Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 (401) 274-4848 WWW.BCBSRI.COM MEDICAL COVERAGE POLICY | 1 OVERVIEW The intent of this policy is to provide information regarding credentialing for professional outpatient behavioral health providers, document provider specialty restrictions for CPT codes, and to provide medical record documentation requirements for behavioral health providers. MEDICAL CRITERIA Not applicable NOTIFICATION OF ADMISSION Not applicable
POLICY STATEMENT Credentialing: BCBSRI credentials the following independently licensed behavioral health clinicians: • Psychiatrists (MD, DO) • Psychiatric Neurologist (MD, DO) • Child/Adolescent Psychiatrist (MD, DO) • Clinical Nurse Specialist (CNS) • Behavioral Health Nurse Practitioner (BH NP) • Behavioral Health Physician’s Assistant (BH PA) • Psychologists (PhD, PsyD) • Licensed Independent Clinical Social Workers (LICSW) • Licensed Mental Health Counselors (LMHC) • Licensed Marriage and Family Therapists (LMFT) • Licensed Behavior Analysts (LBA) • Licensed Chemical Dependency Professionals (LCDP) *Not covered for Medicare Advantage Plans BCBSRI has implemented a supervisory protocol process whereby Licensed Clinical Social Workers (LCSWs), Postdoctoral clinicians, Mental Health Counselor Associates (MHC-As), and Marriage and Family Therapist Associates (MFT-As), and Physician Assistants (PAs) may render services to our members in a professional outpatient setting under the supervision of an independently licensed behavioral health clinician. Please refer to BCBSRI’s Behavioral Health Supervisory Protocol for Licensed Clinical Social Workers, Postdoctoral Clinicians, Mental Health Counselor Associates, and Marriage and Family Therapist Associates policy.
For more information, please contact BCBSRI Behavioral Health Utilization Management at 1-800-274-2958 Coding: Unless specified in a specific payment policy, BCBSRI follows correct coding and payment guidelines published by National and Regional CMS (including DMEMAC) and other correct coding national standards such as Current Procedural Terminology (CPT). Please refer to the Coding and Payment Guidelines policy for additional details. All services rendered should be in accordance with correct coding. Provider specialty restrictions exist for CPT codes for behavioral health services as defined in the coding grids below. EFFECTIVE DATE: 07|01| 2025 POLICY LAST REVIEWED: 12|17|2025 Payment Policy | Behavioral Health Outpatient Professional Services

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 (401) 274-4848 WWW.BCBSRI.COM MEDICAL COVERAGE POLICY | 2 Behavioral Health Services Provided to Children Under the Age of 18: BCBSRI recognizes that the evaluation of children/adolescents often takes longer than adults and requires additional collateral contacts that further differentiate this population. Effective, for dates of service on or after January 1,2013, BCBSRI allows providers to file with a modifier “TU” Special Payment Rate, Overtime for extended psychiatric diagnostic interview examination (90791TU and 90792TU) for children under the age of 18. Extended services are defined as psychiatric diagnostic interview/examinations that extend longer than 75 minutes for our members under 18 years of age.

Medical Record Documentation requirements Please see the attached document that provides the Behavioral Health Medical Record Documentation standards Documentation Standards

For additional information, please contact BCBSRI's Behavioral Health Utilization Management at 800-274-2958.

COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Evidence of Coverage or Subscriber Agreement for applicable Behavioral Health Services for benefits and applicable deductibles and/ or co- payments.

CODING The following is applicable for Medicare Advantage Plans and Commercial Products. Table 1 is regarding the following specialties: Psychologist, Licensed Independent Clinical Social Worker (LICSW), Licensed Marriage/Family Therapist (LMFT), Licensed Mental Health Counselor (LMHC), Licensed Chemical Dependency Professionals (LCDP)

