Behavioral Health Authorizations

Initial Evaluations

Initial evaluations (CPT code 90801) and psychiatric services (CPT codes 90805, 90807, 90862, and 90870) do not require authorization. Claims paid for these services will apply toward the Network Health Plan patient’s benefit year maximum outpatient visit limit, if applicable.

For a complete list of Behavioral Health forms in Word and PDF formats, please visit the Behavioral Health Forms page.

Outpatient Therapy Sessions

All outpatient behavioral health sessions for therapy require an authorization. You may request an authorization by submitting the Outpatient Treatment Request-Initial form to Network Health Plan. If your patient requires visits beyond the number initially authorized, please request additional visits by completing the Outpatient Treatment Request-Concurrent form.

If your Network Health Plan patient has had more than 20 outpatient therapy sessions and you determine that more sessions are required, an in-depth clinical utilization review is necessary. To initiate such a review, please submit the Outpatient Treatment Request – Concurrent form with the patient’s most recent treatment plan and your progress notes from the patient’s last five therapy sessions. We will call you if additional information is needed to evaluate your authorization request.

Alcohol and Other Drug Abuse Services

Network Health Plan participants are allowed to visit a participating Alcohol and Other Drug Abuse (AODA) counselor for an initial assessment without a referral or authorization. AODA treatment required at any level of care after the initial assessment requires prior authorization. Requests for authorization can be made by submitting the Outpatient Treatment Report for AODA Services-Initial form. If additional AODA treatment is required, or if a change in the level of AODA services is recommended, please submit the Outpatient Treatment Report for AODA Services-Concurrent form. A request for a change in the level of care can be indicated under the section titled “Treatment Request, History and Risks.”

Psychology Services

Network Health Plan participants are allowed to visit a participating psychologist for an initial assessment prior to psychological or neuropsychological testing without a referral or authorization. Subsequent psychological and/or neuropsychological testing requires prior authorization. The testing psychologist must submit the completed Psychological Testing Request form or the Neuropsychological Testing Request form with appropriate supporting clinical documentation.