Optum Prior Auth Requirements - Behavioral Health | OpenPayer
CurrentOptumPolicy N/A
Louisiana Prior Authorization Requirements for UnitedHealthcare Exchange Plans
List of behavioral health services and procedure codes that require prior authorization for UnitedHealthcare Exchange plan providers in Louisiana; applies to inpatient and outpatient behavioral health providers and members of those plans.
Policy Summary
PayerOptum
PolicyLouisiana Prior Authorization Requirements for UnitedHealthcare Exchange Plans
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateEffective January 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCProvider.com.
Prior Authorization Requirements: Service is one of the listed procedure/revenue/CPT codes requiring authorization for Exchange plan members in Louisiana AND provider submits prior authorization request via the Prior Authorization and Notification tool on UHCProvider.com
Prior authorization not required for emergency or urgent care; member-specific benefit plan governs coverage specifics
This document lists services that require prior authorization for participating behavioral health providers for UnitedHealthcare Exchange plan members in Louisiana. To request authorization, providers must submit prior authorization requests online via the Prior Authorization and Notification tool on UHCProvider.com. When determining coverage, refer to the member-specific benefit plan because terms vary by state. Prior authorization is not required for emergency or urgent care. Additionally, for these benefit plans members have no non-emergent out-of-network coverage and no coverage outside the service area.
Procedure, Revenue & CPT Codes
Inpatient Mental Health (Revenue Codes)RevenueCovered
Rev 114
Inpatient Mental Health
Rev 124
Inpatient Mental Health
Rev 134
Inpatient Mental Health
Rev 144
Inpatient Mental Health
Rev 154
Inpatient Mental Health
Rev 204
Inpatient Mental Health
Policy Summary
PayerOptum
PolicyLouisiana Prior Authorization Requirements for UnitedHealthcare Exchange Plans
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateEffective January 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCProvider.com.
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Inpatient Substance Use Detoxification (Revenue Codes)RevenueCovered
Rev 116
Inpatient Substance Use Detoxification (hospital based)
Rev 126
Inpatient Substance Use Detoxification (hospital based)
Rev 136
Inpatient Substance Use Detoxification (hospital based)
Rev 146
Inpatient Substance Use Detoxification (hospital based)
Rev 156
Inpatient Substance Use Detoxification (hospital based)
Substance Use Rehabilitation (Revenue Codes)RevenueCovered
Rev 118
Substance Use Rehabilitation (hospital based)
Rev 128
Substance Use Rehabilitation (hospital based)
Rev 138
Substance Use Rehabilitation (hospital based)
Rev 148
Substance Use Rehabilitation (hospital based)
Rev 158
Substance Use Rehabilitation (hospital based)
Other Revenue Codes (Outpatient/Services)RevenueCovered
Rev 513
Psychiatric Clinic
Rev 761
Treatment Room
Rev 900
Evaluation/Initial-BH Treatments/Services
Rev 905
MH Intensive Outpatient
Rev 906
SUD Intensive Outpatient
Rev 912
MH/SUD Partial Hospitalization
Rev 913
MH/SUD Partial Hospitalization
Rev 918
OP Services- Behavioral Health Testing
Rev 919
OP Services- Other Behavioral Health Treatment/Services
Rev 944
Drug Rehabilitation
1–10 of 13
1/2
Residential Treatment Revenue CodesRevenueCovered
Rev 1001
Residential Treatment- Psychiatric
Rev 1002
Residential Treatment- Chem Dep
TMS and Unlisted Psychiatric CPT CodesCPTCovered
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 (TMS) treatment; subsequent motor threshold Re-determination with delivery and management 1 VISIT
Psychological or neuropsychological test admin and scoring by physician or other qualified health care professional, two or more tests, any method, first 30 minutes
96137
Psychological or neuropsychological test admin and scoring by physician or other qualified health care professional, two or more tests, any method, each additional 30 minutes
96138
Psychological or neuropsychological test admin and scoring by technician, two or more tests, any method, first 30 minutes
96139
Psychological or neuropsychological test admin and scoring by technician, two or more tests, any method, each additional 30 minutes
96146
Computer Based Psychological/Neuropsychological Testing
Behavioral/Adaptive Treatment CPT CodesCPTCovered
97151
Behavior ID Assessment by PHYS/QHP EA 15 min
97152
BEHAVIOR ID SUPPORT ASSMT BY 1 TECH EA 15 MIN
97153
ADAPTIVE BEHAVIOR TX BY PROTOCOL TECH EA 15 MIN
97154
GROUP ADAPTIVE BHV TX BY PROTOCOL TECH EA 15 MIN
97155
ADAPT BHV TX PRTCL MODIFICAJ PHYS/QHP EA 15 MIN
97156
FAMILY ADAPT BHV TX GDN PHYS/QHP EA 15 MIN
97157
MULTIPLE FAM GROUP BHV TX GDN PHYS/QHP EA 15 MIN
97158
GRP ADAPT BHV PRTCL MODIFCAJ PHYS/QHP EA 15 MIN
0362T
BEHAVIOR ID SUPPORT ASSMT EA 15 MIN TECH TIME
0373T
ADAPT BHV TX PRTCL MODIFICAJ EA 15 MIN TECH TIME
Digital Assessment and Unlisted E/M CodesCPTCovered
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
Online digital assessment cumulative time
5-10 minutesQualified nonphysician health care professional online digital assessment and management for an established patient, cumulative time during 7 days (CPT 98966)
11-20 minutesQualified nonphysician health care professional online digital assessment and management for an established patient, cumulative time during 7 days (CPT 98967)
21 or more minutesQualified nonphysician health care professional online digital assessment and management for an established patient, cumulative time during 7 days (CPT 98968)
Provider Actions & Requirements
Prior Authorization
Prior Authorization Required
Prior authorization is required for the services and procedure/revenue/CPT codes listed below for participating behavioral health providers treating UnitedHealthcare Exchange plan members in Louisiana. Prior authorization requests must be submitted online using the Prior Authorization and Notification tool via the Sign In function on UHCProvider.com. Prior authorization is not required for emergency or urgent care.
