Exciting News!
We are enhancing our authorization requirements for Medicaid.
Staywell is excited to announce some important Medicaid outpatient prior authorization requirement changes. We are reducing the amount of Medicaid services/procedures requiring prior authorization for Behavioral Health services. These updates are designed to help ease your day-to-day interactions with us while allowing us to continue to exercise responsible stewardship over the government-funded healthcare programs we administer.
For dates of service on or after September 15, 2018, we are standardizing Behavioral Health authorization requirements across ALL outpatient places of service for our Medicaid services. Listed below are the Behavioral Health outpatient procedure codes that will require prior authorization as of the above-mentioned date. All other covered procedure codes do not require authorization and can be rendered and billed as medically necessary.
On September 15, 2018, www.wellcare.com/auth_lookup will be updated to reflect these changes. Prior authorization requirements are subject to periodic changes. You should always use our website’s authorization page to determine whether a procedure code requires prior authorization, and always check eligibility and confirm benefits before rendering Behavioral Health services to members. Failure to do so may result in denial of reimbursement.
For questions regarding this notice, please contact Provider Services at the number located in your Quick Reference Guide. When prompted say “Authorizations” or
press 2.
Thank you for your continued participation and cooperation in our ongoing efforts to render quality healthcare for our members. We look forward to helping you provide the highest quality of care for our members.
OUTPATIENT PROCEDURE CODES REQUIRING PRIOR AUTHORIZATION AS OF SEPTEMBER 15, 2018
90867 Therapeutic Repetitive Transcranial (TMS)
90868 Therapeutic Repetitive Transcranial (TMS)
90869 Therapeutic Repetitive Transcranial (TMS)
90870 Electroconvulsive Therapy
90880 Hypnotherapy
90887 Interpretation/explanation of results of psych exam & procedures Outpatient
Collateral, 15 min.
90899 Unlisted Psychiatric procedure
96105 Assessment of Aphasia of speech/language
H0019 Behavioral health; long term residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board; per diem
H0038 Self-help/peer services; per 15 minutes
H0047 Alcohol and drug services not otherwise specified
H2011 Crisis Intervention Services; per 15 Minutes
H2012 Behavioral health day treatment; per hour
H2015 Comprehensive community support services; per 15 minutes
H2017 Psychosocial rehabilitation services; per 15 minutes
H2019 Therapeutic behavioral services; per 15 minutes
H2020 Therapeutic behavioral services; per diem
H2022 Community-based wrap-around services; per diem (intensive in-home services)
S5145 Behavioral health specialized foster care
S9475 Ambulatory setting substance abuse treatment or detoxification services; per diem
T1017 Targeted case management, each 15 minutes
T1027 Family training & counseling
For routine outpatient services, Staywell will continue to use our outlier management practice to monitor and review appropriate utilization of routine outpatient therapy services. This means we will be reviewing your claims data regularly to identify patterns of service that are at variance with your peers. In addition, based on our current member utilization experience we have set a visit threshold of 20 units per year that, if exceeded, will trigger a request for clinical review to determine the medical necessity of additional units.
Procedure codes considered routine include:
90832 Psychotherapy, 30 minutes
90834 Psychotherapy, 45 minutes
90837 Psychotherapy, 60 minutes
90839 Psychotherapy for Crisis, first 60 minutes
90846 Family Psychotherapy, without patient present
90847 Family Psychotherapy, 45 minutes
90849 Multiple-Family Group Psychotherapy
90853 Group Psychotherapy
For psychological and neuropsychological testing, 5 hours will trigger a request for clinical review to determine the medical necessity of additional testing (96101, 96102, 96103, 96111, 96116, 96118, 96119, 96120 and 96125).
For those HCPC codes (“H” codes) with the following notation, “No auth requirement up to 200 units. Prior Authorization Request = ON after 200 Units Total of identified HCPC Series Codes”, 200 combined units for those HCPC codes will trigger a request for clinical review to determine the medical necessity of additional HCPC units.
For questions regarding this notice, please contact Provider Services at 1-866-334-7927 or your Provider Relations Representative.
