Louisiana Revised Prior Authorization Requirements
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1 Louisiana Revised Prior Requirements Contact: Ann Kay Logarbo, M.D. Chief Medical Officer, All non-emergency inpatient admissions, including planned surgeries, require prior authorization. Procedure Codes not listed in this document may not be covered. Please check your Medicaid Fee Schedule. 17 P (17 Hydroxyprogesterone Capraote) Bill as J3490 with a TH modifier. A low level office visit (99211) may be billed for the administration of the injection if a higher level visit has not been submitted for the recipient on that date. Physician is responsible for obtaining the compounded medication from a compounding pharmacy. Makena product is not a covered benefit. Abortions No Must meet state/federal guidelines. Must submit paper claim. Must be accompanied by state consent and written provider letter of medical necessity , Acupuncture Ambulance and Air Transport s Emergency No Not required for emergencies CAT Scan Submit claim to UnitedHealthcare SPECT Submit claim to UnitedHealthcare 78451, Cardiac Rehabilitation/ Pulmonary Rehabilitation Chemotherapy No Submit claim to UnitedHealthcare Chiropractic s No Must be referred by PCP, members through age 20 only, see Professional s Manual at lamedicaid.com Chronic Pain Management Clinical Trials Cochlear Implants Device covered by Louisiana Department of Health & Hospitals (DHH); see age-specific, medical and social requirements in Professional s Manual Dental s Dialysis No Submit claim to UnitedHealthcare Drugs Botox Review for medical necessity; not a covered benefit for cosmetic services Drugs Synagis EEG No Submit claim to UnitedHealthcare Elective Inpatient Admissions Submit claim to UnitedHealthcare Endometrial Ablation Submit claim to UnitedHealthcare Experimental s Family Planning No s provided through OB-GYN through preventive care and covered contraceptives
2 Louisiana Revised Prior Requirements Genetic Testing No Please see Covered Codes in column Covered Codes: 81265,81267,81380, 81382,88245,88248, 88249,88261,88262, 88263,88264,88267, 88269,88271,88272, 88273,88274,88275, 88280,88283,88285, 88289,88291,88299 Genetic Testing (Prolonged QT Syndrome) Requires prior authorization/paper claim submission and Home Health s Submit claim to UnitedHealthcare; Skilled Nursing/Aide Submit claim to UnitedHealthcare limited to 50 visits per calendar year/adults; one visit/day G0154 OT/PT/Speech Therapy Submit claim to UnitedHealthcare PT-G0151, OT-G0152, ST-G0153 Extended Skilled Nursing (Pediatric Day Health Care/Private Duty Nursing) Hospice s Infertility Tests/Treatment Submit claim to UnitedHealthcare; younger than age 21 only; requires medical necessity review LTAC Submit claim to UnitedHealthcare Mammography, Screening No Ages 40 and older; one/year Mental Health Refer to Magellan MRI Submit claim to UnitedHealthcare Nuclear Cardiac Imaging Submit claim to UnitedHealthcare Nursing Facilities/SNF Contact DHH at Nutrition s. Enteral nutrition only; routine counseling is not a covered benefit. Observation No Obstetrical s No Two ultrasounds allowed per pregnancy; additional ultrasounds require medical necessity review Orthotic/Prosthetic s 97760, 97761, Outpatient Drug/Alcohol Treatment Refer to Magellan Outpatient OT/PT/Speech Therapy Ages 21 and Older Submit claim to UnitedHealthcare; covered benefit (with Provider Type Exclusions) Younger Than Age 21 No prior authorization required for evaluation
3 Louisiana Revised Prior Requirements Speech Therapy Submit claim to UnitedHealthcare 92521, 92522, 92523, 92524,92507, 92508, 92626, 92627, 92630, Occupational Therapy Submit claim to UnitedHealthcare 97003, Physical Therapy Submit claim to UnitedHealthcare 97001, 97110, Pediatric Day Health Care Submit claim to UnitedHealthcare Must meet medical criteria PET Scans ; exceptions must be handled individually Sigmoidoscopy With Ultrasound Submit claim to UnitedHealthcare Sleep Study No Submit claim to UnitedHealthcare Sterilization No See Professional s Manual for specifics; waiting times apply between consent and procedure Hysterectomy Tubal Ligation Vasectomy Transfers Between