Behavioral Health Services - UHCprovider

UnitedHealthcare OxfordAdministrative PolicyBehavioral Health ServicesPolicy Number: BEHAVIORAL 021.33 T0Effective Date: January 1, 2021 Instructions for UseTable of ContentsPagePurpose . 1Definitions . 1Prior Authorization Requirements . 1Policy . 2Procedures and Responsibilities . 3Applicable Codes . 3Benefit Considerations . 13References . 14Policy History/Revision Information . 15Instructions for Use . 15Related Policies Autism Drug TestingPurpose See Benefit ConsiderationsThis policy provides information regarding the coverage of treatment for mental health and substance use disorders, asdetermined by applicable federal and/or state legislation, Oxford certificates of coverage and utilization managementguidelines.DefinitionsNon-Routine Services: Outpatient services that require clinical review for approval, when coverage is available. Non-RoutineServices include, but are not limited to extended length sessions, psychological/ neuropsychological testing, transcranialmagnetic stimulation, intensive outpatient treatment, intensive behavioral therapy, ambulatory ECT, psychiatric consult on amedical bed, and methadone maintenance.Note: Not all Non-Routine services listed may be covered; refer to the member specific benefit plan document or Certificate ofCoverage for specific requirements.Prior Authorization RequirementsStateCT, NJ, and NYReferral and Prior Authorization GuidelinePrior authorization and/or referral are not required for routine outpatient mental health and/orsubstance use disorder services when rendered in the following settings: telehealth setting (02), aphysician's office (11), outpatient (19 or 22), assisted living facility(13), group home (14), or nursingfacility (32) setting.CPT Codes 90875 and 90876 require prior authorization in all sites of service for behavioral healthdisorders.Exception: Neurofeedback/biofeedback is excluded from coverage for NJ Small and Large Groups.Behavioral Health ServicesUnitedHealthcare Oxford Administrative PolicyPage 1 of 15Effective 01/01/20211 1996-2021, Oxford Health Plans, LLC

StateCTNJNY(for individuals18 years old andolder)NY(for individualsunder 18 yearsold)Referral and Prior Authorization GuidelinePrior authorization is required for mental health and substance use disorders when performed in aninpatient [including inpatient partial hospitalization (PHP)] or residential setting or when services arepart of an intensive outpatient treatment program (IOP).For NJ sitused fully insured plans, prior authorization is required for substance use services whenservices are rendered by an out-of-network treatment provider or when services are rendered in amedical or mental health setting.In-network services for substance use disorder do not require prior authorization for the first 28 daysof inpatient/residential and partial/IOP as per NJ Chap 28; prior authorization is not required,however it is strongly recommended for substance use services.Prior authorization is required for mental health services when performed in an inpatient [includinginpatient partial hospitalization (PHP)] or residential setting or when services are part of an intensiveoutpatient treatment program (IOP).Notification is required for NY in-network substance use services within 2 business days of theadmission to inpatient [including partial hospitalization (PHP)] or residential setting or when servicesare part of an intensive outpatient treatment program (IOP). There will be no concurrent review forthese admissions for the first 28 days.Prior authorization is required for all other in-network and out-of-network substance use serviceswhen performed in an inpatient [including partial hospitalization (PHP)] or residential setting or whenservices are part of an intensive outpatient treatment program (IOP).Notification is required for NY in-network mental health and substance use services within 2business days of the admission to inpatient [including partial hospitalization (PHP)] or residentialsetting or when services are part of an intensive outpatient treatment program (IOP). There will be noconcurrent review for these admissions for the first 14 days.Prior authorization is required for all other in-network and out-of-network mental health andsubstance use services when performed in an inpatient [including partial hospitalization (PHP)] orresidential setting or when services are part of an intensive outpatient treatment program (IOP).PolicyOxford administers benefit coverage for behavioral health services in coordination with OptumHealth. OptumHealth useswritten criteria based on sound clinical evidence to make coverage determinations, as well as to inform discussions aboutevidence-based practices and discharge planning. In using its clinical criteria, Optum takes individual circumstances and thelocal delivery system into account when determining coverage of behavioral health services. Optum uses the following clinicalcriteria:American Society of Addiction Medicine (ASAM) for substance-related disordersLevel of Care Utilization System (LOCUS) for adults 18 and olderChild and Adolescent Service Intensity Instrument (CASII) for children and adolescents ages 6-18Early Childhood Service Intensity Instrument (ECSII) for children ages 0-5OptumHealth:Adopts and disseminates clinical practice guidelines relevant to its members for the provision of behavioral health services.The clinical practice guidelines adopted by OptumHealth include those produced by the American Psychiatric Association,and the American Academy of Child and Adolescent Psychiatry.Develops clinical criteria that supersedes its standard set or adopts externally-developed clinical criteria when required todo so by contract or regulation.Annually reviews its clinical criteria and the procedures for applying them, and updates internally-developed clinical criteriawhen appropriate.OptumHealth’s clinical criteria are available to:Practitioners on the Optum website: www.providerexpress.com.Beneficiaries on the Optum website: www.liveandworkwell.com.Paper copies are available to providers and members upon request.Behavioral Health ServicesUnitedHealthcare Oxford Administrative PolicyPage 2 of 15Effective 01/01/20211 1996-2021, Oxford Health Plans, LLC

