Welcome Kentucky Behavioral Health Providers 

How to submit community-based services prior authorization requests

Use the KY community-based services request form.

Submit the completed form after logging in to the Provider Express secure portal and uploading it. 

Medical Necessity

The length and approval of authorizations are often based on medical necessity.

Standard Clinical Criteria

Substance Use Disorder Prior Authorization Clinical Criteria

Documentation

Submit complete and up-to-date documentation to support your authorization requests. 

Community-based Services

Needs Assessment

Optum requires the most recent needs assessment. If the member's clinical presentation has changed, the assessment and treatment plan should be updated to reflect the changes. The assessment will serve as documentation of medical necessity.

LOCUS/CALOCUS/CANS/CASII

Optum does not have a preference for specific assessments (LOCUS, CALOCUS, CANS, CASII), except for ACT. 

For ACT, please use LOCUS.

Prior auth processing 

Optum will begin processing prior auth requests at the time of submission using a rolling calendar.

For example, you submit a request on June 15, 2025, we may approve the prior auth for 3-6 months, based on necessity. If calendar months are preferred, we can process prior auth requests up to 2 weeks earlyto align with the beginning of the month.

Note: If we are unable to reach you, our clinicians will leave Protected Health Information (PHI) and authorization details if you have a voicemail greeting indicating the voicemail box is HIPPA compliant, confidential and secure. 

Frequently-asked questions for community-based services prior auth requests 

How far in advance can providers request prior auths?

While some providers report being allowed to request two weeks in advance, confirmation of a standard timeframe is pending.

H2012 and H2015: How many units can be requested per member?

Authorized units will be based on medical necessity.  On the submittion form please indicate how many units you plan to provide.

H2019 and H2020: When can authorization requests be submitted?

These can be started for new members as of June 25, 2025.  If a member is already receiving these services, you will likely already have an authorization,  so please check the secure portal.

Will there be a separate authorization needed for Individual Peer Support services and Group Peer Support services, or will the same authorization apply to them both?

Typically, we authorize based on the base code. In certain instances, a modifier may be required. 

If a member has been receiving TCM this year, do those units count toward the 100 per year before prior auth is required?

Because TCM is is a monthly code, 1 unit is allocated per month.  

What duration are TCM prior auth approvals?

Initially, they will be staggered with different end dates. For new members, prior auth will be for 6 months or less based on medical necessity.

For TCM prior auths:  do we use the approved Medicaid form?

Claims are set up to pay TCM providers for June without authorization. You can submit for June 25 if you'd like.

Are providers allowed to request 3 months of case management?

While 3 months is standard, some have seen as much as 6 months, depending on medical necessity.

When do we need submit for continued stay?

Requests for continued stay should be submitted when units are exhausted or prior auth expires, whichever comes first.

Could an interpretive summary be submitted in place of a biopsychosocial for the prior authorization submission?

For new members, please include interpretive summary with the assessment.