Outpatient Specialty Referral Request Types

Similar documents
Specialty Referrals. Start of Code Range (Procedure Low Code) Request Request Profile Description. End of Code Range (Procedure High Code)

All TRICARE West Region referral and authorization requests must be submitted online.

MDwise Community Health Network Hoosier Healthwise Medical Services that Require Prior Authorization

MetroPlus Health Plan SCHEDULE OF BENEFITS MetroPlus Gold

2016 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization

Benefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information

MVP PREMIER PLUS SCHEDULE OF BENEFITS Gold 4 MVP Health Plan, Inc. Embedded Deductible Off Exchange

January 2016 Topic of the Month

Molina Healthcare of Washington Member Services: (800) /TTY

2018 HDHP. Denver Health Medical Plan, Inc. Career Service Employees (CSE) and Denver Employee Retirement Plan (DERP) HighPoint Denver Plus Network

Participating Provider Non- Participating Provider Limitations & Exceptions. deductible applies. 75% of the Fund's fee schedule; deductible applies

2018 Anthem Blue Cross Senior Secure HMO - Southern CA - Post 65 (Medicare Eligible)*

New York Essential Plan cost-sharing matrix

MEDICAL SCHEDULE OF BENEFITS

2016 Rochester Regional Health PPO Medical Plan Summary

HealthyBlue Living SM

MEDICAL & RX BENEFIT MATRIX. American Environmental Group/PPO Plan HSB Customer Service: EFFECTIVE DATE: MEDICAL & RX BENEFITS

Excellus BluePPO Signature Hybrid 5

Benefit Name Domestic In Network Out of Network. Benefit Name Domestic In Network Out of Network. 30% Coinsurance Subject to Deductible

NEW YORK STATE TEAMSTERS COUNCIL HEALTH & HOSPITAL FUND APPENDIX A SCHEDULE OF BENEFITS SUPREME BENEFITS

IMPORTANT NOTICES. Office visits and/or procedures at PAR/Network Providers do not require PA. Referrals to PAR/Network Specialists do not require PA.

Allergen specific, each allergen is covered up to 50 units per patient annually; additional units would require medically necessary review.

UNIVERSITY OF THE INCARNATE WORD, S2855 BRONZE RBP PLAN GRANDFATHERED PLAN BENEFIT SHEET

MEDICAL & RX BENEFIT MATRIX. American Environmental Group/HSA Plan EFFECTIVE DATE: MEDICAL & RX BENEFITS

National Accounts Utilization Management Requirements New York based Accounts

Benefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information

REVENUE CODE LIST REQUIRING CPT/HCPCS CODES FOR OUTPATIENT FACILITY CLAIMS

Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2017

*** NOTE *** ALL services subject to deductible, unless otherwise noted.

not require PA. review. MHT

Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018

2018 Anthem Blue Cross HMO*

UNIVERSITY OF THE INCARNATE WORD, S2855 PPO PLAN GRANDFATHERED PLAN BENEFIT SHEET

Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018

UNIVERSITY OF THE INCARNATE WORD, S2855 SILVER RBP PLAN GRANDFATHERED PLAN BENEFIT SHEET

Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018

Arizona Clover Health Choice PPO (040) 2019 Medical Benefits

GILSBAR GROUP HEALTH PLAN S2202 OPTION 2 NON-GRANDFATHERED PLAN BENEFIT SHEET

IN-NETWORK MEMBER PAYS. Out-of-Pocket Maximum (Includes a combination of deductible, copayments and coinsurance for health and pharmacy services)

Medicaid & Market Place Prior Auth (PA) Code Matrix Effective Q1, 2018

PLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK

Excellus BluePPO Signature Deduct 3

IMPORTANT NOTICES. To search this document, use [Ctrl + F] keys; enter Service or Code in search navigation pane at left; press Enter.

Please refer to your Benefit Handbook for further information about how your In-Network and Out-of- Network coverage works.

Pennslyvania Green (Plan 028) 2018 Medical Benefits

Provider Alert. November 30, 2017

Prior Authorization List Effective February 2, 2015

CPT-4 3 HCPCS AMBULANCE I A0021-A0999 C9000-C9010, C9105 J0120-J8999 Q3014, Q3017 AMBULATORY SURGERY

Family Coverage Self-Only Coverage Amounts Per Accumulation Period (a Family of one Member) or more Members

Individual Market Schedule of Benefits

Jan 30, Dear Provider:

Schedule of Benefits PPO MASSACHUSETTS

Georgia Green (Plan 026) 2018 Medical Benefits

Principal benefits for Kaiser Permanente Traditional HMO Plan (10/1/18 9/30/19)

