CurrentUnitedHealthcarePolicy N/A

New Jersey Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Lists behavioral health services and procedure/revenue codes that require prior authorization for UnitedHealthcare Exchange Plans members in New Jersey (inpatient and outpatient behavioral health). Excludes emergency/urgent care and notes members have no non-emergent out-of-network coverage or coverage outside the service area.

Policy Summary

PayerUnitedHealthcare

PolicyNew Jersey Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review Date

Key ActionProviders must submit prior authorization and notification requests for the listed behavioral health services using the Prior Authorization and Notification tool via Sign In on UHCProvider.com.

POLICY UPDATE CHANGES

No material clinical or coverage changes.

~60Procedure/Revenue/CPT codes listed

1/1/24Effective date (New Jersey list)

0Prior auth exemptions (emergency/urgent)

Policy summary

This policy lists behavioral health services and associated procedure/revenue/CPT codes that require prior authorization for participating UnitedHealthcare Exchange Plans members in New Jersey for inpatient and outpatient behavioral health. Emergency and urgent care are exempt. Prior authorization requests must be submitted online via the Prior Authorization and Notification tool accessed through Sign In on UHCProvider.com. Effective date: 2024-01-01. Status: CURRENT. When deciding coverage, reference the member specific benefit plan document because plan terms vary by state.

Prior authorization requirement

Prior Authorization Requirement

Prior authorization is required for the following services for participating behavioral health providers for Exchange Plans members in New Jersey (except emergency or urgent care):

Prior Authorization Requirement: Prior authorization is required for the listed inpatient and outpatient behavioral health services and associated procedure/revenue codes (see code list). Prior authorization requests must be submitted online via the Prior Authorization and Notification tool accessible through Sign In on UHCProvider.com.

Codes include inpatient mental health (Rev 114,124,134,144,154,204); inpatient SUD detox (Rev 116,126,136,146,156); SUD rehabilitation (Rev 118,128,138,148,158); psychiatric clinic (Rev 513); treatment room (Rev 761); evaluation/initial BH treatments/services (Rev 900); MH intensive outpatient (Rev 905); SUD intensive outpatient (Rev 906); MH/SUD partial hospitalization (Rev 912,913); outpatient behavioral health testing (Rev 918); other outpatient BH treatments/services (Rev 919); drug rehab (Rev 944); alcohol rehab (Rev 945); combined drug and alcohol rehab (Rev 953); psychiatric (Rev 961); residential treatment psychiatric (Rev 1001); residential treatment chemical dependency (Rev 1002); TMS codes (90867, 90868, 90869); unlisted psychiatric (90899); psychological testing (96130, 96131) and related admin/scoring codes (96136-96139, 96146); behavior identification and adaptive behavior treatment codes (97151-97158, 0362T, 0373T); qualified nonphysician online assessment codes (98966-98968); unlisted E/M (99499).

Emergency/Urgent Care Exemption: Prior authorization is not required for emergency or urgent care.

Member Benefit Reference: When deciding coverage, the member specific benefit plan document must be referenced because terms vary by state.

No Non‑Emergent OON / No Coverage Outside Service Area: Members under these benefit plans have no non‑emergent out‑of‑network coverage and no coverage outside of the service area; do not expect out‑of‑network payment for non‑emergent services.

