We are enhancing our authorization requirements for Medicaid.
‘Ohana 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 February 1, 2019, 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 February 1, 2019, 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 at1-888-846-4262 or your Provider Relations Representative.
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 February 1, 2019
90867 Therapeutic Repetitive Transcranial (TMS)
90868 Therapeutic Repetitive Transcranial (TMS)
90869 Therapeutic Repetitive Transcranial (TMS)
90870 Electroconvulsive Therapy
90899 Unlisted Psychiatric procedure
96105 Assessment of Aphasia of speech/language
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
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
H2012 Behavioral health day treatment; per hour
H2037 Developmental delay prevention activities, dependent child of client, per 15 minutes
S5108 Home care training to home care client, per 15 minutes
S5110 Home care training, family; per 15 minutes
S5150 Unskilled respite care, not hospice; per 15 minutes
T1001 Nursing Assessment/ Evaluation
T1003 LPN/ LVN services up to 15 minutes
T2027 Specialized childcare, waiver; per 15 minutes
T2036 Therapeutic camping, overnight, waiver; each session
T2037 Therapeutic camping, day, waiver; each sessionFor standard outpatient services, ‘Ohana 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.
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
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 certain HCPC codes (“H” codes) , 200 Units Total of all HCPC Series Codes will trigger a request for clinical review to determine the medical necessity of additional HCPC units. Those codes include: G0396, G0397, H0006, H0010, H0020, H0036, H2000, H2001, H2011, H2014, H2015, H2016, H2017, H2019, H2020, H2021, H2028, H2030, H2031, H2034, H2035, H2036, S9484, S9485, T1006, and T1007.
For questions regarding this notice, please contact Customer Services at 1-888-846-4262 or your Provider Relations Representative