Behavioral health prior authorization for Hawaii Medicaid
Customize your policy alerts
Sign up for all Optum policy alerts
Know when Optum releases new policies or updates existing guidance.
Monitor payer policy activity
Lists behavioral health services and procedure codes that require prior authorization for UnitedHealthcare/Optum Hawaii Statewide Medicaid Managed Care members, including Long-Term Services and Supports; applies to participating and non-participating providers in Hawaii.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
Prior authorization required services
Services and procedure codes listed below require prior authorization for Hawaii Statewide Medicaid Managed Care members. Prior authorization is not required for emergency services. All out-of-network (non‑participating) providers must obtain prior authorization approval before providing behavioral health services.
Includes (examples)
Mental health inpatient/partial/residential
- Mental health inpatient; private room — Procedure Code 114.
- Mental health inpatient; semi-private room — Procedure Code 124.
- Mental health inpatient; 3-4 bed patient room — Procedure Code 134.
- Mental health inpatient; private deluxe room — Procedure Code 144.
- Mental health inpatient; ward patient room — Procedure Code 154.
- Mental health inpatient — Procedure Code 204.
- Mental health partial (adult/eating disorder/dual diagnosis) — Procedure Codes 912 / H0035.
- Mental health intensive outpatient (including eating disorder IOP) — Procedure Code 905.
- Mental health residential and eating disorder residential — Procedure Code 1001.
Substance use disorder (SUD)
- SUD inpatient detoxification — Procedure Codes 136 and 146.
- SUD detoxification; semi-private room — Procedure Code 126.
- SUD intensive outpatient (IOP) — Procedure Codes 906 / H0015.
- SUD residential — Procedure Codes 1002 / H0019.
- SUD Rehabilitation - Drug — Procedure Code 944.
- SUD Rehabilitation - Alcohol — Procedure Code 945.
Therapeutic TMS and psychological testing
Adaptive behavior (ABA) services
- Adaptive behavior treatment by protocol technician; 15 min — Procedure Code 97153 (Modifiers HP, HO, HN, HM).
- Group adaptive behavioral treatment by protocol technician; 15 min — Procedure Code 97154 (Modifier HM).
- Adaptive behavior treatment with protocol modification, physician or qualified professional; 15 min — Procedure Code 97155 (Modifiers HP, HO, HN).
- Family adaptive behavior treatment guidance; 15 min — Procedure Code 97156 (Modifiers HP, HO, HN).
- Multiple-family group adaptive behavior treatment guidance; each 15 min — Procedure Code 97157 (Modifiers HP, HO, HN, UN, UP, UQ, UR, US).
- Group adaptive behavior treatment with protocol modification; 15 min — Procedure Code 97158 (Modifiers HP, HO, HN, UN, UP, UQ, UR, US).
- Adaptive behavior treatment with protocol modification; technicians' time each 15 min (requires physician/qualified professional on site, two or more technicians, patient exhibiting destructive behavior, customized environment) — Procedure Code 0373T (Modifiers HP, HO, HN, HM).
Procedure Codes Requiring Prior Authorization
| 114 | Mental health inpatient; private room |
| 124 | Mental health inpatient; semi-private room |
| 134 | Mental health inpatient; 3-4 bed patient room |
| 144 | Mental health inpatient; private deluxe room |
| 154 | Mental health inpatient; ward patient room |
| 204 | Mental health inpatient |
| 912 | Mental health partial / H0035 |
| 905 | Mental health intensive outpatient |
| 1001 | Mental health residential and eating disorder residential |
| 136 | SUD inpatient detoxification |
| 906 | SUD intensive outpatient (IOP) / H0015 |
| 1002 | SUD Residential / H0019 |
| 944 | SUD Rehabilitation - Drug |
| 945 | SUD Rehabilitation - Alcohol |
| 90867 | Therapeutic rTMS treatment; planning |
| 90868 | Therapeutic rTMS treatment; delivery and management |
| 90869 | rTMS subsequent motor threshold re-determination |
| 96130 | Psychological testing evaluation; first hour |
| 96131 | Psychological testing evaluation; each additional hour |
| 96136 | Test admin and scoring by technician; first 30 min (auth required only if submitted with testing evaluation codes) |
| 96137 | Test admin and scoring by technician; each additional 30 min |
| 96138 | Test admin and scoring by technician, 2+ tests; first 30 min |
| 96139 | Test admin and scoring by technician, 2+ tests; each additional 30 min |
| 97153 | Adaptive behavior treatment by protocol tech; 15 min |
| 97154 | Group adaptive behavioral treatment by protocol technician; 15 min |
| 97155 | Adaptive behavior treatment with protocol modification; 15 min |
| 97156 | Family adaptive behavior treatment guidance; 15 min |
| 97157 | Multiple-family group adaptive behavior treatment guidance; 15 min |
| 97158 | Group adaptive behavior treatment with protocol modification; 15 min |
| 0373T | Adaptive behavior treatment with protocol modification; 15 min technicians' time |
Authorization & Billing Actions for Providers
Prior authorization requirement and exceptions
Prior authorization is required for the behavioral health services listed in this document. All out-of-network (non-participating) providers must obtain prior authorization approval before providing behavioral health services. Prior authorization is not required when rendering emergency services.
Code-level prior authorization list (codes & modifiers)
The procedure codes and associated modifiers shown below require prior authorization when billed for Hawaii Medicaid members: mental health and substance use disorder inpatient/partial/residential codes; SUD IOP and residential; therapeutic rTMS codes; psychological testing and test administration/scoring codes; and adaptive behavior (ABA) codes and modifiers as listed.
- Mental health inpatient/partial/residential: 114, 124, 134, 144, 154, 204, 912 / H0035, 905, 1001, 136, 146, 126 (Modifiers: as shown in tables) [chunk 2].
- SUD and TMS, psychological testing: 906 / H0015, 1002 / H0019, 944, 945, 90867, 90868, 90869, 96130 (Modifiers AH, TD, AJ), 96131 (Modifiers AH, TD, AJ), 96136 (Auth required only if submitted with testing evaluation codes) [chunk 3].
- Testing admin/scoring and ABA codes: 96137, 96138, 96139, 97153 (Modifiers HP, HO, HN, HM), 97154 (Modifier HM), 97155 (Modifiers HP, HO, HN), 97156 (Modifiers HP, HO, HN), 97157 (Modifiers HP, HO, HN, UN, UP, UQ, UR, US), 97158 (Modifiers HP, HO, HN, UN, UP, UQ, UR, US), 0373T (Modifiers HP, HO, HN, HM) [chunks 4, 5].
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.