ALERT - Eligibility & Certification

Because all members have benefit limits, it is important to inquire about benefit eligibility and clarify what is covered under each member’s benefit plan. You may inquire about eligibility and benefits at www.providerexpress.com or by calling the phone number on the back of the member's insurance card. Online eligibility inquiries are secure and available only to Optum in-network clinicians who are registered users of this site. You may request a User ID by selecting the First-time User link in the upper right of this website.

Services and/or conditions not covered under the member's specific benefit plan are not eligible for payment. Optum complies with regulatory requirements related to coverage election periods and payment grace periods. These requirements can lead to delays in Optum's knowledge of a member's eligibility status. As a result, the member is usually the best source of timely information about eligibility, coverage changes, and services utilized to date.

Optum provides referrals to in-network clinicians based on clinical and geographic needs. A certification is generated, allowing the member whose benefit plan requires prior certification for outpatient treatment to see a Optum-contracted clinician for routine outpatient psychotherapy services. This authorization of benefits is valid for one year (12 months) from the date of issue, up to the benefit limit as long as the member's eligibility remains active.

For members obtaining certification:

• Members may go online at www.liveandworkwell.com, to obtain an Authorization Request document with a confirmation number. This document serves as notification of authorization for treatment.

• Members may call the number on the back of their ID card for authorization and will receive a letter indicating that routine outpatient psychotherapy services are certified with any in-network clinician. Members are instructed to bring this letter with them to the initial treatment session.

If a member does not bring the authorization letter (with a certification number) or the Authorization Request document (with a confirmation number), you need to ensure that an authorization has been issued.

For clinicians obtaining certification:

• You may check the status of an authorization through the "Auth Inquiry" function on Provider Express® when you are a registered user of this site, or you may call the number on the back of the member's insurance card.

• If the member does not provide you with an authorization letter reflecting preauthorization of services, you are required to contact Optum to request the certification. You may make this request for an authorization at the time of your online or telephonic inquiry. In the event of unusual circumstances preventing precertification, Optum may retroactively enter an effective date for the certification . Please see the standard process and timeframes for review in the Network Manual section on Benefit Plans, Authorizations, EAP and Access to Care, under "Retrospective Review Process".

• If the member is still in treatment when the authorization expires, another authorization will need to be requested for continued treatment. Either the member is able to access this through www.liveandworkwell.com or by calling Optum, or you may request a authorization through the "Auth Request" feature on Provider Express or by calling the number on the back of the member's insurance card.

For Optum members whose benefit plan does not require prior authorization, there is no need to ensure that an authorization has been issued by Optum.

The open authorization issued to members covers the most common routine outpatient psychotherapy services (please see the CPT codes listed in the chart below). Non-routine services including, but not limited to, psychological testing, home health visits, HCPCS codes, or extended sessions require review in order to certify benefits.

Other levels of care, including intensive outpatient services, require prior and ongoing certification. To determine whether a service is non-routine and requires a clinician-specific certification, please call the number on the back of the member's insurance card.

Typically-used CPT codes included in the authorization of benefits for routine outpatient services:

• 90791
• 90832
• 90834
• 90846
• 90847
• 90849
• 90853
• 99241
• 99242
• 99243

We recommend that registered users of Provider Express use the “Claim Entry” feature for the most efficient claims processing. At the time of submitting a claim, you will also be able to obtain the authorization number for a member, if needed, by using the “Auth Inquiry” feature.

Certification for routine medication management services is not required. The table below reflects some of the most frequently used CPT codes among prescribing clinicians that do not require prior authorization of benefits:

• 90791
• 90792
• 90832
• E/M Code + 90833
• 90834
• E/M Code + 90836
• 90846
• 90847
• 90849
• 90853
• 99211
• 99241
• 99242
• 99243
• 99251
• 99252
• 99253
• 99254
• 99255