorization Requirements

Treatment Request: indicate service requested, service code, number of units, frequency (weeks), and duration. For re-authorizations complete the Treatment Review section showing units used and appointments attended since last authorization. Treating provider signature and date required on re-authorization requests.

Assertive Community Treatment (H0040 or H0040-52) — Prior authorization and concurrent request required by all MCOs.
Psychosocial Rehabilitation Services (H2017 or H2018) — UHCCP and NTC: no prior auth required; WellCare: prior auth required.
Community Support (H2015-HE, H2015-HF) — UHCCP and NTC: no prior auth required; WellCare: prior auth required.
Psychiatric Residential Rehab (H0019-HE) — Prior authorization and concurrent request required by all MCOs.

Note

MCO Submission Procedure

Managed Care Organization submission contacts and authorization date fields: include Authorization Start Date and End Date on forms. Use the appropriate MCO fax/submit channel for the member's plan to avoid delays.

UnitedHealthcare Community Plan Fax: 1-844-881-4926
Nebraska Total Care Fax: 1-866-593-1955
WellCare Outpatient Submissions Fax: 1-855-279-3683; Inpatient Submissions: 1-877-849-5071

Key Program Definitions

Assertive Community Treatment (ACT)

DefinitionAssertive Community Treatment (ACT) is a community-based intensive treatment service billed with H0040 or H0040-52 and requires prior authorization and a concurrent request from all MCOs.

Billing codesH0040; H0040-52 (Assertive Community Treatment)

Authorization requirementPrior Authorization and Concurrent Request required by all MCOs as indicated on the form.

Psychosocial Rehabilitation (Day Rehab)

DefinitionPsychosocial Rehabilitation (Day Rehab) refers to programmatic day rehabilitation services referenced with HCPCS codes H2017 or H2018.

Billing codesH2017; H2018 (Psychosocial Rehabilitation Services)

Authorization notePrior authorization requirements vary by MCO: WellCare requires prior authorization; UHCCP and Nebraska Total Care (NTC) do not require prior authorization for this service per the form.

Policy Context

This form is the Medicaid Rehab Option (MRO) Treatment Review & Authorization Request used by Nebraska Medicaid managed care organizations to request initial authorizations, clinical assessments/plan of care, and re-authorizations for behavioral health rehabilitation services. It captures administrative/member/provider details, the type of request (initial vs re-authorization), and the urgency category with turnaround expectations of Routine (up to 14 days) or Urgent (within 72 hours).

The form collects clinical information that supports medical necessity determinations, including current psychiatric and medical diagnoses; current medications (name, dose, frequency, prescriber); justification for authorization/why now; expectation for improvement; discharge/transition plan; recent inpatient admissions, and prompts to attach treatment history and current clinical documentation. It also documents treatment engagement factors such as motivation, supports, and recent service use to inform admission, continued stay, and discharge decisions.

Service requests on the form cover in-scope behavioral health modalities — Assertive Community Treatment (ACT), Psychosocial Rehabilitation (Day Rehab), Community Support, and Psychiatric Residential Rehabilitation — and require providers to specify the service code, number of units, frequency, and weeks requested. The form indicates which services require prior authorization: ACT and Psychiatric Residential Rehab require prior authorization and a concurrent request by all MCOs, while prior authorization requirements for Psychosocial Rehabilitation and Community Support vary by MCO.

Providers must complete the form fields and attach supporting clinical documentation (treatment history, treatment plan, assessments) and administrative information (provider/facility contact, rendering provider NPI, Medicaid provider number, member identifiers) to enable authorization review. For re-authorizations, the form requires reporting of services and units used since the last authorization and the treating provider’s signature on the Treatment Review section.

OpenPayer

Treatment Review & Authorization Request — Medicaid Rehab Option (MRO) Authorization Form

Authorization Clinical Criteria

Service Codes and Billing

Submission, Documentation, and Prior Authorization

Key Program Definitions

Units, Frequency, and Limits

Policy Context

H0040	Assertive Community Treatment
H0040-52	Assertive Community Treatment (reduced services modifier)

H2017	Psychosocial Rehabilitation Services (Day Rehab)
H2018	Psychosocial Rehabilitation Services (Day Rehab alternate)

H2015	Community Support Services
H2015-HE	Community Support - HE
H2015-HF	Community Support - HF