CurrentUnitedHealthcarePolicy N/A

Michigan Prior Authorization Requirements for UnitedHealthcare Exchange Plans - Behavioral Health Services

Lists behavioral health services and procedure/revenue codes that require prior authorization for UnitedHealthcare Exchange Plan members in Michigan effective January 1, 2025; applies to inpatient and outpatient behavioral health providers. Emergency/urgent care and out-of-network emergency care are excluded from PA requirement.

Policy Summary

PayerUnitedHealthcare

PolicyMichigan Prior Authorization Requirements for UnitedHealthcare Exchange Plans - Behavioral Health Services

Policy CodePolicy N/A

Change TypeAdded consolidated code list and PA submission instructions

Effective DateJan 1, 2025

Next Review Date

Key ActionProviders must submit prior authorization requests for the listed services via the Prior Authorization and Notification tool on UHCProvider.com.

POLICY UPDATE CHANGES

Establishes a list of behavioral health services and codes requiring prior authorization for Michigan Exchange Plans effective January 1, 2025.

~60Procedure/Revenue/CPT codes listed

MichiganState scope

2025-01-01Effective date

Policy summary

This document lists behavioral health services and associated procedure/revenue/CPT codes that require prior authorization for participating behavioral health providers treating UnitedHealthcare Exchange Plan members in Michigan, effective January 1, 2025. Prior authorization requests must be submitted online via the Prior Authorization and Notification tool on UHCProvider.com. Prior authorization is not required for emergency or urgent care. Coverage is determined by the member-specific benefit plan and may vary by state and plan; reference the member’s benefit plan for coverage details.

Prior authorization requirement

Prior Authorization Requirement

Prior authorization is required for the listed behavioral health services for participating providers for Exchange Plan members in Michigan, except as noted.

ALL of the following

Member is enrolled in a UnitedHealthcare Exchange Plan in Michigan
Service is one of the listed inpatient or outpatient behavioral health services (see code lists for specific procedure/revenue/CPT codes)
Request submitted via the Prior Authorization and Notification tool on UHCProvider.com
Providers must submit prior authorization requests online via the Prior Authorization and Notification tool accessed through Sign In on UHCProvider.com
Reference the member-specific benefit plan document to determine coverage terms
Coverage depends on the member specific benefit plan; terms vary by state

Prior authorization is NOT required for

Emergency care
PA not required for emergency care
Urgent care
PA not required for urgent care

Network and service area limitation

Members have no non-emergent out-of-network coverage for these benefit plans
Claims for non-emergent out-of-network services may be denied
No coverage outside of the service area for non-emergent services
Services provided outside the service area are not covered for these plans

Prior Authorization

Submit prior authorization online

Providers must submit prior authorization requests for the listed services via the Prior Authorization and Notification tool on UHCProvider.com.

Documentation Required

Reference member-specific benefit plan

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

Denial Risk

No non-emergent out-of-network coverage

Claims for non-emergent out-of-network services or services provided outside the service area may be denied because members have no non-emergent out-of-network coverage and no coverage outside the service area.

Members have no non-emergent out-of-network coverage for these benefit plans
No coverage outside of the service area for non-emergent services

Codes requiring prior authorization

Inpatient Mental Health - Revenue CodesRevenueCovered

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

Inpatient Substance Use Detoxification (hospital based) - Revenue CodesRevenueCovered

116	Inpatient SUD Detoxification
126	Inpatient SUD Detoxification
136	Inpatient SUD Detoxification
146	Inpatient SUD Detoxification
156	Inpatient SUD Detoxification

Substance Use Rehabilitation (hospital based) - Revenue CodesRevenueCovered

118	Substance Use Rehabilitation
128	Substance Use Rehabilitation
138	Substance Use Rehabilitation
148	Substance Use Rehabilitation
158	Substance Use Rehabilitation

Psychiatric Clinic - Revenue CodeRevenueCovered

513	Psychiatric Clinic

Evaluation/Initial Behavioral Health Treatments/Services - Revenue CodeRevenueCovered

900	Evaluation/Initial BH Treatments/Services

MH Intensive Outpatient - Revenue CodeRevenueCovered

905	MH Intensive Outpatient

SUD Intensive Outpatient - Revenue CodeRevenueCovered

906	SUD Intensive Outpatient

Community Behavioral Health Program, Day Treatment - Revenue CodeRevenueCovered

907	Community Behavioral Health Program, Day Treatment

MH/SUD Partial Hospitalization - Revenue CodesRevenueCovered

912	Partial Hospitalization
913	Partial Hospitalization

OP Services - Behavioral Health Testing - Revenue CodeRevenueCovered

918	Outpatient Behavioral Health Testing

OP Services - Other Behavioral Health Treatment/Services - Revenue CodeRevenueCovered

919	Outpatient Other BH Treatment/Services

Drug/Alcohol Rehabilitation - Revenue CodesRevenueCovered

944	Drug Rehabilitation
945	Alcohol Rehabilitation
953	Combined Drug and Alcohol Rehabilitation

Psychiatric - Revenue CodeRevenueCovered

961	Psychiatric

Behavioral Health Accommodations - Revenue CodeRevenueCovered

1000	Behavioral Health Accommodations

Residential Treatment - Revenue CodesRevenueCovered

1001	Residential Treatment - Psychiatric
1002	Residential Treatment - Chemical Dependency
1003	Supervised Living

Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS) - CPTCPTCovered

90867	TMS planning, 1 visit
90868	TMS delivery and management, per session
90869	Subsequent motor threshold re-determination with delivery and management

Unlisted Psychiatric Service or Procedure - CPTCPTCovered

90899

Unlisted psychiatric service or procedure

Psychological Testing Evaluation - CPTCPTCovered

96130	Psychological testing evaluation
96131	Psychological testing evaluation

Psychological/Neuropsych Test Admin & Scoring by Physician/QHP - CPT (Auth required only if submitted with 96130/96131)CPTCovered

96136	Admin & scoring by physician/QHP, two or more tests, first 30 minutes
96137	Each additional 30 minutes

Psychological/Neuropsych Test Admin & Scoring by Technician - CPT (Auth required only if submitted with 96130/96131)CPTCovered

96138	Admin & scoring by technician, two or more tests, first 30 minutes
96139	Each additional 30 minutes

Computer Based Psychological/Neuropsychological Testing - CPTCPTCovered

96146

Computer based testing

Behavior Identification and Adaptive Behavior Treatment Codes - CPT and HCPCSCPT|HCPCSCovered

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

Unlisted E/M Service - CPTCPTCovered

99499

Unlisted evaluation and management service

Billing and submission actions

Submit all prior authorization requests for the listed behavioral health services via the Prior Authorization and Notification tool accessed through Sign In on UHCProvider.com. Emergency and urgent care are exempt from prior authorization. Determine whether services are covered by referencing the member-specific benefit plan document. Claims for non-emergent out-of-network services or services provided outside the service area may be denied because these benefit plans have no non-emergent out-of-network coverage and no coverage outside the service area.

Billing Rule

Billing and submission note

Submit prior authorization requests online via the Prior Authorization and Notification tool on UHCProvider.com. Emergency and urgent care are exempt from prior authorization requirements for these plans.

OpenPayer

Michigan Prior Authorization Requirements for UnitedHealthcare Exchange Plans - Behavioral Health Services

Policy summary

Prior authorization requirement

Codes requiring prior authorization

Billing and submission actions

Material changes and effective date