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
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
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
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.