CurrentOptumPolicy N/A

Ohio Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Lists behavioral health inpatient and outpatient services and procedure codes that require prior authorization for UnitedHealthcare Exchange Plan members in Ohio; applies to participating behavioral health providers.

Policy Summary

PayerOptum

PolicyOhio Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization online via the Prior Authorization and Notification tool on UHCProvider.com before providing non-emergent listed behavioral health services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~70procedure and CPT/revenue codes listed

Ohiostate applicability

2024-01-01effective date stated

Onlineauthorization submission channel

Coverage and Authorization Rules

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Emergency or urgent care services do not require prior authorization. For non-emergent services, prior authorization must be obtained for the inpatient and outpatient behavioral health services and the procedure/revenue/CPT codes listed in this policy before services are provided to Exchange Plan members in Ohio. Providers should reference the member-specific benefit plan when determining coverage, as plan terms vary by state.

These Exchange Plans do not provide non-emergent out-of-network coverage and do not provide coverage outside the service area; failure to obtain required prior authorization for listed services may result in denied coverage.

Procedure, CPT, HCPCS and Revenue Codes

Inpatient and outpatient service revenue codes (covered)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
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)

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Testing and TMS continuation codes (covered)CPTCovered

90867	Therapeutic Repetitive Transcranial Magnetic Stimulation treatment; planning, first visit
90868	Therapeutic Repetitive Transcranial Magnetic Stimulation treatment; delivery and management, per session
90869	Therapeutic Repetitive Transcranial Magnetic Stimulation treatment; subsequent motor threshold re-determination with delivery and management
90899	Unlisted psychiatric service or procedure
96130	Psychological testing evaluation
96131	Psychological testing evaluation
96136	Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method, first 30 minutes
96137	Psychological or neuropsychological test administration 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 administration and scoring by technician, two or more tests, any method, first 30 minutes
96139	Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method, each additional 30 minutes

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Behavioral- and testing-related CPT/HCPCS codes (covered)mixedCovered

97151	Behavior ID Assessment by PHYS/QHP, each 15 minutes
97152	Behavior ID support assessment by technician, each 15 minutes
97153	Adaptive behavior treatment by protocol technician, each 15 minutes
97154	Group adaptive behavior treatment by protocol technician, each 15 minutes
97155	Adaptive behavior treatment protocol modification by PHYS/QHP, each 15 minutes
97156	Family adaptive behavior treatment guidance by PHYS/QHP, each 15 minutes
97157	Multiple family group behavior treatment guidance by PHYS/QHP, each 15 minutes
97158	Group adaptive behavior protocol modification by PHYS/QHP, each 15 minutes
0362T	Behavior ID support assessment, technician time, each 15 minutes
0373T	Adaptive behavior treatment protocol modification, technician time, each 15 minutes

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Online digital assessment cumulative time

Online digital assessment cumulative timeUp to 7 days cumulative time during the 7 days: 5-10 minutes (98966); 11-20 minutes (98967); 21+ minutes (98968)

Level-of-Care Prior Authorization Rules

Inpatient, Residential, Partial Hospitalization, Intensive Outpatient, Outpatient

Covered when prior authorization is obtained for the listed levels of care and associated procedure/revenue codes

Levels of care subject to prior authorization: The following levels of care require prior authorization for Exchange Plan members in Ohio: Inpatient Mental Health; Inpatient Substance Use Detoxification (hospital based); Substance Use Rehabilitation (hospital based); Psychiatric Clinic; Treatment Room; Evaluation/Initial Behavioral Health Treatments/Services; Mental Health Intensive Outpatient; Substance Use Disorder Intensive Outpatient; Mental Health/Substance Use Partial Hospitalization; Outpatient Services — Behavioral Health Testing; Outpatient Services — Other Behavioral Health Treatment/Services; Drug Rehabilitation; Alcohol Rehabilitation; Combined Drug and Alcohol Rehabilitation; Psychiatric services; Residential Treatment — Psychiatric; Residential Treatment — Chemical Dependency

Reference the specific revenue/procedure codes when submitting authorization requests

Provider Requirements and Submission Instructions

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed inpatient and outpatient behavioral health services and the specified procedure/revenue/HCPCS/CPT codes for Exchange Plan members in Ohio. To request prior authorization, submit requests online via the Prior Authorization and Notification tool accessed through the Sign In function on UHCProvider.com. Refer to the member-specific benefit plan for coverage details; benefits vary by state. Prior authorization is not required for emergency or urgent care. For these benefit plans, members have no non-emergent out-of-network coverage and no coverage outside of the service area.

Affected revenue/procedure group examples: Rev 114, 124, 134, 144, 154, 204 (Inpatient Mental Health)
Rev 116, 126, 136, 146, 156 (Inpatient SUD Detoxification)
Rev 118, 128, 138, 148, 158 (SUD Rehabilitation hospital-based)
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, 913 (MH/SUD Partial Hospitalization)
Rev 918 (Behavioral Health Testing), Rev 919 (Other Behavioral Health Treatment/Services)
Rev 944, 945, 953 (Drug/Alcohol/Combined Rehabilitation)
Rev 961 (Psychiatric), Rev 1001 (Residential Psychiatric), Rev 1002 (Residential Chemical Dependency)
CPT/HCPCS examples: 90867, 90868, 90869 (TMS services); 90899 (unlisted psych service)
Psych testing and administration codes: 96130, 96131, 96136-96139, 96146
Behavioral intervention codes: 97151-97158, 0362T, 0373T
Online digital assessment codes: 98966-98968; 99499 (unlisted E/M)

Note

Provider Action — Reserved

(Reserved) Important provider action — see policy for any future updates to required actions, code lists, or documentation expectations.

Documentation Required

Submission and Documentation

Submit prior authorization requests online via the Prior Authorization and Notification tool accessed through the Sign In function on UHCProvider.com. When submitting, include supporting clinical documentation and the specific procedure/revenue/CPT/HCPCS codes being requested. Reference the member’s benefit plan to confirm coverage limitations and network requirements.

Use the Prior Authorization and Notification tool on UHCProvider.com (Sign In required)
Include clinical documentation and applicable codes (see Prior Authorization Required callout)
Confirm member-specific benefit plan and service area/network restrictions

Denial Risk

Denial Triggers

Failure to obtain prior authorization for the listed behavioral health services for Exchange Plan members in Ohio may result in denied coverage or payment. Denials may also occur if required supporting documentation or correct procedure/revenue/CPT/HCPCS codes are not submitted.

Denied if prior authorization not obtained for non-emergent services listed
Denied if supporting clinical documentation is incomplete or missing
Denied if service is outside member’s service area or out-of-network for these plans

Background and Scope

This document is an administrative notice that lists the inpatient and outpatient behavioral health services and procedure/revenue/CPT codes that require prior authorization for participating providers serving UnitedHealthcare Exchange Plan members in Ohio. It explains how to submit authorization requests and clarifies the scope of applicability.

To request prior authorization, submit clinical transactions online using the Prior Authorization and Notification tool, accessible via the Sign In function on UHCProvider.com. When making coverage determinations, always reference the member-specific benefit plan, since plan terms vary by state. Prior authorization is not required for emergency or urgent care.

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