CurrentUnitedHealthcarePolicy N/A

Indiana Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Lists behavioral health services and procedure codes that require prior authorization for UnitedHealthcare Exchange Plan members in Indiana; applies to participating behavioral health providers requesting inpatient and outpatient authorizations.

Policy Summary

PayerUnitedHealthcare

PolicyIndiana Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~80+procedure/revenue/CPT codes listed for auth

Indianastate governed

2025-01-01policy effective date

Prior Authorization Coverage Criteria

Prior authorization coverage criteria

Covered when prior authorization is obtained for the listed services and codes

Policy Summary

PayerUnitedHealthcare

PolicyIndiana Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

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

SourceLink

On This Page

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Procedure, Revenue, and CPT Code Lists

Inpatient Mental Health (revenue codes)mixedCovered

Rev 114	Inpatient Mental Health
Rev 124	Inpatient Mental Health
Rev 134	Inpatient Mental Health
Rev 144	Inpatient Mental Health
Rev 154	Inpatient Mental Health
Rev 204	Inpatient Mental Health

Inpatient SUD Detoxification (revenue codes)mixedCovered

Rev 116	Inpatient Substance Use Detoxification (hospital based)
Rev 126	Inpatient Substance Use Detoxification (hospital based)
Rev 136	Inpatient Substance Use Detoxification (hospital based)
Rev 146	Inpatient Substance Use Detoxification (hospital based)
Rev 156	Inpatient Substance Use Detoxification (hospital based)

SUD Rehabilitation (revenue codes)mixedCovered

Rev 118	Substance Use Rehabilitation (hospital based)
Rev 128	Substance Use Rehabilitation (hospital based)
Rev 138	Substance Use Rehabilitation (hospital based)
Rev 148	Substance Use Rehabilitation (hospital based)
Rev 158	Substance Use Rehabilitation (hospital based)

Psychiatric clinic (revenue code)mixedCovered

Rev 513

Psychiatric Clinic

Outpatient and specialty revenue codesmixedCovered

Rev 900	Evaluation/Initial-BH Treatments/Services
Rev 905	MH Intensive Outpatient
Rev 906	SUD Intensive Outpatient
Rev 907	Community Behavioral Health Program, Day Treatment
Rev 912	MH/SUD Partial Hospitalization
Rev 913	MH/SUD Partial Hospitalization
Rev 918	OP Services- Behavioral Health Testing
Rev 919	OP Services- Other Behavioral Health Treatment/Services
Rev 944	Drug Rehabilitation
Rev 945	Alcohol Rehabilitation

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Residential and supervised living (revenue codes)mixedCovered

Rev 1001	Residential Treatment- Psychiatric
Rev 1002	Residential Treatment- Chem Dep
Rev 1003	Supervised Living

TMS CPT codesCPTCovered

90867	Therapeutic Repetitive Transcranial magnetic stimulation treatment; planning 1 VISIT
90868	Therapeutic Repetitive Transcranial magnetic stimulation treatment; delivery and management, per session 1 VISIT
90869	Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS) treatment; subsequent motor threshold Re-determination with delivery and management 1 VISIT

Psychological testing and related codesCPTCovered

90899	Unlisted psychiatric service or procedure
96130	Psychological testing evaluation
96131	Psychological testing evaluation
96136	Psychological or neuropsychological test admin & scoring by physician/QHP, two or more tests, first 30 minutes (auth required only if submitted with 96130/96131)
96137	Psychological or neuropsychological test admin & scoring by physician/QHP, two or more tests, each additional 30 minutes (auth required only if submitted with 96130/96131)
96138	Psychological or neuropsychological test admin & scoring by technician, two or more tests, first 30 minutes (auth required only if submitted with 96130/96131)
96139	Psychological or neuropsychological test admin & scoring by technician, two or more tests, each additional 30 minutes (auth required only if submitted with 96130/96131)
96146	Computer Based Psychological/Neuropsychological Testing

Behavioral/ABA and miscellaneous CPT codesCPTCovered

97151	Behavior ID Assessment by PHYS/QHP EA 15 min
97152	Behavior ID Support Assessment by 1 tech EA 15 min
97153	Adaptive Behavior Treatment by protocol tech EA 15 min
97154	Group Adaptive Behavior Treatment by protocol tech EA 15 min
97155	Adaptive Behavior Treatment protocol modification PHYS/QHP EA 15 min
97156	Family adaptive behavior treatment guidance PHYS/QHP EA 15 min
97157	Multiple family group behavior treatment guidance PHYS/QHP EA 15 min
97158	Group adaptive behavior protocol modification PHYS/QHP EA 15 min
0362T	Behavior ID support assessment EA 15 min tech time
0373T	Adaptive behavior treatment protocol modification EA 15 min tech time

