CurrentUnitedHealthcarePolicy N/A

Georgia Prior Authorization Requirements for UnitedHealthcare Exchange Plans

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

Policy Summary

PayerUnitedHealthcare

PolicyGeorgia Prior Authorization Requirements for UnitedHealthcare Exchange Plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online using 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.

~70procedure/revenue/CPT codes listed

Georgiastate governed

2024-01-01effective date stated

Coverage Criteria

Prior authorization is not required for emergency or urgent care for UnitedHealthcare Exchange Plan members in Georgia.

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Procedure, CPT and Revenue Codes

Inpatient Mental Health (Revenue Codes)RevenueCovered

Rev 114	Inpatient Mental Health (revenue)
Rev 124	Inpatient Mental Health (revenue)
Rev 134	Inpatient Mental Health (revenue)
Rev 144	Inpatient Mental Health (revenue)
Rev 154	Inpatient Mental Health (revenue)
Rev 204	Inpatient Mental Health (revenue)

Inpatient Substance Use Detoxification (Revenue Codes)RevenueCovered

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)RevenueCovered

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 761	Treatment Room
Rev 900	Evaluation/Initial-BH Treatments/Services
Rev 905	MH Intensive Outpatient
Rev 906	SUD Intensive Outpatient
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

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CPT and other procedure codes requiring authorizationCPT|HCPCS|Revenue|mixedCovered

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
96130	Psychological testing evaluation
96131	Psychological testing evaluation
96136	Psychological or neuropsychological test admin & scoring by physician or 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 or QHP, 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, each additional 30 minutes (Auth required only if submitted with 96130 & 96131)

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Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed behavioral health inpatient and outpatient services and the specified procedure/Revenue codes. To request prior authorization, submit your request online via the Prior Authorization and Notification tool accessed through Sign In on UHCProvider.com. When requesting authorization, include member-specific documentation and reference the member's benefit plan document as coverage varies by state. Prior authorization is not required for emergency or urgent care. For these Exchange Plans in Georgia, failure to obtain prior authorization for the listed services may result in claim denial.

Online: Use the Prior Authorization and Notification tool via Sign In on UHCProvider.com
Include member-specific documentation and clinical information with each request
Reference the member-specific benefit plan document when deciding coverage
Prior authorization is not required for emergency or urgent care
Members have no non-emergent out-of-network coverage and no coverage outside the service area (Exchange Plans, GA)

Documentation Required

Submission and Documentation

Requests must be submitted online via the Prior Authorization and Notification tool accessed through Sign In on UHCProvider.com. Ensure submitted requests include all member-specific documentation and clinical information necessary to support medical necessity and level-of-care determinations.

Submit clinical transactions through the Prior Authorization and Notification tool on UHCProvider.com
Attach member-specific documentation and clinical records to support the request

Denial Risk

Risk of Denial Without Prior Authorization

Failure to obtain prior authorization for the listed services for Exchange Plan members in Georgia may result in claim denial. Confirm authorization before delivering non-emergent services.

Applies to the behavioral health inpatient and outpatient services and procedure/Revenue codes listed in this policy
Confirm prior authorization status before providing non-emergent care to avoid denial

Note

Provider Action Highlight

Additional provider action: follow the online submission process, include all required documentation, and verify member-specific benefits and network coverage prior to scheduling or providing services.

Verify member benefits and network status for Exchange Plans in Georgia
Do not rely on implied coverage — obtain and document prior authorization when required

Background

This is an administrative document that lists behavioral health services (inpatient and outpatient) that require prior authorization for participating behavioral health providers serving UnitedHealthcare Exchange Plan members in Georgia. Requests for prior authorization must be submitted online using the Prior Authorization and Notification tool accessed via the Sign In function on UHCProvider.com. When determining coverage, reference the member-specific benefit plan document because plan terms vary by state. Note that members on these benefit plans have no non-emergent out-of-network coverage and no coverage outside of the service area.

Definitions

Prior authorization — definition and key points

DefinitionPrior authorization is the process of requesting approval before providing certain behavioral health services to Exchange Plan members in Georgia via UnitedHealthcare's Prior Authorization and Notification online tool (accessed via Sign In on UHCProvider.com).

Who it applies toParticipating behavioral health providers requesting inpatient and outpatient behavioral health services for Exchange Plan members in Georgia.

How to submitSubmit requests online using the Prior Authorization and Notification tool accessed through the Sign In function on UHCProvider.com.

ExceptionsPrior authorization is not required for emergency or urgent care.

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

OpenPayer