Prior authorization codes
South Country Health Alliance
Active CPT codes that appear on the extracted prior authorization list for this health plan.
| Code | Procedure / Service | Effective | Revised | Confidence | Source |
|---|---|---|---|---|---|
| 4797B | Responsibilities and Consent form to the member document how they reviewed the DHS | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90785 | medical services may be used with | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90791 | Standard diagnostic 1 Maximum of four sessions | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90792 | and | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90832 | Psychotherapy – with member 30 min No limit or authorization | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90833 | member of 91 minutes | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90834 | Psychotherapy – with member 45 min | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90836 | Appropriate E/M and psychotherapy – with member 60 min | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90837 | Psychotherapy – with member 60 min | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90838 | E/M and | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90839 | Psychotherapy for crisis 60 min No limit or | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90840 | Psychotherapy for crisis (each additional 30 30 min No limit or | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90846 | Family psychotherapy without member 50 min No limit or authorization | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90847 | Family psychotherapy with member 50 min | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90849 | Multiple family group psychotherapy 1 | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90853 | Group psychotherapy 1 No limit or authorization | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90875 | Individual psychophysiological therapy 30 min | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90876 | Individual psychophysiological therapy 45 min | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90882 | Environmental or 1 Authorization is required for | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 90899 | U8 Clinical care consultation, face to face 5-10 min Calendar | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 96116 | Neurobehavioral status 1 hour • Authorization is | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 96121 | neuropsychologist | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 96130 | Psychological testing evaluation services 1 hour Eight (8) cumulative | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 96131 | Each additional hour 1 hour | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 96132 | neuropsychologist | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 96133 | includes face–to-face time | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 96136 | includes face–to-face time | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 96137 | includes face–to-face time | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 96138 | with patient and , and in a | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 96139 | with patient and , and in a | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 96146 | five sessions of | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 99221 | — Inpatient hospital • Psychiatrist is admitting physician for initial hospital | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 99223 | care visit or medical physician performs a physical | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 99231 | — Subsequent Medical physician manages recipient’s non-psychiatric | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 99233 | hospital care medical care after initial inpatient hospital consultation | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 99251 | — Initial inpatient A physician requests a consultation | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 99255 | consultation Must see the patient face to face | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| 99499 | HE AG Primary care Communication 1 Add the U4 modifier | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| G0396 | intervention, 15-30 mins | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| G0397 | intervention, greater than 30 mins | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| G2011 | intervention, 5-14min | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| G9006 | • Case Aide billing code | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| H0019 | Behavioral health; long term residential (non-medical, non-acute per diem | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| H0031 | Mental health 1 Authorization required for | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| H0032 | Mental health service 1 Authorization required for | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| H0034 | Medication education, Per 15 Authorization is required for | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| H0035 | No modifier Partial hospitalization services - age 18 and over 1 Session | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| H0038 | Self-help / peer services by Level I Certified Peer 15 min | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| H0040 | Assertive Community Treatment Program 1 Daily | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| H2011 | Adult crisis assessment, 15 Except for community | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| H2012 | Behavioral health day treatment 1 hour Maximum 15 hours per | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| H2017 | Basic living and social 15 min Authorization is required for | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| H2019 | U1 Individual DBT therapy 15 min Up to 26 | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| H2027 | Family psychoeducation - 15 104 units/calendar year | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| H2035 | counselor can be provided in individual or group counseling ( or HQ) and | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| H2036 | For residential SUD admissions ( ) including IMD and hospital based inpatient treatment | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| S0280 | U5 BHH services care engagement, initial plan 1=month One | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| S0281 | U5 BHH services ongoing standard care, 1=Month One | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| S5145 | HE Children's Intensive Per diem No limit or authorization | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| T1016 | can also fall under the role of a treatment coordinator ( HN U8) | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |
| T2023 | HE HA Face-to- ace contact between case manager, the 1 unit / month | 2026-07-06 | 2025-10-23 | 97% | [PDF] Chapter 22 - South Country Health Alliance |