Outpatient Auth Info
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- Autism Services
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Due to parity, 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. (For a complete list of service codes that do not require prior authorization, click here.) Prior authorization IS required for sessions that include therapy services. However, for Commercial members, effective on January 1, 2014, outpatient preauthorization will no longer be required for any routine behavioral health care. This means you won’t 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.
The following services will continue to 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
- All EAP services (codes contracted on the EAP Fee Schedule)
- 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.
- Higher levels of care, such as Intensive Outpatient (IOP), Partial Hospitalization (PHP), Residential, Rehabilitation, ECT, and Inpatient Acute care will continue to require preauthorization
**All ABA services for autism treatment will continue to require preauthorization with the submission of the comprehensive treatment plan and Autism OTR.
To help clarify the authorization requirements by service code for the different types of insurance, see below:
- This is the complete list of service codes that do not require prior authorization, for members with Medicare/Medicare Advantra and Medicaid. It also shows the requirements for members with Commercial policies through 12/31/13.
- This is the complete list of service codes which do require prior authorization for Commercial policies effective 1/1/14.
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 or fax the OTR with the original fax cover sheet confirmation to our troubleshooting team at 512.340.4213 for resolution and they will be in touch with you. It is recommended that you wait at least two (2) 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!
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. For complete information about the portal, simply click on the MHNetProvider Portal page.
Here is the List of outpatient service codes that require preauthorization
For Commercial members, MHNet's Medical Necessity Criteria is used to make determinations on preauthorization requests for all levels of care. Not all members have benefit coverage for each of the listed service codes or levels of care. To determine benefit coverage, go to the Provider Portal or call MHNet at the Behavioral Health telephone number on the back of the member's ID card. Please note: Services must be included in your Practitioner's contract before MHNet can issue authorization and payment.
Here is a one page Reference Guide, summarizing information specifically for Maryland Providers with updates that go into effect on 1/1/2014.
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).
Florida Medicaid Providers
MHNet is pleased to announce the release of the redesigned Florida Medicaid Outpatient Treatment Report (OTR). Below you will find a copy of the new Florida Medicaid OTR, Request for TBOS Services, Children’s Mental Health Targeted Case Management, Adult Mental Health Targeted Case Management, and Adult Intensive Mental Health Case Management forms as well as OTR Instructions and the Initial Authorization Bucket List Training. These forms have been specifically designed for providers treating Florida Medicaid members ONLY and are not intended to be used for any other group. Providers can begin using the new forms immediately. The old Florida Medicaid OTR will no longer be accepted after 3/1/13.
For questions about the Florida Medicaid OTR and member authorization requirements, call 800.250.3935, then select option 1 and dial extension 307.4918 to speak with a Florida Medicaid Customer Service Representative.
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 OTR Form
- Kentucky CMHC
Autism OTR Form
Florida Medicaid OTR Form: Children TCM
Florida Medicaid CMHC: Appendix I-Children's Certification
Children's Mental Health Targeted Case Management
Florida Medicaid OTR Form: Adult TCM
Florida Medicaid CMHC: Appendix J-Adult Certification
Adult Mental Health Targeted Case Management
Florida Medicaid OTR Form: Adult ICM-TCM
Florida Medicaid CMHC: Appendix K-Adult Certification-Intensive Case Management Team Services
Adult Mental Health Targeted Case Management
Florida Medicaid OTR Form: TBOS
- Florida Medicaid: Request for Therapeutic Behavioral On-site Services
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