HCPCS Level II › H codes H0004 Alcohol and/or drug servicesBehavioral health counseling and therapy, per 15 minutes
Medicare coverage: Not payable by Medicare Status: active (October 2026 file) Medicare pricing for H0004 Physician Fee Schedule (CY 2026, RVU26D) Status I: not valid for Medicare (Medicare uses another code).
Payer policies and prior authorization for H0004 10 of 10 payer prior-auth lists that name H0004 require prior authorization or set conditions: Blue Cross and Blue Shield of Illinois, Humana, Molina Healthcare of Iowa, Molina Healthcare of Texas, UnitedHealthcare Community Plan.
Payer Plan State Prior auth Conditions Since Source Blue Cross and Blue Shield of Illinois Blue Cross Community Health Plans (BCCHP), Illinois Medicaid IL prior auth required Jan 1, 2025 Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026 Blue Cross and Blue Shield of Illinois Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative) IL prior auth required Jan 1, 2025 Procedure Code List, Effective 1/1/2025 Humana Humana Healthy Horizons IL prior auth required Jan 1, 2027 Humana Healthy Horizons in Illinois Prior Authorization and Notification List To view -specific medical coverage policies, please visit Humana Healthy Horizons in Illinois Clinical coverage policies . Humana Humana LTSS (Dual/integrated plan) IL prior auth required Jan 1, 2027 Humana Dual Fully Integrated (HMO D-SNP) Illinois long-term services and supports prior authorization and notification list Humana Humana LTSS (Dual/integrated plan) IN prior auth required Jul 1, 2024 Humana Gold Plus Integrated Indiana Long‐Term Services and Supports (LTSS) Preauthorization and Notification List Humana Gold Plus Integrated Indiana Long‐Term Services and Supports (LTSS) Preauthoriz Molina Healthcare of Iowa Medicaid IA prior auth required PA required for Waiver services only, otherwise no PA required Jul 1, 2023 IA Prior Authorization Matrix, effective Q3 2023 Molina Healthcare of Texas STAR TX prior auth required Feb 19, 2025 Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19 Molina Healthcare of Texas STAR+PLUS TX prior auth required Feb 19, 2025 Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19 Molina Healthcare of Texas STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix) TX prior auth required Jul 1, 2024 Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 UnitedHealthcare Community Plan KanCare KS prior auth under conditions site of care: home, outpatient Oct 1, 2026 Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
Payer coverage policies that name H0004 H0004 appears in 2 coverage policies from Aetna, Anthem.
Payer Policy Role in policy Reviewed Document Aetna Home Behavioral Healthcare Services (0730) listed, no stance Nov 26, 2025 payer document Anthem Intensive In-home Behavioral Health Services (CG-BEH-14) covered if criteria are met Nov 6, 2025 payer document
Recent prior-auth changes Nov 1, 2025: conditions changed, Blue Cross and Blue Shield of Illinois Feb 19, 2025: PA added, Molina Healthcare of Texas Feb 19, 2025: PA added, Molina Healthcare of Texas Jan 1, 2025: PA added, Molina Healthcare of Texas Medicaid fee-for-service Prior authorization required or conditional in IN, MD, OH.
AZ: $40.97 (behavioral, AHCCCS PT 18), effective Oct 1, 2026 CO: $26.04 (chp_plus_behavioral), effective Jul 1, 2026 IN: $15.78 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KS: $22.88 (default), effective Jul 1, 2022 KY: $28.99 (behavioral_health, billed with AF/AM), effective Jul 15, 2026 LA: $10.00 (epsdt), effective Feb 2, 2026 ND: $28.65 (physician), effective Aug 1, 2026 TX: $23.51 (healthy_texas_women, Chemical Dependency Treatment Facility (Tcada Ap, facility), effective Mar 1, 2026 VA: $25.56 (medical), effective Jul 1, 2025 WA: $31.07 (mental_health_services, facility), effective Jul 1, 2026 WY: $26.86 (professional), effective Jul 1, 2024 From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.