MEMORANDUM. TO: Dermatology Providers FROM: Community Health Center Network SUBJECT: Dermatology Prior Authorization Requirements DATE: May 12, 2017
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1 MEMORANDUM TO: Dermatology Providers FROM: Community Health Center Network SUBJECT: Dermatology Prior Authorization Requirements DATE: May 12, 2017 Please read this important notice regarding prior authorization requirements. Effective June 1, 2017, the dermatology codes listed below do not require authorization. For your convenience, a comprehensive list of dermatology codes, including the new codes, that do not require prior authorization is attached. In addition, see attached updated prior authorization grid, also available on provider portal, CHCN Connect, linked here: Authorizations-Resources Code Description MOHS 1 STAGE H/N/HF/G MOHS ADDL STAGE MOHS 1 STAGE T/A/L MOHS ADDL STAGE T/A/L MOHS SURG ADDL BLOCK CRYOTHERAPY OF SKIN REMOVE EYELID LESION IIV3 VACCINE 3 YRS+ IM THER/PROPH/DIAG INJ SC/IM PHOTODYNAMIC TX SKIN ULTRAVIOLET LIGHT THERAPY PHOTOCHEMOTHERAPY WITH UV B LASER TX SKIN < 250 SQ CM LASER TX SKIN SQ CM LASER TX SKIN >500 SQ CM G8427 DOC CUR MEDS BY PROV J0702 BETAMETHASONE ACET&SOD PHOSP J3301 TRIAMCINOLONE ACET INJ NOS J7308 AMINOLEVULINIC ACID HCL TOP If you have any questions, please contact CHCN Utilization Management department at or umcod@chcnetwork.org
2 Dermatology Procedure Codes that do not Require Prior Authorization for Contracted Providers Effective June 1, 2017 Code Description ACNE SURGERY DRAINAGE OF SKIN ABSCESS TRIM SKIN LESIONS 2 TO TRIM SKIN LESIONS OVER BIOPSY SKIN LESION BIOPSY SKIN ADD ON REMOVAL OF SKIN TAGS <W/ REMOVE SKIN TAGS ADD ON SHAVE SKIN LESION 0.5 CM/< SHAVE SKIN LESION CM SHAVE SKIN LESION CM SHAVE SKIN LESION CM SHAVE SKIN LESION >2.0 CM SHAVE SKIN LESION 0.5 CM/< SHAVE SKIN LESION CM SHAVE SKIN LESION CM SHAVE SKIN LESION >2.0 CM EXC TR EXT B9+MARG 0.5 CM< EXC TR EXT B9+MARG CM EXC TR EXT B9+MARG CM EXC TR EXT B9+MARG 2.1 3CM/< EXC TR EXT B9+MARG CM EXC TR EXT B9+MARG >4.0 CM EXC H F NK SP B9+MARG 0.5/< EXC H F NK SP B9+MARG EXC H F NK SP B9+MARG EXC H F NK SP B9+MARG EXC H F NK SP B9+MARG EXC H F NK SP B9+MARG >4 CM EXC FACE MM B9+MARG 0.5 CM/< EXC FACE MM B9+MARG CM EXC FACE MM B9+MARG CM EXC FACE MM B9+MARG CM EXC FACE MM B9+MARG CM EXC FACE MM B9+MARG >4 CM EXC TR EXT MAL+MARG 0.5 CM/< EXC TR EXT MAL+MARG CM EXC TR EXT MAL+MARG CM EXC TR EXT MAL+MARG CM EXC TR EXT MAL+MARG >4 CM EXC F/E/E/N/L MAL+MRG INJECT SKIN LESIONS </W INJECT SKIN LESIONS >7
3 Code Description INTMD RPR S/A/T/EXT 2.5 CM/< INTMD RPR S/A/T/EXT INTMD RPR N HF/GENIT 2.5CM/< INTMD RPR FACE/MM 2.5 CM/< INTMD RPR FACE/MM CM CMPLX RPR TRUNK CM CMPLX RPR TRUNK CM CMPLX RPR TRUNK ADDL 5CM/< CMPLX RPR S/A/L CM CMPLX RPR S/A/L ADDL 5 CM/> CMPLX RPR F/C/C/M/N/AX/G/H/F CMPLX RPR F/C/C/M/N/AX/G/H/F CMPLX RPR E/N/E/L CM CMPLX RPR E/N/E/L CM TIS TRNFR TRUNK 10 SQ CM/< TIS TRNFR TRUNK SQCM TIS TRNFR S/A/L 10 SQ CM/< TIS TRNFR S/A/L SQCM TIS TRNFR F/C/C/M/N/A/G/H/F TIS TRNFR E/N/E/L 10 SQ CM/< TIS TRNFR ANY SQ CM SKIN FULL GRAFT EEN & LIPS DESTRUCT PREMALG LESION DESTRUCT PREMALG LES DESTROY PREMAL LESIONS 15/> DESTRUCTION OF SKIN LESIONS DESTRUCT B9 LESION DESTRUCT LESION 15 OR MORE DESTRUCTION OF SKIN LESIONS DESTRUCTION OF SKIN LESIONS DESTRUCTION OF SKIN LESIONS DESTRUCTION OF SKIN LESIONS DESTRUCTION OF SKIN LESIONS DESTRUCTION OF SKIN LESIONS DESTRUCTION OF SKIN LESIONS DESTRUCTION OF SKIN LESIONS DESTRUCTION OF SKIN LESIONS MOHS 1 STAGE H/N/HF/G MOHS ADDL STAGE MOHS 1 STAGE T/A/L MOHS ADDL STAGE T/A/L MOHS SURG ADDL BLOCK CRYOTHERAPY OF SKIN CRYOSURGERY PENIS LESION(S) EXCISION OF PENIS LESION(S) BIOPSY OF PENIS
