Prior Authorization : Services Requiring Prior Authorization

Prior Authorization Coding Guidance

All direct treatment hours (represented by CPT codes 97153 and 97155) for behavioral treatment must be requested as a single lump sum using CPT code 97153 (Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, each 15 minutes).

Family adaptive behavior treatment guidance hours must be requested separately using CPT code 97156 (Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional [with or without the patient present], face-to-face with guardian[s]/caregiver[s], each 15 minutes).

Group behavioral treatment hours must be requested separately using CPT procedure codes 97158 (Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes) and 97154 (Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes).