2016 And 2017 Prior Authorization List And Quick Reference-PDF Free Download

2016 and 2017 Prior Authorization List and Quick Reference
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Category Description Details, Uvulopalatoplasty or any type of. palatopharyngoplasty 42145, Tonsillectomy and adenoidecomty T A. 42820 42836, Excision of benign lesions 11400 11471. Prior authorization would NOT be required for, 11400 11471 if the following diagnosis symptom is. OP procedures and surgeries the reason for the excision. Carcinoma in situ 232 232 9, Personal history of malignant melanoma V10 82.
Personal history of other malignant neoplasm of, skin V10 83. Cellulitis or abscess 682 682 9, Hysterectomy 51925 58150 58294 58541 58544. 58548 58554 58570 58573 58951 58956, 11200 11201 11920 11922 11950 11954. 15775 15776 15780 15839 15847 15876 15879, Potentially cosmetic and reconstructive 17106 17108 19300 19316 19396 21740 21743. surgeries 30400 30462 30520 36468 36471 37785, 40650 40761 42200 42281 54660 67900 67975.
69300 or diagnosis 757 32 or 757 33, Heart lung 33930 33945. Liver 47133 47147, Pancreas 48550 48556, Transplants All solid organ bone marrow Intestine 44132 44137 44715 44721. stem cell transplants includes the evaluation Bone Marrow 38240 38242. work up and travel accommodations Heart valve tissue 33933 33944. Stem cell 38204 38215 38230 38232 and, Transplant related Lodging meals and. transportation S9975, PT Revenue codes 420 421 422 423. The initial evaluation does not require 429 and 97002 97546 97750 97762. prior auth Prior authorization is required OT Revenue codes 430 431 432 433 439. Outpatient ST, for services exceeding the 12 visits per ST Revenue codes 440 441 442 443 449.
discipline within a calendar year 92507 92508 92520 92521 92522 92523 92524. 92525 92526, Pulmonary rehabilitation G0237 G0239 G0424 and revenue code 948. Continued on next page, MDwise Marketplace Inc is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise org providers. Category Description Details, DME Durable Medical Equipment and. Supplies over 500 billed charges per claim All DME unless otherwise indicated below Please. including insulin pumps breast pumps also refer to the orthotics category of this. and CPAP whether rented or purchased document for other items that may be considered. replacement or repair unless otherwise DME that require prior authorization. indicated in this list, DME and Medical Diabetic Shoes with custom mold or A5500 A5513. Supplies compression mold or deluxe, Enteral and Parenteral Nutruition B4034 B9998.
Nutritional counseling after the first initial, 97802 97804 G0270 G0271. Prosthetics over 500 billed charges per, L5500 L9900. Orthotics of 250 or more L0100 L4631, Home Health Care. Home and OP Infusion Therapy includes, Tocolytics ALL prior authorization requests. 99601 99602 and Tocolytics S9349, for tocolytics must be referred to an MD.
to determine medical necessity, Home Oxygen including supplies home A4615 A4616 A7046 E0424 E0455. oxygen tent and oxygen concentrators E0460 E0461 E0463 E1352 E1392 E1405 E1406. regardless of billed charges K0738, Revenue codes 651 652 655 and 656 with HCPCS. Hospice Hospice Services Inpatient or Outpatient, codes Q5001 Q5010. Continued on next page, MDwise Marketplace Inc is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise org providers. Category Description Details, 72090 77072 80502 81228 81229 81265 81266.
Genetic testing all requests for genetic, 81331 81400 81408 88230 88262 88289 88291. testing require MD review, Clinical Trials, CT Scan maxillofacial cervical thoracic 70486 70487 70488 72125 72133 71250 71275. and lumbar spine thorax abdomen pelvis 74150 74178 72191 72192 72193 72194 76376. 3D CT scans 76377, Revenue codes 611 612 615 616 71250 71275. 71550 71552 72125 72133 72141 72158, MRIs head brain cervical thoracic and. 73718 73723 72191 72194 74150 74178, lumbar spine chest abdomen pelvis lower.
74181 74183 72195 72197 C8900 C8901, extremity 3D MRIs. C8902 C8909 C8920 C8914 77058 77059, Diagnostics 73700 73706 70551 70559. 74185 73225 71555 70544 70546 73725 70547, MRA 70549 72198 72159 73725 billed under MRI. revenue codes, 340 349 404 G0219 G0235 78459 78491 78492. 78608 78609 78811 78816, The following radiation therapy requires.
