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Commercial and Medicare Members Preauthorization
For Commercial and Medicare members, outpatient preauthorization is not required for any routine behavioral health care. This means you don't need to submit the Outpatient Treatment Request (OTR) for standard Outpatient services. Here's a complete list of service codes which DO require preauthorization (updated 01/01/2016) when treating members with a Commercial or Medicare policy.
As of January 1, 2016, not all Medicare plans will require preauthorization for ABA autism services and/or psychological/neuro-psychological testing services. Please contact MHNet at the phone number on the back of the members’ ID card to verify their requirements. 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. We adhere to State and/or Federal contract requirements and regulations related to prior authorization requirements for members with Medicaid plans.
Outpatient authorization for all MHNet members
To request the necessary authorization for those services that require it, complete the appropriate form found in the Forms Library.
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.