Procedures and ResponsibilitiesProvider StatusParticipatingprovidersBehavioral Health Provider ReimbursementReimburse at the contracted rateNon-participatingprovidersReimburse at the allowed amount (without a reduction for licensure level)Notes: The services discussed in this policy may be subject to one or more of Oxford's Reimbursement Policies. A cost share may apply; refer to the member's Certificate of Coverage and/or health benefits plan documentation forspecific information.Applicable CodesThe following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive.Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service.Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that mayrequire coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claimpayment. Other Policies may apply.CPT CodeBehavioral HealthEligible Provider Type90791, 90785,90832, 90834,90837, 90839,90840, 90845,90845, 90847,90849, 90853,90875, 90876All behavioral healthproviders90792, 90833,90836, 90838,90865Psychiatrist (MD, DO),Nurse Practitioner, andPhysician Assistant90863Select prescribingpsychologists [appliesto psychologistslicensed in the states ofLouisiana (LA) and NewMexico (NM) only]Coding ClarificationsReimbursement for the Behavioral Health and Evaluation and ManagementCPT Codes are subject to the billing requirements established by theAmerican Medical Association (AMA) and the American PsychiatricAssociation (APA).CPT codes (90832-90834, 90836-90839, 90875-90876, and 90899) aretime-based. For purposes of benefit accumulation, Oxford will considereach billed/submitted code as 1 (one) visit or session. For example, if 2(two) twenty-minute psychotherapy sessions are provided on a single dateof service, regardless of provider, these are recognized as 2 (two)separate and distinct sessions.CPT codes 90837 and 90838 are considered non-routine (and priorauthorization is required when rendered in a physician's office or anoutpatient setting).Neurofeedback/Biofeedback (CPT codes 90875 or 90876):o Is not covered for NJ Large and Small group members.o Requires prior authorization in all sites for CT and NY members.Refer to OptumHealth’s clinical criteria available in the followinglocations: Practitioners on the Optum website: www.providerexpress.com. Members on the Optum website: www.liveandworkwell.com.Evaluation and Management99202-99205,99211-99215,99217, 9921899220, 9922199223, 9922499226, 9923199233, 9923499236,Psychiatrist (MD, DO),Nurse Practitioner, andPhysician AssistantReimbursement for the Behavioral Health and Evaluation and ManagementCPT Codes are subject to the billing requirements established by theAmerican Medical Association (AMA) and the American PsychiatricAssociation (APA).Behavioral Health ServicesUnitedHealthcare Oxford Administrative PolicyPage 3 of 15Effective 01/01/20211 1996-2021, Oxford Health Plans, LLC

CPT 99341-99345,99347-99350Eligible Provider TypeCoding ClarificationsDiagnosis CodeCT - Parity ExclusionsDescriptionF11.122Opioid abuse with intoxication with perceptual disturbanceF11.129Opioid abuse with intoxication, unspecifiedF11.13Opioid abuse with withdrawalF11.159Opioid abuse with opioid-induced psychotic disorder, unspecifiedF11.181Opioid abuse with opioid-induced sexual dysfunctionF11.188Opioid abuse with other opioid-induced disorderF11.19Opioid abuse with unspecified opioid-induced disorderF11.222Opioid dependence with intoxication with perceptual disturbanceF11.229Opioid dependence with intoxication, unspecifiedF11.259Opioid dependence with opioid-induced psychotic disorder, unspecifiedF11.281Opioid dependence with opioid-induced sexual dysfunctionF11.288Opioid dependence with other opioid-induced disorderF11.29Opioid dependence with unspecified opioid-induced disorderF11.921Opioid use, unspecified with intoxication deliriumF11.922Opioid use, unspecified with intoxication with perceptual disturbanceF11.929Opioid use, unspecified with intoxication, unspecifiedF11.959Opioid use, unspecified with opioid-induced psychotic disorder, unspecifiedF11.981Opioid use, unspecified with opioid-induced sexual dysfunctionF11.988Opioid use, unspecified with other opioid-induced disorderF11.99Opioid use, unspecified with unspecified opioid-induced disorderF12.122Cannabis abuse with intoxication with perceptual disturbanceF12.129Cannabis abuse with intoxication, unspecifiedF12.13Cannabis abuse with withdrawalF12.159Cannabis abuse with psychotic disorder, unspecifiedF12.180Cannabis abuse with cannabis-induced anxiety disorderF12.188Cannabis abuse with other cannabis-induced disorderF12.19Cannabis abuse with unspecified cannabis-induced disorderF12.222Cannabis dependence with intoxication with perceptual disturbanceF12.229Cannabis dependence with intoxication, unspecifiedF12.259Cannabis dependence with psychotic disorder, unspecifiedBehavioral Health ServicesUnitedHealthcare Oxford Administrative PolicyPage 4 of 15Effective 01/01/20211 1996-2021, Oxford Health Plans, LLC