Facilities (Non-Emergency) s Manual s Manual s Manual Submit claim to UnitedHealthcare Transplant s Submit claim to UnitedHealthcare Refer to specific CPT codes for coverage Vagus Nerve Stimulators Specific state criteria apply; see Professional s Manual 64568, 64569, Vascular Procedures Submit claim to UnitedHealthcare 37191, 37192, 37193, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, Vision s Only covered up to age 21; corrective eyewear requires prior authorization through DHH. s for ages 21 and older limited to eye diseases, infections. Surgical Procedures Abdominoplasty, Panniculectomy, Body Contouring Submit claim to UnitedHealthcare; includes procedures to remove fat 15830, Arthrodesis (Bone Fusing) Submit claim to UnitedHealthcare Artifical Urinary Sphincter Removal/Replacement Submit claim to UnitedHealthcare 53446, 53447, Anal Sphincteroplasty Submit claim to UnitedHealthcare 46762
4 Louisiana Revised Prior Requirements Auditory Canal (EXT) Reconstruction Submit claim to UnitedHealthcare 69310, Baclofan Pump, Intrathecal Must meet state requirements in Professional s Manual; prior authorization needed for ages 4 and older with specific diagnoses Bariatic Surgery State-specific criteria applies 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, Bone Graft Submit claim to UnitedHealthcare 20955, 20962, 20969, 20970, 20972, 20973, 21208, Breast Procedures Breast Reconstruction Submit claim to UnitedHealthcare 11970, 11971, 19295, 19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, Breast Reduction Weight/height restrictions apply; see Professional s Manual Implant Removal Submit claim to UnitedHealthcare Mastopexy Inverted Nipples Gynecomastia-Mastectomy Submit claim to UnitedHealthcare Chest Procedure Miscellaneous Submit claim to UnitedHealthcare Circumcision unless deemed medically necessary Cystourethroscopy For treatment of congenital conditions 54150, 54160, Endometrial Ablation Submit claim to UnitedHealthcare Eyelid Procedures Submit claim to UnitedHealthcare 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67914, 67916, 67917, 67921, 67923, 67924, 67961, 67966, 67971, 67973, 67974, Forehead and Brow Procedures Submit claim to UnitedHealthcare 15820, 15821,15822, Hair Transplant Lipectomy/Removal of Excess Skin Submit claim to UnitedHealthcare Only covered as Ambulatory Surgical Procedure 15832, 15833, 15834, 15835, 15876, 15877, 15878, 15879
5 Louisiana Revised Prior Requirements Neurostimulator/Receiver For implantation, removal or revision 61885, 61888, 64568, 64569, Nose Procedures Submit claim to UnitedHealthcare 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30520, 30620, 30630, Osteocutaneous Flap Applies to multiple sites 20969, 20970, 20972, Osteoplasty Refers to facial 21208, Otoplasty (Repair of Visible Ear Defects) Pancreatectomy Refers to autologous transplantation Pectus Excavatum/Carinatum Submit claim to UnitedHealthcare 21742, Penile Surgeries Submit claim to UnitedHealthcare 54162, 54163, 54300, 54304, 54360, Prostate Laser Enuclation Ablation Submit claim to UnitedHealthcare 52649, 53446, 53447, Removal of Excessive Skin/ Fat Submit claim to UnitedHealthcare 15830, Nasal Reconstruction Procedures See code limitation Sex Change Surgery Submit claim to UnitedHealthcare 55970, Spinal/Intrathecal Catheter Submit claim to UnitedHealthcare 62350, 62351, 62355, 62360, 62361, 62362, Tissue Expanders For use other than in the breast 11960, 11970, Vaginal Procedures Vaginal Construction Submit claim to UnitedHealthcare 57291, Vaginal Dilitation With Anesthesia Submit claim to UnitedHealthcare Pelvic Exam With Anesthesia Submit claim to UnitedHealthcare Vein Stripping/Ligation Submit claim to UnitedHealthcare 37650, 37700, 37718, 37722, 37735, 37760, 37780, Outpatient procedures not listed above do not require prior authorization. Highlighted services represent revised prior authorization requirements. Updated 3/4/2014.
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Policy Name: Cosmetic Services Policy Number: CMO 500 Effective Date of current policy: 9/1/2018 Description and Scope This policy applies to procedures that primarily affect the appearance of the member.
