Exciting News!
We are enhancing our authorization requirements for Medicaid.
MissouriCare 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 July 31, 2018, we are standardizing Behavioral Health authorization requirements across ALL outpatient places of service for our Medicaid services. The following page outlines 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 July 31, 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 if 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 JULY 31, 2018
90870 Electroconvulsive Therapy
90880 Hypnotherapy
96105 Assessment of Aphasia of speech/language
H2019 Therapeutic behavioral services; per 15 minutes
S9480 Intensive outpatient psychiatric services; per diem
For standard outpatient services, MissouriCare/WellCare will continue to use our outlier management practice to monitor and review appropriate utilization of routine outpatient therapy services. This means that 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 mins
90834 Psychotherapy, 45 mins
90837 Psychotherapy, 60 mins
90839 Psychotherapy for crisis, first 60 min.
90846 Family Psychotherapy, without patient present
90847 Family Psychotherapy, 50 min
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, 96103, 96111, 96116, and 96120).
For the following HCPC codes (“H” codes), 200 Units Total will trigger a request for clinical review to determine the medical necessity of additional HCPC units: H0010, H0020, H0036, H2011, H2014, H2015, H2017, H2019, T1006.
For questions regarding this notice, please contact Provider Services at 1-800-322-6027 or your Provider Relations Representative.
