Individual Psychotherapy Medical Necessity Review (post-24-visit prior authorization)
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Select Health requires a medical necessity prior authorization review once a member reaches 24 outpatient individual psychotherapy visits (CPT 90832, 90834, 90837) for private-practice LIPs and RBHS providers rendering outpatient individual psychotherapy. It clarifies submission requirements and limits for subsequent visits.
A medical necessity review is required once a member has reached 24 individual psychotherapy visits (any combination of 90832, 90834 and 90837), effective May 1, 2022.
The six visits per month limitation remains in effect and the 24-visit count for 2022 runs from May 1 through December 31, restarting January 1, 2023.
Providers must submit prior authorization via the NaviNet/JIVA portal with the recent Individual Plan of Care (IPOC), the most recent progress note, and the three most recent clinical service notes in one file.
Coverage Criteria
Authorization trigger
Covered outpatient individual psychotherapy is subject to prior authorization after the following condition is met:
The post-24-visit prior authorization requirement does not apply to members who are children and youth in Foster Care, those served by the Department of Mental Health (DMH), or those receiving services through the Medical University of South Carolina (MUSC). For all other members receiving outpatient individual psychotherapy from private-practice Licensed Independent Practitioners (LIPs) and Rehabilitative Health Services (RBHS) providers, the medical necessity review requirement applies once the member has reached 24 individual psychotherapy visits (any combination of CPT codes 90832, 90834, 90837), effective May 1, 2022.
Coding
Provider Actions & Requirements
Submit prior authorization after 24 visits
Once a member has reached 24 individual psychotherapy visits (any combination of CPT codes 90832, 90834, 90837), submit a prior authorization request through the NaviNet/JIVA prior authorization provider portal for subsequent visits and specify the number of additional visits requested for each code.
Use the NaviNet/JIVA portal and follow-up on claim submission
Submit the authorization request through the NaviNet/JIVA prior authorization provider portal and, after approval, submit the claim for the 25th visit; if denied, resubmit the denied claim after obtaining authorization.
- Use the NaviNet/JIVA portal for submission.
- After approval, submit the claim for the 25th visit; if you received a denial, resubmit the denied claim after authorization.
Upload IPOC, progress note, and three clinical notes in one file
Upload the most recent Individual Plan of Care (IPOC), the most recent progress note, and the three most recent clinical service notes in one file when submitting the prior authorization request via the NaviNet/JIVA portal; failure to upload all requested documents in one file will result in denial.
- Required documents: most recent IPOC, most recent progress note, and three most recent clinical service notes.
- All documents must be uploaded as a single file into JIVA.
Risk of claim denial without timely authorization (X01)
If prior authorization is not obtained for visits after the 24th (for example, waiting until after the 25th visit), claims will be denied with X01 — authorization or referral not obtained.
- Denial code referenced: X01 — authorization or referral not obtained.
Background
This communication clarifies a utilization management procedure: Select Health requires a medical necessity prior authorization review once a member has reached 24 outpatient individual psychotherapy visits (any combination of CPT 90832, 90834, 90837) for services delivered by private-practice LIPs and RBHS providers. The requirement is administrative — it establishes when a prior authorization is required for continued outpatient individual psychotherapy rather than prescribing clinical treatment. The policy is effective May 1, 2022, the six-visit-per-month limit remains in effect, and for 2022 the 24-visit count runs from May 1 through December 31, 2022 with the count resetting on January 1, 2023.
Definitions
Level of Care Criteria
Treatment Modalities
Visit Limits
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