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Prior Authorization Requirements

Exciting News!

We are enhancing our authorization requirements for Medicaid.

Harmony 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 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 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

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

97537              Community integration counseling 

H0016             Alcohol and/or drug services; medical/somatic (medical intervention in

                        ambulatory setting)

H0036             Community psychiatric supportive treatment, face to face

H0037             Community psychiatric supportive treatment program; per diem

H0039             Assertive Community Treatment; per 15 min

H0040             Assertive Community Treatment; per diem

H0047             Alcohol and drug services not otherwise specified

H2012             Behavioral health day treatment; per hour

H2013             Psychiatric health facility service per diem   

H2018             Psychosocial rehabilitation services; per diem

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

H2037             Developmental delay prevention activities, dependent child of client, per 15 minutes

S0109              Methadone, oral, 5mg

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   

S9475              Ambulatory setting substance abuse treatment or detoxification services; per diem

S9480              Intensive outpatient psychiatric services; per diem

S9482              Family stabilization services; per 15 minutes

T1001              Nursing Assessment/ Evaluation

T1002              RN services up to 15 minutes

T1003              LPN/ LVN services up to 15 minutes

T1017              Targeted case management, each 15 minutes

T1019              Personal care services; per 15 minutes

T1020              Personal care services; per diem

T2036              Therapeutic camping, overnight, waiver; each session

For standard outpatient services, Harmony 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 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 explanation 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, 96119, 96120 and 96125).

For the following HCPC codes, 200 Units Total will trigger a request for clinical review to determine the medical necessity of additional HCPC units. Those codes include:  G0396, G0397, H0010, H0020, H0036, H2000, H2001, 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 Provider Services at <1-800-608-8158> or your Provider Relations Representative.

You should always check the Illinois Department of Healthcare and Family Services (HFS) website for Medicaid approved services prior to submitting a claim. Go to https://www.illinois.gov/HFS/Pages/default.aspx for more information.

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Last Updated On: 8/15/2018