Affected procedure, revenue and CPT codes

Inpatient Mental Health (requires prior authorization)Revenue

114	Rev 114
124	Rev 124
134	Rev 134
144	Rev 144
154	Rev 154
204	Rev 204

Inpatient Substance Use Detoxification (hospital based)Revenue

116	Rev 116
126	Rev 126
136	Rev 136
146	Rev 146
156	Rev 156

Substance Use Rehabilitation (hospital based)Revenue

118	Rev 118
128	Rev 128
138	Rev 138
148	Rev 148
158	Rev 158

Psychiatric ClinicRevenue

513

Rev 513

Treatment RoomRevenue

761

Rev 761

Evaluation/Initial Behavioral Health Treatments/ServicesRevenue

900

Rev 900

MH Intensive OutpatientRevenue

905

Rev 905

SUD Intensive OutpatientRevenue

906

Rev 906

MH/SUD Partial HospitalizationRevenue

912	Rev 912
913	Rev 913

Outpatient Services - Behavioral Health TestingRevenue

918

Rev 918

Outpatient Services - Other Behavioral Health Treatment/ServicesRevenue

919

Rev 919

Drug RehabilitationRevenue

944

Rev 944

Alcohol RehabilitationRevenue

945

Rev 945

Combined Drug and Alcohol RehabilitationRevenue

953

Rev 953

PsychiatricRevenue

961

Rev 961

Residential Treatment - PsychiatricRevenue

1001

Rev 1001

Residential Treatment - Chemical Dependency (Chem Dep)Revenue

1002

Rev 1002

Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS) - planningCPT

90867

Therapeutic Repetitive Transcranial magnetic stimulation treatment; planning 1 VISIT

TMS - delivery and management, per sessionCPT

90868

Therapeutic Repetitive Transcranial magnetic stimulation treatment; delivery and management, per session 1 VISIT

TMS - subsequent motor threshold re-determination with delivery and managementCPT

90869

Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management 1 VISIT

Unlisted psychiatric service or procedureCPT

90899

Unlisted psychiatric service or procedure

Psychological testing evaluationCPT

96130	Psychological testing evaluation
96131	Psychological testing evaluation

Psychological/Neuropsychological test administration & scoring (physician or QHP)CPT

96136	Two or more tests, any method, first 30 minutes (Auth required only if Admin & Scoring codes are submitted with 96130 & 96131)
96137	Two or more tests, any method, each additional 30 minutes (Auth required only if Admin & Scoring codes are submitted with 96130 & 96131)

Psychological/Neuropsychological test administration & scoring (technician)CPT

96138	Two or more tests, any method, first 30 minutes (Auth required only if Admin & Scoring codes are submitted with 96130 & 96131)
96139	Two or more tests, any method, each additional 30 minutes (Auth required only if Admin & Scoring codes are submitted with 96130 & 96131)

Computer Based Psychological/Neuropsychological TestingCPT

96146

Computer Based Psychological/Neuropsychological Testing

Behavior Identification and Adaptive Behavior Treatment CodesCPT/HCPCS

97151	Behavior ID Assessment by PHYS/QHP EA 15 min
97152	BEHAVIOR ID SUPPORT ASSMT BY 1 TECH EA 15 MIN
97153	ADAPTIVE BEHAVIOR TX BY PROTOCOL TECH EA 15 MIN
97154	GROUP ADAPTIVE BHV TX BY PROTOCOL TECH EA 15 MIN
97155	ADAPT BHV TX PRTCL MODIFICAJ PHYS/QHP EA 15 MIN
97156	FAMILY ADAPT BHV TX GDN PHYS/QHP EA 15 MIN
97157	MULTIPLE FAM GROUP BHV TX GDN PHYS/QHP EA 15 MIN
97158	GRP ADAPT BHV PRTCL MODIFCAJ PHYS/QHP EA 15 MIN
0362T	BEHAVIOR ID SUPPORT ASSMT EA 15 MIN TECH TIME
0373T	ADAPT BHV TX PRTCL MODIFICAJ EA 15 MIN TECH TIME

Qualified nonphysician health care professional online digital assessment and management (established patient, up to 7 days)CPT

98966	5-10 minutes
98967	11-20 minutes
98968	21 or more minutes

Unlisted evaluation and management serviceCPT

99499

Unlisted evaluation and management service

What providers must do

Prior Authorization

Submit prior authorization requests online

Providers must submit prior authorization and notification requests for the listed behavioral health services using the Prior Authorization and Notification tool via Sign In on UHCProvider.com.

Documentation Required

Reference member specific benefit plan

When deciding coverage, reference the member specific benefit plan document because terms vary by state.

Billing Rule

No non-emergent out-of-network coverage / no coverage outside service area

Members under these benefit plans have no non-emergent out-of-network coverage and no coverage outside of the service area; billers/providers should not expect OON payment for non-emergent services.

OpenPayer

New Jersey Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Policy summary

Prior authorization requirement

Affected procedure, revenue and CPT codes

What providers must do

Definitions

Document history