77385 and 77386, prior auth IMRT, Bone Density Study for members under 65. G0130 76977 77078 77082 78350 78351, years of age, 76801 76817 with the following diagnosis. Routine OB ultrasounds greater than 2 per, O00 xx O003 xx and O00 0 O03 9 O24 31. O24 311 O24 319, Ambulance Facility to facility and or non. A0426 A0428, emergent transfers, Ambulance Ambulance Fixed Wing Air a.
retrospecitve review of rotary wing air A0430 A0435. Continued on next page, MDwise Marketplace Inc is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise org providers. Category Description Details, Pain Management services procedures. listed below Office place of service only, TENS unit including electrodes batteries. A4556 A4558 A4595 A4630 E0720 E0730 E0731, etc regardless of billed charges. Facet Joint and or Facet Joint Nerve, 64490 64495, Pain Management Injection.
62310 62311 64479 64484 72275 77003 Codes, Epidural Steroid Injection Anesthesia for. 72275 and 77003 require an auth only if billed with. Facet Joint and Epidural Injection, one of the codes listed here. 64550 64581 61850 61888 64561 64581, Neurostimulator. E0744 E0749 E0762 E0766 L8679 L8695, Hyperbaric, Hyperbaric Oxygen A4575 C1300 G0277 99183. Diabetic education if more than 10 hours, Diabetic services G0108 G0109 with diagnosis codes E10 E10 9 and.
within the first calendar year of diagnosis or, and supplies E11 0 E11 9. more than 2 hours for subsequent years, Vision Surgery as indicated are to be filed. Vision S0800 S0810 S0812 65767, with the Vision Carrier. Dental Emergency procedures services, including general anesthesia to treat dental. Dental D0100 D0199, emergencies for children 6 years of age and.
Podiatry visits require prior authorization AFTER the. All services rendered during the visit unless, Podiatry Prior authorization is needed after 6 visits. otherwise noted on this prior authorization list, are included in the visit limit without authorization. 99201 99215 11055 11057 11719 11721, Chiropractic Spinal Manipulation for. Chiropractic 98940 98941 and 98942, members less than 5 years old. Continued on next page, MDwise Marketplace Inc is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise org providers.
Category Description Details, TMJ Services including Arthroplasty. Arthroscopy Reconstruction Discectomy, with or without disc replacement 21010 21025 21026 21050 21060 21070 21073. Mandibular orthopedic repositioning 21116 21193 21196 21240 21249 21255 29800. appliances MORA Trigger Point 29804 S8262 and diagnosis M26 60 M22 69 S03 0. Injections Arthrocentesis Treatment S03 4 M19 9 M19 93 M24 30 M24 40 T84 018. plan services ordered for TMJ may also T84 019 T84 098 099 T84 029 T84 038 39. be a service that is included on the Prior T84 89 T84 9. Authorization list e g physical therapy, DME or prosthetic greater than 500. Behavior Health Mental Health Substance Coding PA requirement as outlined below and on the. Behavioral Health following pages, MDwise Marketplace Behavioral Health Services that Require PA. Service Type PA requirements, Psychiatric Diagnostic Interview 1 Unit per member per billing provider per calendar year allowed.
CPT code 90791 or 90792 Interactive Inter with no PA 2 units are allowed without PA when member is. view separately evaluated both by a physician an advanced practice nurse. or HSPP and another mid level practitioner, Psychotherapy Visits. 90832 Psytx Office 30 min, 90834 Psytx Office 45 min. 90837 Psytx off 60 min, Does not requires PA contracted providers. 90846 Family medical psychotherapy, 90847 Family Psytx conjoint. 90849 Multi family group therapy, 90853 Group psychotherapy.
Continued on next page, MDwise Marketplace Inc is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise org providers. Service Type PA requirements, Prior to 10 1 14 after the initial diagnostic interview 90791 or. Rule prior to 10 1 14 19 Medication, 90792 PA is not required for the first 19 visits per billing provider. Management visit per billing provider PA rule, for this group of codes Service provided by a psychiatrist or nurse. 99201 99205 New patient office, practitioners clinical nurse specialists who have prescription authority.
