Covered Professional Services & Authorization Guidelines Arkansas, Florida, Georgia, Indiana, Massachusetts, Mississippi, Ohio, Texas, and Washington Exchange Marketplaces Please note that the listing below may not fully comprise all Ambetter covered services. Please refer to your Provider Agreement with Ambetter to identify services you are contracted and eligible to provide. Services are covered in all states unless specifically stated otherwise under “State Specific Coverage Comments.” All services provided by non-participating providers will require prior authorization except for emergency services. Service Description Billable Provider Type(s) Billing Codes Modifiers Locations State Specific Coverage Comments Auth Required Hospital Provider Services (private rooms only covered if medically necessary) Inpatient Admission – Behavioral Health Inpatient Hospital, Inpatient Psychiatric Facility 114, 124, 134, 144, 154, 204 n/a 21, 51 Yes Inpatient Admission – Substance Use Disorder Inpatient Hospital, Inpatient Psychiatric Facility 116, 126, 136, 146, 156 n/a 21, 51 For TX, inpatient services only covered at a Chemical Dependency Treatment Center. Yes Crisis Stabilization Inpatient Hospital, Inpatient Psychiatric Facility 100, 101 n/a 21, 51 Yes PRTF/RTC – Behavioral Health Inpatient Hospital, Inpatient Psychiatric Facility 1001 n/a 21, 51, 56 (56 not allowed in AR) All ages covered in AR, MA, and WA. Under 21 years of age covered in TX. No coverage in other states. Yes PRTF/RTC – Substance Use Disorder Inpatient Hospital, Inpatient Psychiatric Facility 1002 n/a 21, 51, 55 (55 not allowed in AR) Covered in AR, MA, and WA only. No coverage in other states. Yes HEDIS Bridge Appointment (7- day follow-up after discharge) Inpatient Hospital, Inpatient Psychiatric Facility 510, 513 n/a 21, 51 No 1
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Covered Professional Services & Authorization Guidelines Arkansas, Florida, Georgia, Indiana, Massachusetts, Mississippi, Ohio, Texas, and Washington Exchange Marketplaces Please note that the listing below may not fully comprise all Ambetter covered services. Please refer to your Provider Agreement with Ambetter to identify services you are contracted and eligible to provide. Services are covered in all states unless specifically stated otherwise under “State Specific Coverage Comments.” All services provided by non-participating providers will require prior authorization except for emergency services.
Service Description
Billable Provider Type(s)
Billing Codes Modifiers Locations State Specific
Coverage Comments
Auth Required
Hospital Provider Services (private rooms only covered if medically necessary)
Inpatient Admission – Behavioral
Health
Inpatient Hospital, Inpatient
Psychiatric Facility
114, 124, 134, 144, 154, 204 n/a 21, 51 Yes
Inpatient Admission –
Substance Use Disorder
Inpatient Hospital, Inpatient
Psychiatric Facility
116, 126, 136, 146, 156 n/a 21, 51
For TX, inpatient
services only covered at a
Chemical Dependency Treatment
Center.
Yes
Crisis Stabilization
Inpatient Hospital, Inpatient
Psychiatric Facility
100, 101 n/a 21, 51 Yes
PRTF/RTC – Behavioral
Health
Inpatient Hospital, Inpatient
Psychiatric Facility
1001 n/a
21, 51, 56 (56 not
allowed in AR)
All ages covered in AR, MA, and WA.
Under 21 years of age covered
in TX. No coverage in other states.
Yes
PRTF/RTC – Substance Use
Disorder
Inpatient Hospital, Inpatient
Psychiatric Facility
1002 n/a
21, 51, 55 (55 not
allowed in AR)
Covered in AR, MA, and WA
only. No coverage in other states.
Yes
HEDIS Bridge Appointment (7-
day follow-up after discharge)
Inpatient Hospital, Inpatient
Psychiatric Facility
510, 513 n/a 21, 51 No
1
Service Description
Billable Provider Type(s)
Billing Codes Modifiers Locations State Specific
Coverage Comments
Auth Required
Observation
Inpatient or Outpatient Hospital,
Inpatient or Outpatient Psychiatric
Facility
760, 761, 762 n/a 21, 22, 51, 52 Yes
ECT
Inpatient or Outpatient Hospital, Inpatient
Psychiatric Facility
901 with 90870 n/a 21, 22, 51 Yes
Intensive Outpatient Program – Behavioral
Health
Outpatient Hospital,
Outpatient Psychiatric
Facility
905 with one of the following
Group therapy: 90853;
Individual therapy: 90832,
90833, 90834, 90836, 90837, 90838, 90845
Family therapy: 90846 or 90847 Testing: 96101, 96102, 96103, 96116, 96118,
Covered diagnoses include a mental disease, disorder, or condition listed in the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, as revised, or other diagnostic coding system used by Ambetter, with the following limitations and/or exceptions:
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Eating disorder diagnoses are covered only in Arkansas and Massachusetts. These diagnoses are not covered in other states. Autism Spectrum Disorder diagnoses are covered in all states however Applied Behavior Analysis (ABA) services are covered only in Massachusetts and Texas with limitations indicated in the Covered Services and Authorization Guidelines. Diagnoses known as “V Codes” are allowed as primary diagnoses only in Washington and only for children under age of 5. Rape diagnoses (including applicable “V code”) are allowed as primary diagnosis in Massachusetts. Developmental delay/intellectual disability (DD/ID) diagnoses are not covered as primary diagnosis in any state. Primary diagnosis for members with DD/ID must be behavioral health or substance use disorder related. Oppositional defiant disorder, conduct disorder, and adjustment reaction diagnoses are not covered in any state. Diagnoses with demonstrable organic disease including, but not limited to, dementia, Alzheimer’s Disease, and acquired brain injury are covered under the medical plan in Texas.