Members have no non-emergent out-of-network coverage and no coverage outside of the service area.
When deciding coverage, reference the member-specific benefit plan document as benefits vary by state.
Note
To submit clinical prior authorization requests, use the Prior Authorization and Notification tool accessible via Sign In on UHCProvider.com.
Note
Submission and Benefit Reference
When requesting prior authorization, reference the member's benefit plan document to determine coverage details and route requests through the online Prior Authorization and Notification tool.
Online: Prior Authorization and Notification tool via Sign In on UHCProvider.com
Prior Authorization
Prior Authorization Required for Listed Services
Participating behavioral health providers must obtain prior authorization for the listed inpatient, outpatient, residential, evaluation, testing, TMS, behavioral, and related services for Exchange plan members in Louisiana. Prior authorization is required for the specific procedure/revenue/CPT codes listed.
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
Level of Care Criteria
Inpatient, Residential, PHP, IOP, Outpatient
Admission/Authorization requirement: Admission or initiation of services at the following levels (inpatient mental health, inpatient SUD detox, residential, partial hospitalization, intensive outpatient) requires prior authorization for Exchange plan members in Louisiana as indicated by listed revenue/CPT codes
Specific clinical criteria not provided in this list; reference member-specific benefit plan and clinical prior authorization tool
Continued stay/ongoing authorization: Continued stay or ongoing sessions for services identified (e.g., partial hospitalization, IOP, TMS sessions) require prior authorization as per the listed codes; exact clinical continuation criteria not specified in this document
Use prior authorization tool for required documentation
Treatment Modalities (e.g., TMS)
TMS
TMS prior auth: TMS planning (90867), delivery (90868), and subsequent motor threshold redetermination (90869) require prior authorization as listed
Clinical eligibility criteria for TMS are not provided in this list
Definitions
Prior authorization (as used here)
DefinitionPrior authorization: a requirement that listed inpatient, outpatient, residential, testing, behavioral and procedural services obtain approval before services are rendered for Exchange plan members in Louisiana; requests must be submitted online via the Prior Authorization and Notification tool on UHCProvider.com
ScopeApplies to participating behavioral health providers for Exchange Plans members in Louisiana for the procedure/revenue/CPT codes listed in this document
ReferenceWhen deciding coverage, the member-specific benefit plan document must be referenced as terms vary by state
Emergency/Urgent care
ExemptionPrior authorization is not required for emergency or urgent care
Member network limitsFor these benefit plans, members have no non-emergent out-of-network coverage and no coverage outside of the service area
Action for providersIf emergency or urgent care is provided, do not submit prior authorization; follow emergent care billing and notification as applicable
Background
This document identifies behavioral health service categories and the specific procedure, revenue and CPT codes that require prior authorization for Exchange plan providers in Louisiana, covering inpatient and outpatient behavioral health services. The list includes inpatient mental health and substance use detoxification and rehabilitation revenue codes, outpatient and partial hospitalization revenue codes, and other behavioral health procedure and CPT codes; providers should submit authorization requests online via the Prior Authorization and Notification tool on UHCProvider.com and consult the member’s benefit plan for coverage details.
Residential Treatment - Psychiatric: Rev 1001
Residential Treatment - Chemical Dependency: Rev 1002
TMS planning (1 visit): 90867
TMS delivery & management, per session: 90868
TMS subsequent motor threshold re-determination with delivery and management: 90869
Unlisted psychiatric service or procedure: 90899
Psychological testing evaluation: 96130, 96131
Psych test admin & scoring by physician/other QHP, two or more tests, first 30 min (auth required only if submitted with 96130/96131): 96136
Psych test admin & scoring by physician/other QHP, two or more tests, each additional 30 min (auth required only if submitted with 96130/96131): 96137
Psych test admin & scoring by technician, two or more tests, first 30 min (auth required only if submitted with 96130/96131): 96138
Psych test admin & scoring by technician, two or more tests, each additional 30 min (auth required only if submitted with 96130/96131): 96139
Computer-based psych/neuropsych testing: 96146
Behavior ID assessment by PHYS/QHP ea 15 min: 97151
Behavior ID support assessment by 1 tech ea 15 min: 97152
Adaptive behavior tx by protocol tech ea 15 min: 97153
Group adaptive behavior tx by protocol tech ea 15 min: 97154
Adaptive behavior tx protocol modification PHYS/QHP ea 15 min: 97155
Family adaptive behavior tx gdn PHYS/QHP ea 15 min: 97156
Multiple family group behavior tx gdn PHYS/QHP ea 15 min: 97157
Group adaptive behavior protocol modification PHYS/QHP ea 15 min: 97158
Behavior ID support assessment ea 15 min tech time: 0362T
Adaptive behavior tx protocol modification ea 15 min tech time: 0373T
Qualified nonphysician health care professional online digital assessment and management for established patient, up to 7 days cumulative: 98966, 98967, 98968