Table 1 Provider Specialty CPT Code Name CPT Code Comments

• Psychologist • Licensed Independent Clinical Social Worker (LICSW) • Licensed Marriage/Family Therapist (LMFT) • Licensed Mental Health Counselor (LMHC) • Licensed Chemical Dependency Professionals (LCDP) *Not covered for Medicare Advantage Plans Psychiatric Diagnostic Evaluation 90791 Psychotherapy 90832, 90834, 90837 Interactive Complexity Add-On Code 90785 Must be billed with appropriate primary procedure per CPT coding guidelines Psychotherapy Crisis 90839, 90840 Family/Group Therapy 90846, 90847, 90849, 90853, 90857 Psychological and Neuro- Psychological Testing Refer to Psychological and Neuropsychological Testing policy CPT coding details These procedures are limited to the following specialties:

1. Neuropsychologist,
2. Psychologist

3. Pediatric neurodevelopmental specialist.

   Refer to the Psychological and

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 (401) 274-4848 WWW.BCBSRI.COM MEDICAL COVERAGE POLICY | 3

Neuropsychological Testing policy for additional details. Health Behavior Assessment/ Intervention Refer to Health and Behavior Assessment policy for CPT coding details Table 2 is regarding the following specialties: Psychiatry (MD, DO), Psychiatric Neurologist (MD, DO), Child/Adolescent Psychiatry (MD, DO), Clinical Nurse Specialist (CNS), Behavioral Health Nurse Practitioner (BH NP), Behavioral Health Physician’s Assistant (BH PA)

Table 2 Provider Specialty CPT Code Name CPT Code Comments

• Psychiatry (MD, DO)
• Psychiatric Neurologist (MD, DO) • Child/Adolescent Psychiatry (MD, DO) • Clinical Nurse Specialist (CNS)
• Behavioral Health Nurse Practitioner (BH NP) • Behavioral Health Physician’s Assistant (BH PA) Psychiatric Diagnostic Evaluation 90791

Psych Diagnostic Medical 90792

Psychotherapy 90832, 90834, 90837

Psychotherapy/E/M Add-On Codes 90833, 90836, 90838 Must be billed with appropriate primary procedure per CPT coding guidelines E/M Codes 99201-99205, 99211- 99215, 99221-99223, 99231-99233, 99238, 99239

Interactive Complexity Add-On Code 90785 Must be billed with appropriate primary procedure per CPT coding guidelines Psychotherapy Crisis 90839, 90840

Family/Group Therapy 90846, 90847, 90849, 90853

Transcranial Magnetic Stimulation (TMS) Refer to Transcranial Magnetic Stimulation policy for CPT coding details

Electro Convulsive Therapy (ECT) 90870

Psychological and Neuro-Psychological Testing Refer to
Psychological and Neuropsychological Testing policy CPT coding details

These procedures are limited to the following specialties:

1. Neuropsychologist,
2. Psychologist
3. Pediatric neurodevelopmental

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 (401) 274-4848 WWW.BCBSRI.COM MEDICAL COVERAGE POLICY | 4 CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. specialist. Refer to the Psychological and Neuropsychological Testing policy for additional details. Table 3 is regarding the following specialties: Licensed Behavior Analyst (LBA) and Psychologists Table 3 Provider Specialty CPT Code Name CPT Code Comments • Licensed Behavior Analyst (LBA) • Psychologists Applied Behavior Analysis Codes. Please refer to Autism Spectrum Disorders Mandate policy for additional details Please refer to Autism Spectrum Disorders Mandate policy for details on CPT coding LBAs are only allowed to file claims for the codes in this code set. Please refer to Autism Spectrum Disorders Mandate policy for additional details

RELATED POLICIES Autism Spectrum Disorders Mandate Behavioral Health Supervisory Protocol for Licensed Clinical Social Workers, Postdoctoral Clinicians, Mental Health
Counselor Associates, and Marriage and Family Therapist Associates
Coding and Payment Guidelines Health and Behavior Assessment
Preventative Services for Commercial Provider Credentialing and Recredentialing Process Psychological and Neuropsychological Testing
Telemedicine Services for Medicare Advantage Telemedicine Services for Commercial Products
Transcranial Magnetic Stimulation PUBLISHED Provider Update, July 2025 Provider Update, February/December 2024 Provider Update March 2023 Provider Update August 2022 Provider Update August 2021

REFERENCES None