CurrentUnitedHealthcarePolicy N/A

Nc Exchange Bh Prior Auth Req 2025

Lists behavioral health services and procedure/revenue/CPT codes that require prior authorization for UnitedHealthcare Exchange plan members in North Carolina, effective January 1, 2025. Applies to inpatient and outpatient behavioral health services; emergency/urgent care excluded.

Policy Summary

PayerUnitedHealthcare

PolicyNc Exchange Bh Prior Auth Req 2025

Policy CodePolicy N/A

Change TypeAdded prior authorization list

Effective DateJan 1, 2025

Next Review Date

Key ActionPrior authorization must be requested for listed services via the Prior Authorization and Notification tool on UHCProvider.com (Sign In required).

SourceLink

POLICY UPDATE CHANGES

Effective January 1, 2025 this list indicates services requiring prior authorization for participating behavioral health providers for Exchange Plans members in North Carolina.

~60Listed procedure/revenue/CPT codes requiring prior auth

2025-01-01Effective date (YYYY-MM-DD)

Policy summary

This rule lists behavioral health services that require prior authorization for participating providers serving UnitedHealthcare Exchange plan members in North Carolina. Effective January 1, 2025, the document identifies inpatient and outpatient behavioral health services and associated procedure/revenue/CPT codes that must receive prior authorization.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior authorization requirement and exceptions

Prior Authorization Requirement

Prior authorization is required for the listed behavioral health services for participating providers for Exchange Plan members in North Carolina, except emergency or urgent care and when member-specific benefits provide otherwise.

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Exceptions

Prior authorization is not required when ANY of the following apply:

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Codes requiring prior authorization

Revenue Codes (Inpatient/Facility/Behavioral Health)RevenueCovered

114	Inpatient Mental Health
124	Inpatient Mental Health
134	Inpatient Mental Health
144	Inpatient Mental Health
154	Inpatient Mental Health
204	Inpatient Mental Health
116	Inpatient Substance Use Detoxification (hospital based)
126	Inpatient Substance Use Detoxification (hospital based)
136	Inpatient Substance Use Detoxification (hospital based)
146	Inpatient Substance Use Detoxification (hospital based)

1–10 of 30

1/3

CPT / HCPCS / Procedure Codes (Therapies, Testing, TMS, Residential, etc.)CPTCovered

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); subsequent motor threshold redetermination
90875	Individual psychophysiological therapy incorporating biofeedback training by any modality with psychotherapy (20-30 min)
90876	Individual psychophysiological therapy incorporating biofeedback training by any modality with psychotherapy (45-50 min)
90899	Unlisted psychiatric service or procedure
96130	Psychological testing evaluation
96131	Psychological testing evaluation
96136	Psychological or neuropsychological test admin and scoring by physician/QHP, two or more tests, first 30 minutes (Auth required only if submitted with 96130 & 96131)
96137	... each additional 30 minutes (Auth required only if submitted with 96130 & 96131)

1–10 of 24

1/3

Residential / Supervised Living / Behavioral Health AccommodationsmixedCovered

1000	Behavioral health accommodations (Revenue code as listed)
1001	Residential Treatment - Psychiatric
1002	Residential Treatment - Chemical Dependency
1003	Supervised Living

What providers must do

Prior Authorization

Submit Prior Authorization

Prior authorization must be requested for listed services via the Prior Authorization and Notification tool on UHCProvider.com (Sign In required).

Documentation Required

Reference Member Benefit Plan

When deciding coverage, reference the member-specific benefit plan document because plan terms vary by state and may alter authorization needs.

Denial Risk

No Out-of-Network/Out-of-Area Coverage

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