4 Code Description REMOVE EYELID LESION URINE PREGNANCY TEST SKIN FUNGI CULTURE SMEAR WET MOUNT SALINE/INK TISSUE EXAM BY PATHOLOGIST TISSUE EXAM BY PATHOLOGIST SPECIAL STAINS GROUP SPECIAL STAINS GROUP MICROSLIDE CONSULTATION IMMUNOHISTO ANTB 1ST STAIN IMMUNOFLUOR ANTB 1ST STAIN IMMUNOFLUOR ANTB ADDL STAIN IIV3 VACCINE 3 YRS+ IM PERCUT ALLERGY SKIN TESTS ALLERGY PATCH TESTS THER/PROPH/DIAG INJ SC/IM PHOTODYNAMIC TX SKIN ULTRAVIOLET LIGHT THERAPY PHOTOCHEMOTHERAPY WITH UV B LASER TX SKIN < 250 SQ CM LASER TX SKIN SQ CM LASER TX SKIN >500 SQ CM SPECIAL SUPPLIES PHYS/QHP A4550 SURGICAL TRAYS A4649 SURGICAL SUPPLIES A6219 GAUZE <= 16 SQ IN W/BORDER G8427 DOC CUR MEDS BY PROV J0702 BETAMETHASONE ACET&SOD PHOSP J3301 TRIAMCINOLONE ACET INJ NOS J7308 AMINOLEVULINIC ACID HCL TOP
5 Click Here for CHCN's Provider Portal Community Health Center Network (CHCN) PRIOR AUTHORIZATION GRID Before services are provided PLEASE CHECK Provider Portal for: *Member Eligibility *Benefit Coverage *Contracted Provider Questions Call CHCN at /1/2017 Non Covered Benefit All Services from non contracted providers Excluding sensitive services All Out of Area Services Outpatient and office Bariatric psychiatric evaluations Biofeedback Refer to plan Evidence Of Coverage (EOC) for exceptions Cataract spectacles and lenses Cataract Surgery AAH ABC Laser Surgery Cardiac Rehab Children's Developmental Evaluations Chiropractic services Refer to plan Clinical Trials Cosmetic Services Excluding reconstructive or certain transgender surgeries. Refer to plan EOC Custodial Care Services Coumadin Clinic Services Medi Cal: IV Sedation and general anesthesia Dental Care Refer to plan EOC for coverage criteria and exceptions Group Care: Covered through Public Authority Keloid Scar Treatments such as 5 FU, cryotherapy, surgery, radiation, laser therapy (effective 5/1/17) Dermatology Keloid Scar Treatments such Topical pressure/silicone gel, intralesional steroid injection (effective 5/1/17) Diabetes Self Management Lab tests performed by Quest Diagnostics Diagnostic and Laboratory Services Lab tests performed by providers other than Quest Diagnostics All genetic testing performed by Quest Diagnostics AAH: Refer to plan. Dialysis ABC: Extended authorizations for 6 months Authorization No Authorization Last Revision: 6/1/2017
6 Community Health Center Network (CHCN) PRIOR AUTHORIZATION GRID Before services are provided PLEASE CHECK Provider Portal for: *Member Eligibility *Benefit Coverage *Contracted Provider Questions Call CHCN at /1/2017 AAH: Submit CHME DME Prior Authorization (PA) form to CHME: Phone: ; fax: ; aaquestions@chme.org; aaquestions@chme.org Non Covered Benefit Authorization No Authorization ABC: Submit CHCN Prior Authorization form to CHCN, ONLY for the following DME: *Air Durable Medical Equipment/Repair Fluidized Beds, *Bone Growth Stimulators, *Cervical Collars, *Cold Therapy Units, *Compression Hosiery & Support Stockings, *Continuous Glucose Pump, *CPM device, *Cranial Helmets, *Diabetic Shoes, *Dynamic Splint, *Electric Patient Lifts, *Electric Seat Lift Chairs, *Home Infusion Therapy, *Insulin Pump, *Mastectomy Related Accessories, *Ocular Prosthetics, *Respiratory Therapy Medication, *Lymphedema Pumps, *Speech Generating Devices, *Tractions, *Vest Airway Clearance