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Provider Requirements and Authorization Process

Prior Authorization

Prior Authorization Required

Prior authorization is required for the inpatient and outpatient behavioral health services and specific procedure codes listed for Exchange Plan members. Providers must submit prior authorization requests online via the Prior Authorization and Notification tool accessed through Sign In at UHCProvider.com. Prior authorization is not required for emergency or urgent care. When determining coverage, always reference the member-specific benefit plan document, as benefits vary by state. For these benefit plans, members have no non-emergent out-of-network coverage and no coverage outside the service area.

Inpatient Mental Health (Rev 114, 124, 134, 144, 154, 204)
Inpatient Substance Use Detoxification (Rev 116, 126, 136, 146, 156)
Substance Use Rehabilitation (hospital based) (Rev 118, 128, 138, 148, 158)
Psychiatric Clinic (Rev 513)
Evaluation/Initial BH Treatments/Services (Rev 900)
MH Intensive Outpatient (Rev 905)
SUD Intensive Outpatient (Rev 906)
Community Behavioral Health Program, Day Treatment (Rev 907)
MH/SUD Partial Hospitalization (Rev 912, 913)
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 Accommodations (Rev 1000)
Residential Treatment - Psychiatric (Rev 1001)
Residential Treatment - Chemical Dependency (Rev 1002)
Supervised Living (Rev 1003)
Therapeutic Repetitive Transcranial Magnetic Stimulation planning (90867)
TMS delivery and management per session (90868)
TMS subsequent motor threshold re‑determination (90869)
Unlisted psychiatric service or procedure (90899)
Psychological testing evaluation (96130, 96131)
Psychological/neuropsych test admin & scoring (96136, 96137, 96138, 96139)
Computer based psychological/neuropsych testing (96146)
Behavior ID assessment (97151)
Behavior ID support assessment by tech (97152)
Adaptive behavior tx by protocol tech (97153)
Group adaptive behavior tx by protocol tech (97154)
Adaptive behavior tx protocol modification PHYS/QHP (97155)
Family adaptive behavior tx GDN PHYS/QHP (97156)
Multiple family group behavior tx GDN PHYS/QHP (97157)
Group adaptive behavior protocol modification PHYS/QHP (97158)
Behavior ID support assessment tech time (0362T)
Adaptive behavior protocol modification tech time (0373T)
Unlisted evaluation and management service (99499)

Note

Submission Method

Providers must submit prior authorization requests online via the Prior Authorization and Notification tool accessed through Sign In at UHCProvider.com. Use the member-specific benefit plan when verifying coverage and benefits prior to requesting authorization.

Denial Risk

Risk of Denial for Unauthorized Services

Failure to obtain prior authorization for the listed services for Exchange Plan members may result in denial of coverage for those services.

Documentation Required

Provider Responsibilities

Providers are responsible for verifying member eligibility and benefit limitations and for ensuring prior authorization is obtained when required. Prior authorization is not required for emergency or urgent care. For any services outside the listed codes or for questions about authorization requirements, contact UnitedHealthcare through the Prior Authorization and Notification tool.

Key Definitions

Exchange Plans members — definition

DefinitionExchange Plans members: members enrolled in UnitedHealthcare Exchange Plans in Indiana.

Applies toParticipating behavioral health providers requesting prior authorization for inpatient and outpatient behavioral health services in Indiana.

Prior authorization requirementPrior authorization is required for the listed inpatient and outpatient behavioral health services and procedure codes for Exchange Plan members in Indiana; emergency or urgent care does not require prior authorization.

Submission methodRequests must be submitted online via the Prior Authorization and Notification tool accessible through the Sign In function on UHCProvider.com.

Benefit noteWhen deciding coverage, the member-specific benefit plan document must be referenced because plan terms vary by state.

OpenPayer

Indiana Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Prior Authorization Coverage Criteria

Procedure, Revenue, and CPT Code Lists

Provider Requirements and Authorization Process

Policy Background and Scope

Key Definitions

Level of Care — Inpatient, Residential, Partial Hospitalization, Intensive Outpatient, Outpatient

Modality-Specific Criteria

Policy Revision History