CurrentUnitedHealthcarePolicy N/A

Ohio Prior Authorization Requirements for UnitedHealthcare Exchange Plans — Behavioral Health

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

Policy Summary

PayerUnitedHealthcare

PolicyOhio Prior Authorization Requirements for UnitedHealthcare Exchange Plans — Behavioral Health

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online using the Prior Authorization and Notification tool via Sign In on UHCProvider.com and reference the member-specific benefit plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~70procedure/revenue/CPT codes listed

Ohiostate governed

2025-01-01effective date

Coverage Criteria

This policy lists behavioral health services that require prior authorization for participating providers delivering inpatient and outpatient care to UnitedHealthcare Exchange Plan members in Ohio. To request authorization, providers must submit the request online using the Prior Authorization and Notification tool accessed via Sign In on UHCProvider.com. When determining coverage for a member, always reference the member-specific benefit plan document, as plan terms vary by state.

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Codes Requiring Prior Authorization

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 Substance Use 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)

Substance Use 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/Program 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

Rehabilitation Revenue CodesmixedCovered

Rev 944	Drug Rehabilitation
Rev 945	Alcohol Rehabilitation
Rev 953	Combined drug and alcohol rehabilitation

Psychiatric/Residential Revenue CodesmixedCovered

Rev 961	Psychiatric
Rev 1000	Behavioral health Accommodations
Rev 1001	Residential Treatment- Psychiatric
Rev 1002	Residential Treatment- Chem Dep
Rev 1003	Supervised Living

TMS and Unlisted Psychiatric 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; subsequent motor threshold Re-determination with delivery and management 1 VISIT
90899	Unlisted psychiatric service or procedure

Psychological Testing CPT CodesCPTCovered

96130	Psychological testing evaluation
96131	Psychological testing evaluation
96136	Psychological or neuropsychological test admin and scoring by physician or other qualified health care professional, two or more tests, any method, first 30 minutes (Auth required only if submitted with 96130 & 96131)
96137	Psychological or neuropsychological test admin and scoring by physician or other qualified health care professional, two or more tests, any method, each additional 30 minutes (Auth required only if submitted with 96130 & 96131)
96138	Psychological or neuropsychological test admin and scoring by technician, two or more tests, any method, first 30 minutes (Auth required only if submitted with 96130 & 96131)
96139	Psychological or neuropsychological test admin and scoring by technician, two or more tests, any method, each additional 30 minutes (Auth required only if submitted with 96130 & 96131)
96146	Computer Based Psychological/Neuropsychological Testing

Behavioral Therapy / Adaptive Behavior Codes and Unlisted E/MCPTCovered

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

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Coding inventory notes

Inventory noteMiscellaneous coding and grouping follow the document's exact code groups (revenue codes, CPT, and unlisted codes) — do not change groupings or add codes.

Covered code countApproximately 70 procedure/revenue/CPT codes are listed in the policy.

Auth requirementPrior authorization is required for the listed inpatient and outpatient behavioral health services and the specific procedure codes shown for UnitedHealthcare Exchange Plan members in Ohio.

Grouping conventionsMaintain the policy's exact groups: Inpatient Mental Health; Inpatient Substance Use Detoxification; Substance Use Rehabilitation; Psychiatric Clinic; Outpatient/Program; Rehabilitation; Psychiatric/Residential; TMS & Unlisted Psychiatric CPT; Psychological Testing CPT; Behavioral Therapy/Adaptive Behavior and Unlisted E/M.

Level of Care — Criteria

Inpatient, Residential, PHP, IOP, Outpatient

Prior authorization is required for the following levels of care and associated facility/program revenue codes for UnitedHealthcare Exchange Plan members in Ohio.

Inpatient Mental Health (Revenue Codes): Rev 114, Rev 124, Rev 134, Rev 144, Rev 154, Rev 204
Inpatient Substance Use Detoxification (hospital based): Rev 116, Rev 126, Rev 136, Rev 146, Rev 156
Substance Use Rehabilitation (hospital based): Rev 118, Rev 128, Rev 138, Rev 148, Rev 158
Psychiatric Clinic (Revenue Code): Rev 513
Outpatient / Program Revenue Codes: Rev 900, Rev 905, Rev 906, Rev 907, Rev 912, Rev 913, Rev 918, Rev 919
Rehabilitation Revenue Codes: Rev 944, Rev 945, Rev 953
Psychiatric / Residential Revenue Codes: Rev 961, Rev 1000, Rev 1001, Rev 1002, Rev 1003

Treatment Modalities

TMS (90867, 90868, 90869)

Prior authorization is required for Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS) and related CPT procedure codes.

