CurrentUnitedHealthcarePolicy N/A

Behavioral Health prior authorization requirements for Rocky Mountain Health Plans Medicare Advantage and Dual Special Needs Plans (DSNP)

This document governs prior authorization and single case agreement requirements for behavioral health services (mental health and substance use) for Rocky Mountain Health Plans Medicare Advantage and Dual Special Needs Plans (DSNP), and explains how providers should request authorization and notifications.

Policy Summary

PayerUnitedHealthcare

PolicyBehavioral Health prior authorization requirements for Rocky Mountain Health Plans Medicare Advantage and Dual Special Needs Plans (DSNP)

Policy CodePolicy N/A

Change TypeAdministrative update (no material coverage changes)

Effective DateNov 21, 2024

Next Review DateN/A

Key ActionFax requests and documentation to 888-240-2689 or email rmhpbhvm@uhc.com to request prior authorization; call 800-701-9054 (DSNP) or 877-842-3210 (MA) for questions and admission/notification.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2plans covered (MA and DSNP)

multiplecodes referenced

2behavioral health phone numbers

Behavioral Health Authorization and Single Case Agreement Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Single Case Agreement: The following CPT codes do NOT require prior authorization but do require a single case agreement for payment; initiate SCA requests via bh.sca.requests@uhc.com: 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 90849, 90839+ET, 90853.

Inpatient behavioral health hospitalization: Medicare Advantage (MA) requires notification of admission and discharge; Dual Special Needs Plans (DSNP) require prior authorization of inpatient hospitalization.

ALL of the following

Relevant billing codes: Revenue codes 912, 913.

ALL of the following

Relevant billing code: Revenue code 905.

ALL of the following

Relevant billing codes: G0137, Revenue code 906.

ALL of the following

Relevant CPT/HCPCS codes: 90868, 90869, 90867.

ALL of the following

Relevant codes: 90899, 99499.

ALL of the following

Relevant codes: 90870, Revenue code 901.

Codes Requiring Authorization or Single Case Agreement

Single Case Agreement codesCPTCovered

90832	90832
90833	90833
90834	90834
90836	90836
90837	90837
90838	90838
90839	90839
90840	90840
90846	90846
90847	90847

1–10 of 13

1/2

Authorization-required servicesmixedCovered

Rev code 912	Partial Hospitalization Programming (PHP) - Rev code 912
Rev code 913	Partial Hospitalization Programming (PHP) - Rev code 913
Rev code 905	Behavioral health intensive outpatient programming (BH IOP) - Rev code 905
G0137	Substance use disorder intensive outpatient programming (SUD IOP) - G0137
Rev code 906	Substance use disorder intensive outpatient programming (SUD IOP) - Rev code 906
90868	Therapeutic repetitive transcranial magnetic stimulation (TMS) - 90868
90869	Therapeutic repetitive transcranial magnetic stimulation (TMS) - 90869
90867	Therapeutic repetitive transcranial magnetic stimulation (TMS) - 90867
90899	Unlisted service code - 90899
99499	Unlisted service code - 99499

1–10 of 12

1/2

How Providers Request Authorization and Required Notifications

Prior Authorization

How to request prior authorization and contact information

How to request prior authorization and contact information for participating and non-participating providers.

Participating and non-participating health care professionals may fax requests and documentation to 888-240-2689 or email rmhpbhvm@uhc.com.
For questions about behavioral health services (including mental health and substance use disorders), call 800-701-9054 (DSNP) or 877-842-3210 (MA).
Admitting facility may give notification by calling 800-701-9054 (DSNP) or 877-842-3210 (MA).
Prior authorization is not required for emergency or urgent care.
Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services, excluding emergent or urgent care.

Prior Authorization

Inpatient hospitalization notification/authorization requirements

Admission and discharge notification / authorization requirements for inpatient behavioral health hospitalization.

Medicare Advantage (MA) plans require notification of admission and discharge for behavioral health inpatient hospitalization.
Dual Special Needs Plans (DSNP) require prior authorization for behavioral health inpatient hospitalization.
Admitting facilities may provide notification by calling 800-701-9054 (DSNP) or 877-842-3210 (MA).
Prior authorization is not required for emergency or urgent care admissions.

Prior Authorization

Program-level prior authorization requirements

Program-level prior authorization and preservice review requirements for specific behavioral health programs and services.

Partial Hospitalization Programming (PHP) — Requires prior authorization. Relevant revenue codes: 912, 913.
Behavioral Health Intensive Outpatient Programming (BH IOP) — Requires preservice notification; authorization necessary for services greater than 15 sessions. Relevant revenue code: 905.
Substance Use Disorder Intensive Outpatient Programming (SUD IOP) — Requires prior authorization. Relevant codes: G0137; revenue code 906.
Therapeutic repetitive transcranial magnetic stimulation (TMS) — Requires prior authorization. CPT/HCPCS codes: 90867, 90868, 90869.
Electro-convulsive therapy (ECT) — Requires prior authorization. CPT/HCPCS code: 90870; revenue code 901.
Unlisted service codes (e.g., 90899, 99499) — Require prior authorization.
If requesting prior authorization for a member's DSNP Medicaid services, refer to Behavioral health prior authorization RAE/PRIME.

Definitions and Exceptions

Dual Complete — Dual Complete plan (DualCare Plus) definition

Plan nameDual Complete (DualCare Plus)

Payer organizationRocky Mountain Health Plans

Document contextBehavioral Health prior authorization requirements for Medicare Advantage and Dual Special Needs Plans (DSNP)

Effective dateNov. 21, 2024

ScopeApplies when Rocky Mountain Health Plans is the primary payer

Prior authorization exceptions — emergency/urgent care exceptions and out-of-network rules

Emergency and urgent carePrior authorization is not required for emergency or urgent care

Out-of-network providersOut-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services excluding emergent or urgent care

How to submit requestsParticipating and non-participating providers may fax requests and documentation to 888-240-2689 or email rmhpbhvm@uhc.com

Questions and admission/notification linesCall 800-701-9054 (DSNP) or 877-842-3210 (MA) for questions and admitting facility notification

Policy Summary

PayerUnitedHealthcare

PolicyBehavioral Health prior authorization requirements for Rocky Mountain Health Plans Medicare Advantage and Dual Special Needs Plans (DSNP)

Policy CodePolicy N/A

Change TypeAdministrative update (no material coverage changes)

Effective DateNov 21, 2024

Next Review DateN/A

SourceLink

On This Page