Precertification Requirements for Select Behavioral Health Services
The information below outlines precertification requirements for behavioral health and substance use disorders treatments. This information should be used only as reference and is not intended to replace any medical or payment policies. For medical necessity determination of services, HMSA uses evidence-based clinical criteria and guidelines developed by Magellan Healthcare Inc., MCG guidelines and where applicable Medicare National and Local Coverage Determinations.
Commercial Plans
|
Level of Care
|
Common Billing Codes
|
Prior Authorization Requirement
|
| Acute Hospitalization | 114, 124, 134, 116, 126, 136, 128 | Not required for admission. Concurrent reviews are required once a patient has been admitted. |
| Residential Treatment Program | 1001, 1002 | Required |
| Partial Hospitalization Program | 912, 913 | Required for non-participating providers only. |
| Intensive Outpatient Program | 905, 906 | Required for non-participating providers only. |
| Psychological/Neuropsychological Testing | 96130-3, 96136-7 | Not required |
| Electroconvulsive Therapy | 901 | Not required |
QUEST Integration Plans
|
Level of Care
|
Common Billing Codes
|
Prior Authorization Requirement
|
| Acute Hospitalization | 114, 124, 134, 116, 126, 136, 128 | Not required for admission. Concurrent reviews are required once a patient has been admitted. |
| Residential Treatment Program | 1001, 1002 | Required |
| Partial Hospitalization Program | 912, 913 | Required for non-participating and out-of-state providers only |
| Intensive Outpatient Program | 905, 906 | Required for non-participating and out-of-state providers only |
| Psychological/Neuropsychological Testing | 96130-3, 96136-7 | Required for non-participating and out-of-state providers only |
| Electroconvulsive Therapy | 901 | Required for non-participating and out-of-state providers only |
Medicare Advantage Plans
|
Level of Care
|
Common Billing Codes
|
Prior Authorization Requirement
|
| Acute Hospitalization | 114, 124, 134, 116, 126, 136, 128 | Not required for admission. Concurrent reviews are required once a patient has been admitted. |
| Residential Treatment Program | Not applicable | Not a Medicare benefit |
| Partial Hospitalization Program | 912, 913 | Not required for admission. Concurrent reviews are required once a patient has started treatment by non-participating providers. |
| Intensive Outpatient Program | 905, 906 | Not required for admission. Concurrent reviews are required once a patient has started treatment by non-participating providers. |
| Psychological/Neuropsychological Testing | 96130-3, 96136-7 | Not required |
| Electroconvulsive Therapy | 901 | Not required |
Note: Please refer to the precertification requirements for Transcranial Magnetic Stimulation, IV Ketamine Infusions as an Alternative to Electroconvulsive Therapy (ECT), and Esketamine Nasal Spray for Treatment of Resistant Depression in the medical policies under their respective titles on the Provider Resource Center.
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Magellan Healthcare, Inc., doing business as Magellan Hawaiʻi, is an independent company providing designated behavioral health services on behalf of HMSA.
