CurrentUnitedHealthcarePolicy N/A

Texas Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Lists behavioral health services and procedure/revenue codes that require prior authorization for UnitedHealthcare Exchange plan participating providers in Texas (effective Jan 1, 2025). Applies to inpatient and outpatient behavioral health services for Exchange plan members in Texas.

Policy Summary

PayerUnitedHealthcare

PolicyTexas 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 prior authorization requests online through 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.

~80+procedure and revenue codes listed

Texasstate-specific list

2025-01-01effective date

Coverage Criteria — Prior Authorization Applicability

Prior authorization is not required for emergency or urgent care. Providers should follow standard emergency and urgent care procedures and reference the member-specific benefit plan for coverage details.

Affected Procedure and Revenue Codes

Inpatient Mental Health revenue codesRevenueCovered

Rev 114	Inpatient Mental Health (listed revenue codes)
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 detox revenue codesRevenueCovered

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 codesRevenueCovered

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)

Other revenue codes for behavioral health servicesRevenueCovered

Rev 513	Psychiatric Clinic
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 917	Biofeedback
Rev 918	OP Services- Behavioral Health Testing
Rev 919	OP Services- Other Behavioral Health Treatment/Services

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CPT/HCPCS and test/admin 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
90875	Individual psychophysiological therapy incorporating biofeedback (20-30 min)
90876	Individual psychophysiological therapy incorporating biofeedback (45-50 min)
90899	Unlisted psychiatric service or procedure
96130	Psychological testing evaluation
96131	Psychological testing evaluation
96136	Test admin & scoring by physician/QHP, two or more tests, first 30 minutes (Auth required only if submitted with 96130/96131)
96137	Test admin & scoring by physician/QHP, each additional 30 minutes (Auth required only if submitted with 96130/96131)

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Provider Requirements and Authorization Process

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed inpatient and outpatient behavioral health services and specified revenue/procedure codes. To request prior authorization, submit your request online using the Prior Authorization and Notification tool via the Sign In function on UHCProvider.com. Prior authorization is not required for emergency or urgent care. When determining coverage, reference the member-specific benefit plan document; benefit terms vary by state. For these Exchange plans in Texas, members have no non-emergent out-of-network coverage and no coverage outside the service area.

Affected revenue/procedure codes include (not exhaustive): Rev 114,124,134,144,154,204; Rev 116,126,136,146,156; Rev 118,128,138,148,158; Rev 513; Rev 900; Rev 905; Rev 906; Rev 907; Rev 912,913; Rev 917; Rev 918; Rev 919; Rev 944; Rev 945; Rev 953; Rev 961; Rev 1000; Rev 1001; Rev 1002; Rev 1003; 90867, 90868, 90869; 90875, 90876, 90899; 96130-96131, 96136-96139, 96146; 97151-97158; 0362T; 0373T; 99499
Submit authorizations online: Prior Authorization and Notification tool on UHCProvider.com (Sign In required).
Prior authorization is not required for emergency or urgent care services.
Member benefit documents control coverage; verify state-specific plan terms.

Denial Risk

Risk of Denial if Unauthorized

Failure to obtain prior authorization for the listed services may result in denial of payment for Exchange plan members in Texas. Providers should obtain authorization before delivering non-emergent services to avoid claim denials.

Denial risk applies to the inpatient and outpatient behavioral health services and codes listed in this policy.
No non-emergent out-of-network coverage or coverage outside the service area for these plans — denials likely if services are provided outside network without authorization.

Note

How to Submit Authorization

Providers must submit prior authorization requests online. Use the Prior Authorization and Notification tool accessed via Sign In on UHCProvider.com for all clinical transactions described in this section.

Online submission only: Prior Authorization and Notification tool on UHCProvider.com.
Have the member-specific benefit plan available when submitting to confirm coverage rules and any state-specific limitations.

Documentation Required

Providers should note additional action items: verify member benefits, obtain prior authorization for the specific revenue/procedure codes listed, and document medical necessity per the member's plan. Contact UHCProvider.com support if you have questions about the online tool.

Verify member eligibility and benefits before scheduling services.
Document and retain authorization details and any supporting clinical documentation.
Contact UHCProvider.com support for technical assistance with the Prior Authorization and Notification tool.

Levels of Care Referenced by Codes

Level-of-Care Mapping (Inpatient, Outpatient, PHP/IOP, Residential)

Prior authorization is required for the following levels of care when billed with the listed revenue/procedure codes:

Inpatient Mental Health — 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 — Rev 513

Evaluation/Initial Behavioral Health Treatments/Services — Rev 900

Mental Health Intensive Outpatient — Rev 905

Substance Use Disorder Intensive Outpatient — Rev 906

Community Behavioral Health Program / Day Treatment — Rev 907

Partial Hospitalization (MH/SUD) — Rev 912, Rev 913

Biofeedback (facility revenue) — Rev 917

Outpatient Behavioral Health Testing — Rev 918

Outpatient 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

Specific Treatment Modalities Requiring Authorization

Transcranial Magnetic Stimulation (TMS)

Prior authorization is required for Transcranial Magnetic Stimulation (TMS) services billed with the following CPT codes:

TMS treatment; planning (one visit) — CPT 90867

TMS treatment; delivery and management, per session — CPT 90868

TMS subsequent motor threshold re‑determination with delivery and management — CPT 90869

Biofeedback and Psychological Testing

Prior authorization is required for the following biofeedback and psychological testing services billed with the listed CPT codes:

Individual psychophysiological therapy incorporating biofeedback (20–30 minutes) — CPT 90875

Individual psychophysiological therapy incorporating biofeedback (45–50 minutes) — CPT 90876

Psychological testing evaluation — CPT 96130, CPT 96131

Test administration & scoring by physician/QHP, two or more tests, first 30 minutes — CPT 96136

Authorization required only if submitted with 96130/96131

Test administration & scoring by physician/QHP, two or more tests, each additional 30 minutes — CPT 96137

Authorization required only if submitted with 96130/96131

Test administration & scoring by technician, two or more tests, first 30 minutes — CPT 96138

Authorization required only if submitted with 96130/96131

Test administration & scoring by technician, two or more tests, each additional 30 minutes — CPT 96139

Authorization required only if submitted with 96130/96131

Computer-based psychological/neuropsychological testing — CPT 96146

Definitions and Key Terms

Prior authorization — definition / key term

DefinitionPrior authorization: a requirement to obtain approval before providing certain inpatient and outpatient behavioral health services for UnitedHealthcare Exchange plan members in Texas.

When requiredApplies to the inpatient and outpatient behavioral health services and specific revenue/procedure codes listed in this document; providers must request prior authorization before delivering those services.

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

ExceptionsPrior authorization is not required for emergency or urgent care.

Reference to benefitsCoverage decisions also require review of the member-specific benefit plan document, as plan terms vary by state.

OpenPayer

Texas Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Coverage Criteria — Prior Authorization Applicability

Affected Procedure and Revenue Codes

Provider Requirements and Authorization Process

Levels of Care Referenced by Codes

Specific Treatment Modalities Requiring Authorization

Definitions and Key Terms

Background and Scope