Tanta University. Faculty of Medicine. Plastic and Reconstructive Surgery Department. Doctorate Degree in Plastic Surgery
Componenets : Tanta University Faculty of Medicine Plastic and Reconstructive Surgery Department Doctorate Degree in Plastic Surgery Students should fulfill the designated number of credit hours, including
* PLACE OF SERVICE REQUIREMENTS FOR ADDITIONAL HIGHMARK WV MEDICAL POLICIES ANNOUNCED IN THE FEBRUARY 2011 ISSUE OF PROVIDER NEWS *
* PLACE OF SERVICE REQUIREMENTS FOR ADDITIONAL HIGHMARK WV MEDICAL POLICIES ANNOUNCED IN THE FEBRUARY ISSUE OF PROVIDER NEWS * Read this bulletin on-line via NaviNet MARCH 25, HWVPROV--004 TO: FROM: (1)
Ancillary Revenue. Past, Present, Future
Ancillary Revenue Past, Present, Future Today s Driving Forces Declining Reimbursement Inability to add additional patient volumes Practice Expansion Increasing the Top Line Increasing Overhead Declining
Oregon CPT Preapproval Grid
Not Applicable Home Health Stays - For all Initial Certification and Recertification periods Notes: Initial Certification review required effective 1/1/12. Not Applicable Skilled Nursing Facility Stays
Principal benefits for Kaiser Permanente Traditional HMO Plan (10/1/18 9/30/19)
Disclosure Form SISC - Self Insured Schools Of California Home Region: California Principal benefits for Kaiser Permanente Traditional HMO Plan (10/1/18 9/30/19) Accumulation Period The Accumulation Period
MyCare Advisor is our online suite of tools that assist Members in understanding and comparing cost, quality, and satisfaction among Providers.
January 2012 What is MyCare Advisor SM? Thinking about health care services in a different light is the first step to educating yourself on health care costs. Capital BlueCross is taking the second step
Principal Benefits for Kaiser Permanente Traditional Plan (10/1/16 9/30/17)
Benefit Summary SISC-SELF INSURED SCHOOLS OF CALIFORNIA Principal Benefits for Kaiser Permanente Traditional Plan (10/1/16 9/30/17) The Services described below are covered only if all of the following
Regence HSA Individual Direct Plan Highlights
Plan Features Provider choice: Member coinsurance levels are lowest for In-Network providers. If a member chooses an Out-of-Network provider, the member may be required to pay costs above the allowed amount.
Principal benefits for Kaiser Permanente Traditional Plan (10/1/15 9/30/16)
Disclosure Form SISC-SELF INSURED SCHOOLS OF CALIFORNIA Principal benefits for Kaiser Permanente Traditional Plan (10/1/15 9/30/16) The Services described below are covered only if all of the following
PLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK
PLAN FEATURES Deductible (per plan year) Out-of-Pocket Maximum (per plan year) None Individual None Family $250 Individual $500 Family In-Network expenses include coinsurance/copays and deductibles. Pharmacy
ESSURE A RESOURCE FOR CODING
ESSURE REIMBURSEMENT GUIDE A RESOURCE FOR CODING INDICATION Essure is indicated for women who desire permanent birth control (female sterilization) by bilateral occlusion of fallopian tubes. IMPORTANT
IMPORTANT NOTICES. Office visits and/or procedures at PAR/Network Providers do not require PA. Referrals to PAR/Network Specialists do not require PA.
, PA Code Matrix IMPORTANT NOTICES This document is updated quarterly. Please check this document prior to PA submission as codes may be removed or added. All codes listed require PA unless there is a
AXA MANSARD PERSONAL PLATINUM PLUS PLAN Cover & Exclusions
AXA MANSARD PERSONAL PLATINUM PLUS PLAN Cover & Exclusions This plan covers the following services; EMERGENCY CARE: Initial stabilization and care, it also covers intensive care if required. EVACUATION:
Unlimited except where otherwise indicated. Primary Care Physician Selection
PLAN FEATURES Deductible (per calendar year) None Individual None Family Out-of-Pocket Maximum (per calendar year) $2,000 Individual In-Network expenses include coinsurance/copays and deductibles. $4,000
Subject to Routine Physical Exam benefit. Same as applicable participating provider office visit member cost sharing Allergy Testing
PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) None Individual None Family $2,000 Individual $4,000 Family Member cost sharing for certain services may not apply