ccpcares

Behavioral Health Authorization Guidelines

Quick Links

FHK Services Requiring Prior Auth |
MMA Services Requiring Prior Auth

To identify services / procedure codes you are contracted and eligible to provide,
please refer to your Provider Agreement.

All Non-Participating providers require prior authorization.
All service codes not included in this table require prior authorization.

PROFESSIONAL BEHAVIORAL HEALTH SERVICES
Service Description	Billable Provider Type(s)	Billing Codes & Add On(s)	Allowed Locations	No Prior Authorization Required
Psychiatric Diagnostic Evaluation	MD, DO, PhD, PsyD, ARNP., LMHC, LCSW, LMFT	90791 (with modifier or without modifier GT)	03,04,11,12, 13,19,22,33, 50,71,72,99	No
Psychiatric Diagnostic Evaluation with Medical Services	MD, DO, ARNP	90792 (with modifier or without modifier GT)	03,04,11,12, 13,19,22,33, 50,71,72,99	No
Medication Management	MD, DO, ARNP	99211 – 99213 (with modifier or without modifier GT) T1015 (with and without modifier)	11,19, 22, 49, 50, 71, 72,	No – 99211-99213 (For up to 11 follow- ups within plan year), with or without add- on 90833 Medication management is not reimbursable on the same day, for the same recipient, as brief group medical therapy or brief individual medical psychotherapy.
Individual Psychotherapy Family Psychotherapy (without patient) Family Psychotherapy (with patient) Group Psychotherapy	MD, DO, PhD, PsyD, ARNP, LCSW, LMFT, LMHC	90832,90834, 90846, 90847, 90853	03,04,11,12, 13,19,22,33, 50,71,72,99	No – 90832, 90834, 90846, 90847, 90853 combined (For up to 9 follow-up visits within plan year).
Consults at Skilled Nursing Facility or Custodial Care - Assessment	MD, ARNP	99305	31, 32	No
Consults at Skilled Nursing Facility or Custodial Care - Follow-up	MD, ARNP	99308	31, 32	No – up to 11 visits in plan year
Consults at ALF - Initial	MD, ARNP	99325	12, 13	No
Consults at ALF - Follow-up	MD, ARNP	99334	12, 13	No - up to 6 visits in plan year

COMMUNITY MENTAL HEALTH CENTER (CMHC) SERVICES Please note that Community Mental Health Centers must submit a roster of clinicians rendering services in order to avoid claim denials / pends.
Service Description	Billable Provider Type(s)	Billing Codes & Modifier(s)	Allowed Locations	No Prior Authorization Required
Behavioral Health Day Services, mental health (for children ages 2 through 5 years) *1 unit = 1 hour* *Must provide a minimum of 2 hours to a max of 4 hours per day.* *Same day hours do not have to be consistent.* *190-hour units per member per fiscal year* – *combined with H2012HF*	MD, PhD, PsyD, ARNP, LPC, LCSW, LMFT, LMHC, CAP- Masters Level	H2012	53, 57	No authorization is required for 120 units (30 hours) per fiscal year. Pre-authorization is required for additional units.
Behavioral Health Day Services, mental health *1 unit = 1 hour 190-hour units per member per fiscal year - combined with H2012 HF*	MD, PhD, PsyD, ARNP, LPC, LCSW, LMFT, LMHC, CAP- Masters Level	H2012	03, 04,11, 12, 33, 53, 57, 99	No authorization is required for 120 units (30 hours) per fiscal year. Pre-authorization is required for additional units.
Behavioral Health Day Services, substance abuse *1 Unit = 1 hour* *190-hour units per member per fiscal year* – *combined with H2012*	MD, PhD, PsyD, ARNP, LPC, LCSW, LMFT, LMHC, CAP- Masters Level	H2012 HF	03, 04,11, 12, 33, 53, 57, 99	No authorization is required for 120 units (30 hours) per fiscal year. Pre-authorization is required for additional units.
Psychosocial Rehabilitation Services *1 unit = 15 minutes 1,920 Units (480 hours; 20 days) per member per fiscal year*	MD, PhD, PsyD, ARNP, LPC, LCSW, LMFT, LMHC, CAP- Masters Level	H2017	03, 04,11, 12, 33, 53, 57, 99	No authorization is required for 960 units (240 hours) per fiscal year. Pre-authorization is required for additional units.
Therapeutic Behavioral On-Site Services , Therapy *(Child/Adolescent) Services limited to recipients under age 21* *1 unit = 15 minutes 36 Units per member per month* – *combined with H2019HN*	MD, Psychologist, LCSW, LMFT, LMHC, CAP- Master Level	H2019 HO	03, 04,11, 12, 33, 53, 57, 99	No authorization required for up to 162 units (40.5 hours) for 6 months, for an Initial Request Pre-authorization is required for additional units.
Comprehensive Behavioral Health Assessment *0-20 years of age* *1 per member per* *fiscal year* *1 unit = 15 minutes* *80 units (20 hours) per* *member per fiscal year*	MD, DO, PhD, PsyD, ARNP, LCSW, LMFT, LMHC	H0031 HA	03, 11, 12, 33, 53, 99		No Authorization for initial 15 hours. Pre-authorization required for up to 5 additional hours.

COMMUNITY MENTAL HEALTH CENTER (CMHC) SERVICES Please note that Community Mental Health Centers must submit a roster of clinicians rendering services in order to avoid claim denials / pends.
TARGETED CASE MANAGEMENT
Service Description	Billable Provider Type(s)	Billing Codes & Modifier(s)	Allowed Locations	No Prior Authorization Required
Children’s Mental Health Target Group *Birth through age 17 1 unit = 15 minutes* *344 units per month*	Masters, some at Bachelor's with Masters Supervision	T1017 HA	03, 04,11,12, 53, 99	No authorization is required for 516 units (129 hours) per fiscal year. Pre-authorization is required for additional units.
Adult Mental Target Group *18 years or older* *1 unit = 15 minutes* *344 units per month*	Most Masters, some at Bachelor's with Masters Supervision	T1017	03, 04,11,12, 53, 99	No authorization is required for 516 units (129 hours) per fiscal year. Pre-authorization is required for additional units.

TARGETED CASE MANAGEMENT

Service Description

Billable Provider Type(s)

Billing Codes
& Modifier(s)

Allowed Locations

No Prior
Authorization
Required

Adult Mental Target Group

18 years or older

1 unit = 15 minutes

48 units per day

Most Masters,

some at
Bachelor's with

Masters

Supervision

T1017
HK

03, 04,11,12, 53, 99

No authorization is
required for 516
units (129 hours)
per fiscal year.

Pre-authorization is
required for
additional units.