CurrentUnitedHealthcarePolicy N/A

North Carolina Prior Authorization Requirements for UnitedHealthcare Exchange Plans

This document lists behavioral health services and procedure codes requiring prior authorization for UnitedHealthcare Exchange plan members in North Carolina and explains submission channels and basic applicability.

Policy Summary

PayerUnitedHealthcare

PolicyNorth Carolina Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit authorization requests online using the Prior Authorization and Notification tool via Sign In on UHCProvider.com.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~70+behavioral health procedure codes requiring authorization (approximate)

Onlineauthorization request channel

Exchange NCgeographic & product scope

Excluded

Related Billing Codes

CPT-96138-TECHNICIAN-TEST-ADMINISTRATION-SCORING-30-MINUTES

CPT 96138: Technician Administration and Scoring of Multiple Tests, First 30 Minutes

CPT-0362T-BEHAVIORAL-FOLLOW-UP-ASSESSMENT-TECHNICIAN-15MIN

CPT 0362T: Follow-Up Assessment of Maladaptive Destructive Behavior

CPT-99499-UNLISTED-EVALUATION-AND-MANAGEMENT-SERVICE

CPT 99499: Unlisted Evaluation and Management Service

CPT-97158-ADAPTIVE-BEHAVIOR-TREATMENT-SOCIAL-SKILLS-GROUP

CPT 97158: Adaptive Behavior Treatment in Social Skills Group

CPT-90875-PSYCHOPHYSIOLOGICAL-THERAPY-BIOFEEDBACK-PSYCHOTHERAPY-30MIN

CPT 90875: Psychophysiological Therapy with Biofeedback and Psychotherapy, 30 Minutes

CPT-97154-GROUP-ADAPTIVE-BEHAVIOR-TREATMENT-TECHNICIAN

CPT 97154: Group Adaptive Behavior Treatment by Technician

CPT-96146-ELECTRONIC-SINGLE-TEST-AUTOMATED-SCORING

CPT 96146: Electronic Single-Test Psychological/Neuropsychological Assessment

CPT-0373T-ADAPTIVE-BEHAVIOR-TREATMENT-MULTI-TECH-SEVERE-BEHAVIOR

CPT 0373T: Adaptive Behavior Treatment with Protocol Modification

CPT-97153-ADAPTIVE-BEHAVIOR-TREATMENT-TECHNICIAN-15-MIN

CPT 97153: Adaptive Behavior Treatment by Technician, per 15 Minutes

CPT-96139-TECHNICIAN-TEST-ADMINISTRATION-SCORING-ADDITIONAL-30-MINUTES

CPT 96139: Technician Administering and Scoring Tests, Additional 30 Minutes

Showing 1–10 of 24

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Services Requiring Prior Authorization

Prior authorization required services

The following inpatient and outpatient behavioral health services and procedure codes require prior authorization for UnitedHealthcare Exchange plan members in North Carolina. Prior authorization is not required for emergency or urgent care. Authorized requests must be submitted online via the Prior Authorization and Notification tool.

ALL of the following

Inpatient facility and program revenue codes
- Inpatient Mental Health — Rev 114, 124, 134, 144, 154, 204
- Inpatient Substance Use Detoxification (hospital based) — Rev 116, 126, 136, 146, 156
- Substance Use Rehabilitation (hospital based) — Rev 118, 128, 138, 148, 158
- Psychiatric Clinic — Rev 513
- Evaluation/Initial—Behavioral Health Treatments/Services — Rev 900
- MH Intensive Outpatient — Rev 905
- SUD Intensive Outpatient — Rev 906
- Community Behavioral Health Program, Treatment Day — Rev 907
- Biofeedback — Rev 917
- OP Services - Behavioral Health Testing — Rev 918
- OP Services - Other Behavioral Health Treatment/Services — Rev 919
- Drug Rehabilitation — Rev 944
- Alcohol Rehabilitation — Rev 945
- Combined drug and alcohol rehabilitation — Rev 953
- Psychiatric — Rev 961
Behavioral health therapy, testing, TMS, and behavior codes
- Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS) planning — 90867
- TMS delivery and management, per session — 90868
- TMS subsequent motor threshold re-determination — 90869
- Individual psychophysiological therapy with biofeedback (20–30 min) — 90875
- Individual psychophysiological therapy with biofeedback (45–50 min) — 90876
- Unlisted psychiatric service or procedure — 90899
Submission channel: To request authorization, submit online using the Prior Authorization and Notification tool accessible via Sign In on UHCProvider.com; verify coverage against the member-specific benefit plan document.

Relevant Procedure and Revenue Codes

Facility / Revenue Codes (covered)RevenueCovered

114	Inpatient Mental Health
124	Inpatient Mental Health
134	Inpatient Mental Health
144	Inpatient Mental Health
154	Inpatient Mental Health
204	Inpatient Mental Health
116	Inpatient Substance Use Detox (hospital based)
126	Inpatient Substance Use Detox (hospital based)
136	Inpatient Substance Use Detox (hospital based)
146	Inpatient Substance Use Detox (hospital based)

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Behavioral Health CPT / HCPCS / Other Codes (covered)mixedCovered

90867	Therapeutic repetitive transcranial magnetic stimulation treatment; planning 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
90875	Individual psychophysiological therapy incorporating biofeedback with psychotherapy, 20-30 minutes
90876	Individual psychophysiological therapy incorporating biofeedback with psychotherapy, 45-50 minutes
90899	Unlisted psychiatric service or procedure
96130	Psychological testing evaluation services by physician or other qualified health care professional, first hour
96131	Psychological testing evaluation services by physician or other qualified health care professional, each additional hour
96136	Psychological or neuropsychological test administration and scoring by physician or qualified health care professional, two or more tests, first 30 minutes
96137	Psychological or neuropsychological test administration and scoring by physician or qualified health care professional, two or more tests, each additional 30 minutes

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What Providers Must Do

Prior Authorization

Submit authorizations online via UHCProvider

To request authorization, submit the request online using the Prior Authorization and Notification tool accessed via the Sign In function on UHCProvider.com.

Denial Risk

No prior auth for emergency or urgent care

Prior authorization is not required for services provided in emergency or urgent care settings.

Documentation Required

Check member-specific benefit plan for coverage

Verify coverage by referencing the member-specific benefit plan document because benefit terms vary by state.

Key Terms

Prior authorization — definition / short explanation

DefinitionA determination required before certain behavioral health services will be covered for UnitedHealthcare Exchange plan members in North Carolina; providers must obtain approval prior to delivering the listed services.

When requiredPrior authorization is required for the inpatient and outpatient behavioral health services and procedure/revenue codes listed in this policy (see coding section).

How to requestSubmit authorization requests online using the Prior Authorization and Notification tool accessed via Sign In on UHCProvider.com.

ExceptionsNot required for emergency or urgent care services.

Benefit verificationAlways reference the member-specific benefit plan document because plan terms vary by state.

ScopeApplies to UnitedHealthcare Exchange plan members in North Carolina; members have no non-emergent out-of-network coverage or coverage outside the service area for these plans.