CurrentUnitedHealthcarePolicy N/A

Behavioral health prior authorization requirements for Northeast Health Partners RAE 2 Medicaid

Lists behavioral health services that require prior authorization or notification for members of Northeast Health Partners RAE 2 Medicaid and describes how providers should request authorization; applies to participating and non-participating providers when this plan is the primary payer.

Policy Summary

PayerUnitedHealthcare

PolicyBehavioral health prior authorization requirements for Northeast Health Partners RAE 2 Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionFax requests and documentation to 888-240-2689 or email rmhpbhvm@uhc.com to request prior authorization; call 800-599-4716 for questions and admitting facility notifications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-07-01policy effective date

~30+behavioral health codes referenced

>15 IOP / ≥5 daysutilization thresholds

email & faxauthorization request channels

Behavioral Health Prior Authorization and Notification Requirements

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Behavioral health prior authorization and notification requirements

The following behavioral health services require prior authorization or notification as specified:

Behavioral health inpatient hospitalization - Requires prior authorization; all admissions to freestanding inpatient psychiatric facilities or hospital psychiatric facilities must be authorized

Psychiatric residential treatment (acute treatment unit) - Requires prior authorization

Code: H0017

Psychiatric residential treatment facility (PRTF) - Requires prior authorization

Code: Rev code 0911

Qualified residential treatment program (QRTP) and associated services - Requires prior authorization

Code: H0019

Behavioral health partial hospitalization program (PHP) - Requires prior authorization

Code: H0035

Behavioral health intensive outpatient programming (IOP) - Requires pre-service notification; prior authorization required for services greater than 15 sessions

Codes: S9480, rev code 905

Multisystemic therapy (MST), enhanced MST - Notification required at admission; prior authorization required after 90 days

Codes: H2033, T2022

Functional family therapy (FFT), enhanced FFT - Notification required at admission; prior authorization required after 90 days

Codes: H0036, T2022

Electroconvulsive therapy (ECT) - Requires prior authorization

Code: 90870

Neuropsychological and psychological testing (and related codes) - Requires prior authorization

Codes: 96132-96139, 96146, 96130-96131

Neurobehavioral status exam - Requires prior authorization

Codes: 96116, 96121

ASAM level 3.7 medically monitored inpatient withdrawal management - Notification required at admission; prior authorization required for 5 or more days

Code: H0011

ASAM level 3.7 medically monitored intensive inpatient services - Requires prior authorization

Code: H2036 with Modifier U7 (Modifier HD for Special Connections cases)

ASAM level 3.5 clinically managed high-intensity residential services (including Special Connections) - Requires prior authorization

Code: H2036 with Modifier U5 (Modifier HD for Special Connections cases)

ASAM level 3.3 clinically managed population-specific high-intensity residential services - Requires prior authorization

Code: H2036 with Modifier U3 (Modifier HD for Special Connections cases)

ASAM level 3.1 clinically managed low-intensity residential services - Requires prior authorization

Code: H2036 with Modifier U1 (Modifier HD for Special Connections cases)

ASAM level 2.1 SUD intensive outpatient programming (SUD IOP) - Notification required at admission; prior authorization required after 15 sessions

Codes: G0137, H0015, rev code 906

ASAM level 2.5 partial hospitalization program (PHP) - Requires prior authorization

Code: H0016

Codes, Thresholds, and Service-Specific Rules

Behavioral health IOP / SUD IOP / PHP and related codesmixedCovered

S9480	Behavioral health intensive outpatient programming (IOP)
G0137	ASAM level 2.1 SUD IOP
H0015	SUD IOP service
rev code 906	Revenue code for SUD IOP
H0035	Behavioral health partial hospitalization program (PHP)
H0016	ASAM level 2.5 PHP

ASAM residential / inpatient and withdrawal management codes & modifiersmixedCovered

H0011	ASAM 3.7 inpatient withdrawal management
H2036	ASAM residential services — use with Modifiers U7, U5, U3, U1 as applicable
Modifier U7	H2036 — ASAM 3.7 medically monitored intensive inpatient
Modifier U5	H2036 — ASAM 3.5 clinically managed high-intensity residential
Modifier U3	H2036 — ASAM 3.3 population-specific high-intensity residential
Modifier U1	H2036 — ASAM 3.1 low-intensity residential
Modifier HD	Modifier HD for Special Connections cases (used with H2036)

MST / FFT and related codesmixedCovered

H2033	Multisystemic therapy (MST)
H0036	Functional family therapy (FFT)
T2022	MST/FFT enhanced service code

Psychiatric residential / PRTF / QRTP codesmixedCovered

H0017	Psychiatric residential treatment (acute treatment unit)
Rev code 0911	Psychiatric residential treatment facility (PRTF)
H0019	Qualified residential treatment program (QRTP)

Neuropsychological / psychological testing and related codesCPTCovered

96130	Psychological testing evaluation services by technician
96131	Psychological testing by computer-administered instrument
96132	Neuropsychological testing evaluation services, first 60 minutes
96133	Neuropsychological testing evaluation services, each additional 30 minutes
96136	Psychological or neuropsychological test administration and scoring
96137	Interpretation and report services
96138	Psychological or neuropsychological test administration
96139	Psychological or neuropsychological test administration
96146	Psychological or neuropsychological testing test administration-scoring-report
96116	Neurobehavioral status exam (clinical assessment)

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Electroconvulsive therapy (ECT)CPTCovered

90870

Electroconvulsive therapy (ECT)

How to Request Authorization and Single-Case Agreement (SCA) Rules

Prior Authorization

How to request prior authorization

Participating and non-participating providers must submit prior authorization requests and supporting documentation by fax to 888-240-2689 or by email to rmhpbhvm@uhc.com. For questions about behavioral health services or to provide admitting facility notification, call 800-599-4716. Prior authorization is not required for emergency or urgent care; however, out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services when the care is not emergent or urgent.

Fax prior authorization requests and documentation to 888-240-2689.
Email prior authorization requests and documentation to rmhpbhvm@uhc.com.
Call 800-599-4716 for behavioral health questions or to notify admitting facilities.
Out-of-network providers: request prior authorization for all non-emergent/non-urgent services.

Documentation Required

Single-case agreement (SCA) codes and process

The listed CPT codes do not require prior authorization for out-of-network providers but do require a single-case agreement (SCA) for payment; SCA requests should be initiated by emailing bh.sca.requests@uhc.com.

90832
90833
90834
90836
90837
90838
90839
90839+ET
90840
90846
90847
90849
90853
Email SCA requests to bh.sca.requests@uhc.com.

Definitions and Authorization Scope

SCA definition (inv-09)

DefinitionSingle-case agreement (SCA) is an agreement required for payment for certain services provided by out-of-network providers

When requiredApplies to specified behavioral health services listed in the policy (see associated CPT/HCPCS codes)

SCA contactSCA requests via bh.sca.requests@uhc.com

Example codesIncludes codes such as 90832-90840 series, 90846-90853, and others listed in policy for which SCA applies

Prior authorization definition (inv-10)

DefinitionPrior authorization is pre-service approval required for specified services; not required for emergency or urgent care

Out-of-network responsibilityOut-of-network providers must request prior authorization for all procedures and services except emergent or urgent care

How to requestFax requests and documentation to 888-240-2689 or email rmhpbhvm@uhc.com; questions or admitting facility notifications via 800-599-4716