99211 99215 Existing patient office, All other therapy visits for these codes beyond initial 19 require PA. See note below for authorization application guideline. Effective for claims processed on or after, After 10 1 14 processing dates no PA is required. 10 1 14 PA is not required for CPT codes, 99201 99203 and 99211 99215 contracted. Interactive Complexity CPT code 90785 is an add on code to this. providers only, CPT group and does not require a separate authorization. Therapy visits with E M, Prior to 10 1 14 dates of service requires PA With dates of service.
90838 Interactive Psytx w medical EM, 10 1 14 and beyond PA is not required. Health and Behavioral Assessment Codes, PA is required for persons with Autism Spectrum Disorder Diagnosis. CPT 96151 96155 Applied Behavioral, 299 0 299 8 Authorizations are to be given in accordance with. treatment plan which can only be required every six months. Continued on next page, MDwise Marketplace Inc is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise org providers. Service Type PA requirements, Requires PA Anesthesia CPT code 00104 and outpatient facility.
Electroconvulsive Therapy ECT 90870, i e observation room may also be provided If ECT authorized. anesthesia anesthesia provider and facility service to be authorized. Screening Brief Intervention Services SBI PA not required for one G0396 or G0397 per member per. Drug Alcohol Abuse contracted billing provider PA is required for non contracted. G0396 Alcohol or SA structured SBI 15 30 providers except if provided as emergency service SBI services. min are not typically billed by behavioral health clinics as screening and. G0397 Alcohol or SA SBI greater than 30 interventions are already included in behavioral health assessment. min treatment CPT codes, Acute Outpatient Services. Partial Hospitalization and Intensive, Requires PA. Outpatient Services, Service is provided for individuals who require less than full time. Partial Half Day Rev Code 912 HCSPCS, hospitalization but need more extensive or structured treatment than.
intermittent outpatient mental health services The number of days. Partial Full Day Rev Code 913 HCSPCS, per week required is determined by what is medically necessary and. indicated in the member s treatment plan, IOP Psychiatric Rev Code 905 HCSPCS. IOP SA Rev Code 906 HCSPCS H0015, Residential Services Requires PA. Continued on next page, MDwise Marketplace Inc is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise org providers. MDwise Marketplace Behavioral Health Professional Services During Medical Surgical Stay. Service Type PA requirements, Diagnostic Interview PA is not required per inpatient episode of care.
CPT codes 90791 or 90792, Inpatient Services With the exception of emergency admissions prior authorization is required for any. psychiatric admission stay including admissions for substance abuse and any observation stay or partial. hospitalization Residential Services requires prior authorization for Psychiatric and Substance Abuse stays. Please note For services requiring authorization authorizations provided for a higher level code may be. applied to the claim submitted by that provider with a lower level code rather than denying the lower level. code for no authorization For example in the event an authorization is given for a more involved visit i e. 90837 but in turn a claim is submitted with CPT code 90832 or 90834 the claim would be paid on the. 90837 authorization rather than denied for no authorization Individual and Family therapy sessions can be. used interchangeably therefore authorization applies to this group of codes. Non contracted BH providers Except for emergency services all BH services provided by non contracted. behavioral health providers require PA, Continued on next page. MDwise Marketplace Inc is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise org providers. Medical Benefit Drugs That Require PA, Therapeutic Category Brand Name Generic Name Applicable Code s. Botox onabotulinumtoxin A J0585, Dysport abobtulinumtoxin A J0586. Botulinum toxins, Myobloc rimabotulinumtoxin B J0587.
Xeomin incobotulinumtoxin A J0588, H P Acthar corticotropin J0800. Endocrine Agents, Makena hydroxyprogesterone caproate None. Cerezyme imiglucerase J1786, Elelyso taliglucerase J3060. Enzyme Replacement Lumizyme alglucosidase alfa J0221. Rherapy Myozyme alglucosidase alfa J0220, Vimizim elosulfase alfa J1322. VPRIV velaglucerase J3385, Eligard Lupron leuprolide J9217 J9218 J1950.
Sandostatin octreotide J2354, Hormonal modifiers Sandostatin LAR octreotide J2353. Trelstar LA triptorelin J3315, Zoladex goserelin J9202. Bivigam immune globulin human J1556, Carimune immune globulin hum. 2016 and 2017 Prior Authorization List and Quick Reference Guide Certain services provided to MDwise Marketplace members require prior authorization Requests for authorization should be submitted to the delivery system of the member Authorization requests must be submitted on the MDwise

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