Exciting News!
We are enhancing our authorization requirements for Medicaid.
WellCare 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 September 15, 2018, 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 September 15, 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 SEPTEMBER 15, 2018
90867 Therapeutic Repetitive Transcranial (TMS)
90868 Therapeutic Repetitive Transcranial (TMS)
90869 Therapeutic Repetitive Transcranial (TMS)
90870 Electroconvulsive Therapy
90880 Hypnotherapy
90887 Interpretation or explanation of results of psych exam and procedures Outpatient Collateral, 15 min.
90899 Unlisted Psychiatric procedure
96105 Assessment of Aphasia of speech/language
0359T Behavior Identification Assessment (ABA)
0360T Observational Behavioral Follow-up Assessment
0361T Observational Behavioral Follow-up Assessment
0362T Exposure Behavioral Follow-up Assessment
0363T Exposure Behavioral Follow-up Assessment
0364T Adaptive Behavior Treatment By Protocol
0365T Adaptive Behavior Treatment By Protocol
0368T Adaptive Behavior Treatment With Protocol Modification
0369T Adaptive Behavior Treatment With Protocol Modification
0370T Family Adaptive Behavior Treatment Guidance
H0010 Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient)
H0011 Alcohol and/or drug services; acute detoxification (residential addiction program inpatient)
H0012 Alcohol and/or drug services; sub-acute detoxification (residential addiction program outpatient)
H0015 Alcohol and/or drug services; intensive outpatient treatment (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan) including assessment, counseling, crisis intervention, and activity therapies or education
H0018 Behavioral health; short-term residential (nonhospital residential treatment program), without room and board; per diem
H0019 Behavioral health; long term residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board; per diem
H0020 Alcohol and/or drug services; methadone administration and/or service (provisions of the drug by a licensed program)
H0035 Mental health partial hospitalization, treatment, less than 24 hours
H2037 Developmental delay prevention activities, dependent child of client, per 15 minutes
S9482 Family stabilization services; per 15 minutes
For standard outpatient services, WellCare 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. 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
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 will trigger a request for clinical review to determine the medical necessity of additional HCPC units. Those codes include: G0396, G0397, H0010, H0020, H2000, H2014, H2017, H2019 H2035, and H2036.
For questions regarding this notice, please contact Provider Services at 1-888-588-9842 or your Provider Relations Representative.
