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Prior Authorization Requirements

Exciting News!

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

90880              Hypnotherapy

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

                        mins, In-Clinic

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 session

For 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

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Last Updated On: 10/29/2018