Exciting News!
We are enhancing our authorization requirements for Medicaid.
WellCare 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 31st, 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 31st, 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.
OUTPATIENT PROCEDURE CODES REQUIRING
PRIOR AUTHORIZATION AS OF JULY 31, 2018
90867 Therapeutic Repetitive Transcranial (TMS)
90868 Therapeutic Repetitive Transcranial (TMS)
90869 Therapeutic Repetitive Transcranial (TMS)
90870 Electroconvulsive Therapy
90880 Hypnotherapy
90889 Prep of report of pt psych status
90899 Unlisted Psychiatric procedure
96105 Assessment of Aphasia of speech/language
97537 Community integration counseling
0359T Behavior Identification Assessment (ABA)
0360T-0361T Observational Behavioral Follow-up Assessment
0362T-0363T Exposure Behavioral Follow-up Assessment
0364T-0365T Adaptive Behavior Treatment By Protocol
0366T Group adaptive behavior treatment by protocol, In-Clinic
0367T Group adaptive behavior treatment by protocol, Additional 30 mins
0368T-0369T Adaptive Behavior Treatment With Protocol Modification
0370T Family Adaptive Behavior Treatment Guidance
0371T Multiple-family group adaptive behavior treatment guidance, In-Clinic
0372T Adaptive behavior treatment social skills group, In-Clinic
0373T Exposure adaptive behavior treatment with protocol modification, In-Clinic
0374T Exposure adaptive behavior treatment with protocol modification Additional 30 mins, In-Clinic
H0016 Alcohol and/or drug services; medical/somatic (medical intervention in ambulatory setting)
H0037 Community psychiatric supportive treatment program; per diem
H0039 Assertive Community Treatment; per 15 minutes
H0040 Assertive Community Treatment; per diem
H0047 Alcohol and drug services not otherwise specified
H2022 Community-based wrap-around services; per diem (intensive in-home services)
H2029 Sex Offend Tx Svc, Per Diem
H2033 Multi-systemic Therapy for Juveniles; per 15 minutes
H2034 Alcohol and/or drug abuse halfway house services; per diem
H2037 Developmental delay prevention activities, dependent child of client, per 15 minutes
S0201 Alcohol and/or drug treatment program; per hour
S5108 Home care training to home care client, per 15 minutes
S5110 Home care training, family; per 15 minutes
S5145 Behavioral health specialized foster care
S5150 Unskilled respite care, not hospice; per 15 minutes
S9123 In home psychiatric nursing
T1001 Nursing Assessment/ Evaluation
T1002 RN services up to 15 minutes
T1003 LPN/ LVN services up to 15 minutes
T1016 Case management, each 15 minutes
T1017 Targeted case management, each 15 minutes
T1019 Personal care services; per 15 minutes
T1020 Personal care services; per diem
T2001 Nonemergency transportation; patient attendant/escort
T2002 Non-emergency transportation; per diem
T2003 Non-emergency transportation; encounter/trip
T2004 Non-emergency transport; commercial carrier, multi-pass
T2005 Non-emergency transportation; stretch van
T2022 Other specified case management service not elsewhere classified
T2023 Targeted Case Management- per month
T2027 Specialized childcare, waiver; per 15 minutes
T2036 Therapeutic camping, overnight, waiver; each session
T2037 Therapeutic camping, day, waiver; each session
For standard outpatient services, 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, 45 min
90849 Multiple-family group psychotherapy
90853 Group psychotherapy
90887 Interpretation or explain of results of psych exam and procedures Outpatient Collateral, 15 min.
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 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: H0006, H0010, H0020, H0036, H2000, H2001, H2011, H2014, H2015, H2016, H2017, H2019, H2020, H2021, H2028, H2030, H2031, H2035, H2036, S9484, S9485, T1006, and T1007.
For questions regarding this notice, please contact Provider Services at 1-888-453-2534 or your Provider Relations Representative.
