Outpatient Auth Info
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Effective January 1, 2015, the authorization requirements for Medicare members will be the same as the current requirements for Commercial members (see specifics below).
Commercial Members Preauthorization
For Commercial members, outpatient preauthorization is not required for any routine behavioral health care. This means you do not need to submit the Outpatient Treatment Request (OTR) for standard Outpatient services, such as CPT codes 90834, 90836+, 90837, 90838+, 90846, 90847, 90853, etc. Here is a complete list of service codes which DO require preauthorization when treating members with a Commercial policy. Our clinical department will continue to review treatment, applying the appropriate medical necessity criteria. We may contact you as part of the review process. We may also ask for clinical records.
As a guide, the following services DO require preauthorization for all members and follow the established authorization procedures:
- Psychological Testing* (CPT codes 96101, 96102, 96103)
- Neuro-psychological Testing* (CPT codes 96116, 96118, 96119, 96120, 96125)
- Applied Behavior Analysis (ABA) autism services** (CPT codes contracted on the Autism Fee Schedule)
- Psychiatric home care services (CPT codes 99341-99345, 99347-99350)
- Outpatient detoxification
- Higher levels of care, such as Intensive Outpatient (IOP), Partial Hospitalization (PHP), Residential, Rehabilitation, ECT, and Inpatient Acute care do require preauthorization
- Services to MHNet Medicaid and Medicare or Medicare Advantra members. MHNet adheres to State and/or Federal contract requirements and regulations related to prior authorization requirements. Please contact MHNet for prior authorization exceptions for these populations.
**All ABA services for autism treatment will continue to require preauthorization with the submission of the comprehensive treatment plan and Autism OTR.
Medicare Members Preauthorization
NO authorization is required for the initial assessment; CPT codes 90791, 90792, E/M codes 99201-99205; or for medication management, CPT E/M codes 99211-99215. Prior authorization IS required for sessions that include therapy services. (Click here for a complete list of service codes that do NOT require prior authorization for Medicare members.) Effective January 1, 2015, the authorization requirements for Medicare members will be the same as the current requirements for Commercial members (see specifics above).
Medicaid Members Preauthorization
Effective January 1, 2015, the authorization requirements for Medicaid members in Missouri, Kentucky, Michigan and Virginia will be changing. Preauthorization will be required for the service codes listed here as of January 1, 2015.
MHNet adheres to State and/or Federal contract requirements and regulations related to prior authorization requirements for members with Medicaid plans. Please contact MHNet for the prior authorization requirements for these members.
OTR Submission for Preauthorization
Outpatient Authorizations for all MHNet members, except HealthCare USA
To request the necessary authorization for those services that require it, complete the Outpatient Treatment Report (OTR) after your intake appointment or at least 10 days before you need the authorization.
You can complete the OTR online through our portal and submit it instantly. More information on how to register is available in the MHNet Provider Portal section. From within MHNet’s portal, select “Online Help” from the top navigation bar.
Select the “Health Plan Tutorials” drop down menu on the right and you will find all five of our tutorials. Choose “Authorization Inquiry” and you will find instructions on how to use the authorization functions, including submitting a request for authorization. You can also click here for detailed instructions to assist you. This Frequently Asked Questions document will be helpful too.
“Estimated Length of Treatment”: In the “Select Procedure Code” section of the authorization module, we have replaced three fields (units, days, and treatment) with a new field named “Estimated Length of Treatment.” We also increased the size of the box to hold up to 9,999 units. For each procedure code, fill in the number of units you are requesting in the Estimated Length of Treatment box. It does NOT refer to the number of minutes per individual session.
MHNet’s turn-around time goal for processing OTRs (except where otherwise mandated) is approximately 10 business days. If there are any concerns that an OTR has not been received, you can speak with a Customer Service Representative. It is recommended that you wait two weeks before considering an OTR as possibly lost. Remember, you can always check the status of your authorizations on the Provider Portal, available 24/7!
If you do not have internet access to use the portal, completed OTRs (see below for the appropriate OTR form, except for Maryland providers who use their state-mandated form) can be faxed to 1.512.340.4213.
Effective Monday, February 9, 2015, ALL preauthorization requests for all levels of care will be managed by HealthCare USA as part of the integration efforts. For more details, click here to read the provider notification, including the assigned UM staff for each listed facility. Our portal at MHNetProvider.com will NO longer accept authorization requests.