System Enteral and nutrition formulas AAH: refer to plan. ABC: submit PA to CHCN Emergency Care/Treatment Early and Periodic Screening, Diagnostic and Treatment (EPSDT) supplemental services Experimental/Investigational treatments Facility admissions Inpatient, SNF, LTAC, Hospice, Acute Rehab, Respite, Burn Centers Gender Identity/Transgender Services Surgical Treatments Hearing Aids AAH: refer to plan. ABC: Submit PA to CHCN Home Health: Evaluation Skilled Nursing, OT,PT, ST Visits beyond evaluation Hospice Services Home or Inpatient Incontinence creams and washes Infertility treatment Injectable, Chemotherapy, Infusion, Transfusions Outpatient Refer to plan website for Drug Formulary Mild to Moderate: Refer to plan Mental Health Services AAH: Submit PA to BEACON for Pre Bariatric surgery Psych Eval ABC: Submit PA to CHCN for Pre Bariatric surgery Psych Eval Nutrition and dietician assess/counseling Pre Bariatric surgery OB/GYN Services Including ultrasounds Ophthalmology Annual services and care related to DM, glaucoma, ocular degeneration Orthodontics, orthognathic and appliance therapy for TMJ Orthotics and Prosthetics (e.g. breast prostheses, AAH: Refer to plan footwear to treat/prevent diabetes complications, ABC: submit PA to CHCN Outpatient surgery and specialty procedures Outpatient Therapy (OT, PT, ST) OT, PT, ST Initial Evaluations OT, PT, ST follow up visits Last Revision: 6/1/2017
7 Podiatry Preventive Care Pulmonary Rehab Interventional Radiology Radiology Community Health Center Network (CHCN) PRIOR AUTHORIZATION GRID Before services are provided PLEASE CHECK Provider Portal for: *Member Eligibility *Benefit Coverage *Contracted Provider Questions Call CHCN at /1/2017 Medi Cal: performed in FQHC all ages Medi Cal: performed outside of FQHC under 21 y.o. or with diabetes Medi Cal: performed outside of FQHC and over 21 y.o. for members with chronic disese or, acute condition impairing ability to walk. Group Care: All ages, clinic settings, and continuous Advanced Radiology provided within the Hospital: CT with or without contrast, MRI, MRA, Nuclear Med, PET Scans, DEXA Scans. Advanced Radiology provided within Non Hospital/Freestanding facilities: CT with contrast, MRI, MRA, PET Scans, and DEXA Scans for members 64 years of age and younger. Advanced Radiology provided within Non Hospital/Freestanding facilities: CT without contrast, Nuclear Med, and DEXA Scans for members 65 years of age and older. Non Covered Benefit Authorization No Authorization Routine: X ray, Ultrasound including OB, Mammography, VCUG, IVP, BE, Upper GI Second Opinions Medi Cal: (contracted and non contracted providers) Sensitive Services (including therapeutic abortion Group Care: (contracted providers only) & HIV testing & counseling Group Care: (non contracted providers) Sleep Studies Specialist and Hospitalist Referrals (In network) PA required only for Dr. Scott Taylor Standard diagnostic procedures EKG, PFT, EGD, KUB, Nuchal Translucency Scan, Transthoracic Echocardiograms Specialty diagnostic procedures Stress/Pharmacologic or Trans esophageal Echocardiograms, Colonoscopy/Sigmoidoscopy Surgery Services Outpatient Transplant Services All pre transplant service evaluations, Kidney and Corneal Medi Cal: Refer to plans for major organ transplants (heart, lung, liver, bone marrow, etc.) Group Care: All major organ and bone marrow transplants Vaccines Wound Care services Last Revision: 6/1/2017
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