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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 and Medicare Members Preauthorization
For Commercial and Medicare 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. Here is a complete list of service codes which DO require preauthorization (updated 09/15/2015) when treating members with a Commercial or Medicare 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 96118, 96119, 96120, U918)
- 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
**All ABA services for autism treatment will continue to require preauthorization with the submission of the comprehensive treatment plan and Autism OTR.
Medicaid Members Preauthorization
For Medicaid members preauthorization is required for the service codes listed here.
MHNet adheres to State and/or Federal contract requirements and regulations related to prior authorization requirements for members with Medicaid plans.
OTR Submission for Preauthorization
Outpatient Authorizations for all MHNet members
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, you'll find a field named “Estimated Length of Treatment” that will 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. 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.
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.
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.
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. Also, all authorization requests for any level of care can be submitted electronically through the portal. For complete information about the portal, simply click on the MHNetProvider Portal page.
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: 1.724.741.4554
OTR Instruction Tool
- Includes "How to Complete" balloons when the cursor is moved over a specific area of the OTR