HealthCare USA Member Prior Authorization/Case Management Contacts
- Prior Authorization/Outpatient Services
- Telephone: 1.800.882.9666
- Fax: 1.866.341.1327
- Intensive Outpatient Services: Contact Desley Wells 1.314.655.7619
- Inpatient and Partial Hospitalization Services: See list of Utilization Management assignments or Call 1.800.882.9666 and ask to speak to the UM staff person for your facility
- Case Management Services: Call HCUSA at 1.800.882.9666 And ask to speak with a Case Manager
Authorizations can cross-walk to cover services for other similar codes!
To streamline the authorization request and claim filing process, MHNet uses authorizations given for a specific code to cover services billed under different codes for similar services. MHNet’s Service Code Group Matrix illustrates how the codes "crosswalk" for authorization purposes to another code in the same group for the purposes of claims processing. For example, in group #8-Outpatient Therapy Service, an authorization for 90834 also will cover the authorization requirement for 90832 or 90837. Likewise, an authorization for 90833+ will crosswalk to cover an authorization for 90836+. In group # 6, note the standard autism service codes crosswalk to cover each other, and in group #16/#17 the testing codes will crosswalk. You don't need to call and change your authorized codes, simply bill it!
To summarize, when an authorization is obtained, a provider can bill any of the codes in the same Service Code Group as the authorized code, and claims submitted will crosswalk to cover any other procedure code in the same group.
Appointments for Members Discharged from Acute Care
When you accept appointments for members being discharged from an inpatient facility, keep in mind that you can bill the crisis code 90839 for the first 30-74 minutes of treatment and +90840 for up to 30 additional minutes WITHOUT preauthorization for ANY member (Medicare/Medicare Advantra or Commercial) and receive the higher, contracted reimbursement rate.
For Medicare/Medicare Advantra members, MHNet will automatically authorize 6 sessions upfront! We appreciate your willingness to work with these members and want to reduce your paperwork. We also recognize that these members can have increased treatment needs and the additional sessions will enhance your flexibility to see these members more than once a week to maintain their stability.
In compliance with the Maryland regulation regarding Prior Authorizations for commercial members, MHNet offers online access for providers to view all submitted authorizations through the MHNetProvider portal. As of August 1, 2014, all authorization requests can be submitted electronically through the portal. For complete information about the portal, simply click on the MHNetProvider Portal page.
Here is the List of outpatient service codes that require preauthorization.
Here is a one page Reference Guide, summarizing information specifically for Maryland Providers.
Missouri and Illinois Providers
In-Home Services Code Changes. Effective for dates of service on or after August 1, 2013, MHNet will no longer accept the 99341-99350 codes for in-home services from non-prescribing providers (i.e. psychologists and Master’s level therapists). Providers must use the current psychotherapy CPT codes (for example, 90791, 90832, 90834, 90839, 90846, and 90847) for services provided in the member’s home or school, and add the modifier U8, with the appropriate place of service code (home=12, school=3) to indicate treatment did not occur in the practitioner’s office.
- For in-home services done before August 1, 2013, obtain authorization and bill with codes 99341-99350.
- For in-home services done on or after August 1, 2013, obtain authorization for the standard psychotherapy codes (e.g. 90832, 90834, 90839, 90846, and 90847) and request the U8 modifier on the OTR. However, all authorizations for these codes (with or without the U8 modifier) will cover services billed with the U8 modifier.
- For in-home services done on or after August 1, 2013, billing should be submitted using the standard psychotherapy codes with the U8 modifier and appropriate place of service code (home=12, school=3).
Verify Member Eligibility & Benefits
To verify member eligibility and obtain benefit information, providers have two (2) options. The Provider Portal offers secured, online access to this information anytime. To learn more and register for this free service, go to the MHNet Provider Portal page. Our Customer Service Representatives (CSRs) also are available to assist providers and members by calling the BH phone number on the back of the member's ID card.
REVISED Outpatient Treatment Report [OTR] Forms
CoventryCares of Kentucky CMHC OTR Form
- for Kentucky CMHC providers
CoventryCares of Kentucky Standard OTR Form
- for Kentucky individual/group providers
Autism OTR Form
OTR Instructions and Hints
Maryland Providers OTR Instructions
In addition to the above change:
- Please continue to use the State-mandated OTRs
- Fax the completed form to: 1.512.340.4213
OTR Instruction Tool
- Includes "How to Complete" balloons when the cursor is moved over a specifc area of the OTR