Prior Authorization for Mental Health: Complete Therapist Guide

Prior authorization (PA) is a requirement by some insurance plans that you obtain approval before providing certain services. For mental health therapy, PA requirements vary significantly by payer, plan, and service type — and OON therapists are often exempt from them entirely.

When Is Prior Authorization Required for Therapy?

PA requirements in mental health are most common for:

• Initial psychiatric evaluations (90791, 90792) — Some plans require PA before the first intake session with a psychiatrist or for any new psychiatric evaluation.
• Ongoing therapy beyond a session threshold — A plan may cover the first 10–20 sessions without PA, then require authorization to continue treatment.
• Intensive outpatient programs (IOP) — Almost always require PA.
• Psychological testing — Usually requires PA regardless of payer.
• ABA therapy for autism — Consistently requires PA and often requires periodic re-authorization (every 6 months).
• Partial hospitalization programs (PHP) — Always requires PA.

OON Therapists and Prior Authorization

This is the most important point for OON superbill practices: out-of-network therapists generally do not need to obtain prior authorization. Prior authorization is a contractual requirement between the insurer and in-network providers. Since OON providers are not contracted, the PA requirement doesn't technically apply to the provider.

However, the patient'sability to receive OON reimbursement may still be subject to PA — meaning the insurer can require that the patient obtain PA for the OON services before they will reimburse. Check the patient's specific plan documents. Plans that require PA for OON mental health services are in the minority but they exist, particularly among HMO-like plans or plans with managed behavioral health carve-outs.

How to Obtain Prior Authorization

For in-network providers (or OON providers whose client's plan requires it):

1. Call the number on the back of the patient's insurance card for behavioral health or obtain PA online through the payer portal
2. Have the following ready: patient name and member ID, provider NPI and Tax ID, diagnosis code (ICD-10), CPT code(s) you plan to use, number of sessions or date range requested
3. Submit the request and obtain a PA reference number
4. Document the PA number and note the authorized dates and session count
5. Include the PA number on claims and superbills if required by the payer

CPT Codes That Commonly Require PA

• 90791 / 90792 — Psychiatric diagnostic evaluation (some plans)
• 90837 — Ongoing individual therapy (usually only after a session threshold)
• 97153, 97154, 97155 — ABA therapy codes
• 96130–96133 — Psychological and neuropsychological testing
• H0015 — Intensive outpatient substance use treatment

PA for ABA and Psychological Testing

Applied Behavior Analysis (ABA) for autism spectrum disorder and psychological testing are two areas where PA is nearly universal across payers. For ABA, initial authorization typically requires a recent ASD diagnosis, a behavioral assessment, and a treatment plan signed by a BCBA. Re-authorization occurs every 6 months and usually requires updated progress reports. For psychological testing, PA must specify the tests planned; adding tests later may require a PA amendment.

What to Do When PA Is Denied

If a prior authorization request is denied:

1. Request the written denial reason in writing
2. Request a peer-to-peer review — a call between your clinician and the insurer's medical reviewer (this reverses a significant percentage of denials)
3. File a formal appeal with clinical documentation supporting medical necessity
4. Cite the Mental Health Parity and Addiction Equity Act (MHPAEA) if the denial appears to apply stricter criteria to mental health than to comparable medical/surgical benefits

For more on the appeals process, see how to appeal a denied mental health insurance claim. On the parity law rights that support appeals, see mental health parity law: your rights as a therapy patient.