90867 - Therapeutic Repetitive Transcranial magnetic stimulation treatment; planning (1 visit)
90868 - Therapeutic Repetitive Repetitive Transcranial magnetic stimulation treatment; delivery and management, per session (1 visit)
90869 - Therapeutic Repetitive Transcranial Magnetic Stimulation; subsequent motor threshold re-determination with delivery and management (1 visit)
90899 - Unlisted psychiatric service or procedure (related unlisted CPT included in TMS section)

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for the inpatient and outpatient behavioral health services and procedure codes listed below for participating providers. Submit prior authorization requests online via the Prior Authorization and Notification tool available through the Sign In function on UHCProvider.com. Prior authorization is not required for emergency or urgent care. When determining coverage, always reference the member-specific benefit plan document as plan terms vary by state. Members in these benefit plans have no non-emergent out-of-network coverage and no coverage outside the service area.

Documentation Required

Submission and Documentation

To request prior authorization for the services and procedure codes listed in this policy, submit the request using the Prior Authorization and Notification tool on UHCProvider.com. Include clinical documentation that supports medical necessity (e.g., evaluation notes, treatment history, diagnostic testing, prior interventions, and progress notes). Ensure submitted documentation clearly links the requested level of care or service to the member's clinical condition and functional status.

Submit online via Prior Authorization and Notification tool at UHCProvider.com
Include supporting clinical documentation: evaluation notes, treatment history, diagnostic test results, prior interventions, progress notes

Denial Risk

Denial Risk for Missing Prior Authorization

Failure to obtain prior authorization for the listed inpatient or outpatient behavioral health services may result in claim denials or reductions in reimbursement. Always verify member benefits and any prior authorization requirements for the specific member and plan before providing non-emergent services. Use the Prior Authorization and Notification tool to submit requests and avoid potential denials.

Missing prior authorization may result in denied or reduced payment
Verify member-specific benefits and prior authorization requirements before providing non-emergent services
Submit requests via the Prior Authorization and Notification tool on UHCProvider.com

Note

Provider Action

Provider action: For the Exchange Plans members in Ohio, prior authorization is required for the specific revenue and CPT/procedure codes listed in this policy (including but not limited to Rev codes 114, 116, 118, 124, 126, 128, 134, 136, 138, 144, 146, 148, 154, 156, 158, 513, 900, 905, 906, 907, 912, 913, 918, 919, 944, 945, 953, 961, 1000–1003, 90867–90869, 90899, 96130–96139, 96146, 97151–97158, 0362T, 0373T, 99499). Prior authorization requests must be submitted online and include all required clinical documentation. Emergency and urgent care services are exempt from prior authorization.

Affected procedure codes include (examples): Rev 114,116,118,124,126,128,134,136,138,144,146,148,154,156,158
Behavioral health CPT/procedure codes include: 90867, 90868, 90869, 90899, 96130–96139, 96146, 97151–97158, 0362T, 0373T, 99499
Submit all prior authorization requests and supporting documentation via the Prior Authorization and Notification tool at UHCProvider.com

Background

Purpose: This document identifies the specific behavioral health services (inpatient and outpatient) that require prior authorization for UnitedHealthcare Exchange Plan members in Ohio. It also clarifies submission procedures and coverage scope for these Exchange plans.

Scope notes: Prior authorization is not required for emergency or urgent care. For these benefit plans, members have no non-emergent out-of-network coverage and no coverage outside of the service area. Providers must use the online Prior Authorization and Notification tool (via Sign In on UHCProvider.com) to submit requests.

Definitions & Portal

Portal for submitting clinical transactions

Tool namePrior Authorization and Notification tool (access via Sign In on UHCProvider.com)

PurposeSubmit clinical transactions and prior authorization requests for participating behavioral health providers.

Access instructionAccess the tool using the Sign In function on UHCProvider.com.

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

Revision History

2025-01-01Effective dateLatest

Policy effective date for prior authorization requirements for UnitedHealthcare Exchange Plans in Ohio

Overview published

Document lists services and procedure codes requiring prior authorization for participating behavioral health providers for Exchange Plan members in Ohio and notes submission via the Prior Authorization and Notification tool