Principal Benefits for Kaiser Permanente Traditional Plan (10/1/16 9/30/17)

See the benefits table below. None. $2,000 per Member per Calendar Year $4,000 per family per Calendar Year

UnitedHealthcare SignatureValue TM Focus Offered by UnitedHealthcare of California

Principal Benefits for Kaiser Permanente Traditional HMO (1/1/16 12/31/16)

IN-NETWORK MEMBER PAYS. Contract Year Plan Deductible (Deductible is combined for health services and prescription drugs) $5,000 Individual

PLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK

Individual Market Schedule of Benefits

See the benefits table below. $250 per Member per Calendar Year $500 per family per Calendar Year

Anthem Blue Cross Your Plan: Premier HMO 20/200 admit/100 OP Your Network: California Care HMO

Schedule of Benefits. Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM POS MAINE

PLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK

Anthem Blue Cross High HMO

Tusculum College. Benefit Summary. $25 Copay. $25 Copay. after Deductible. 20% after Deductible 20% after Deductible

Prior Authorization List for Physician Alliance of the Rockies, UnitedHealthcare Medicare Advantage Effective January 1, 2019

Tusculum College. Benefit Summary Option/Quote: 2. 30% after Deductible. $35 Copay. 30% after Deductible

Effective April 7, 2014 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST IMPORTANT

Principal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (7/1/18 6/30/19)

PLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK

Summary of Benefits Chart for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/17 9/30/18)

Principal benefits for Kaiser Permanente Traditional Plan (10/1/15 9/30/16)

Unlimited except where otherwise indicated. Primary Care Physician Selection

Louisiana Revised Prior Authorization Requirements

Principal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/15 9/30/16)

NEIGHBORHOOD HEALTH PARTNERSHIP HMO SUMMARY OF BENEFITS

PUBLICATIONS SYSTEM CHANGE TRANSMITTAL FOR TRICARE POLICY MANUAL (TPM), AUGUST 2002

Inpatient ALL TEXAS REFERRAL / AUTHORIZATION FORMS MUST BE SIGNED BY THE PCP OR ORDERING PHYSICIAN THAT HAS A VALID REFERRAL FROM THE PCP.

IMPORTANT NOTICES. To search this document, use [Ctrl + F] keys. Enter Service or Code in Navigation pane; press Enter.

Schedule of Benefits - CENTRAL HMO Group CITY OF MARSHFIELD Benefit Year: January 1st through December 31st Effective Date: 01/01/2017

Prior Authorization List for Physician Alliance of the Rockies, UnitedHealthcare Medicare Advantage Effective April 1, 2018

MEDICAL BENEFITS. Eff. 1/1/15 Medicare Advantage is through HUMANA

Subject to Routine Physical Exam benefit. Same as applicable participating provider office visit member cost sharing Allergy Testing

PLAN DESIGN. Customer Name: High Desert & Inland Employee-Employer Trust. Effective Date: Plan: HMO Plan. Location(s): California

II. BENEFITS AND SERVICES


April 4, 2016 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST

MEDICAL CODING FUNDAMENTALS

SUMMARY OF P BENEFITS AND SCHEDULE OF COPAYMENTS

Letter to the AMGA Board of Directors...1 Introduction...3

Global Series Elite Executive Schedule of Medical & Dental Benefits Effective August May

Long-stay patients methodology Published by NHS England and NHS Improvement

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services. Coverage Period: Beginning On or After 1/1/2018

Global Series Schedule of Medical & Dental Benefits Effective July May

Anthem Blue Cross Your Plan: Custom Premier HMO 10/100% Your Network: Select HMO

Revenue/Procedure Code Service Group Matrix

Transcription:

What is a request type? Request types are templates created for use with Health Net Federal Services, LLC s (HNFS) online referral and authorization submission tools, available at www.tricare-west.com > Provider. Each request type has been developed by HNFS in accordance with the TRICARE manuals. When a request type is selected, the associated CPT codes, number of visits, and duration of the authorization will pre-populate on the request. Outpatient Specialty Referrals... 1 Outpatient Authorizations (physical and behavioral health)... 2 Durable Medical Equipment.... 4 Inpatient Authorizations... 5 Outpatient Specialty Referral Request Types The associated CPT codes, number of visits, and duration of the authorization will populate based on the request type selected. Description Included CPT Code(s) Request Type Evaluate and Treat Specialty Referral Evaluate Only Specialty Referral 99201 99205, 99211 99215, 99241 99245 P1 99201 99205, 99211 99215, 99241 99245 P3 Pre/Post Transplant 99211 99215, 99241 99245 P58 Routine Eye Examination 92002 92015 P63 Second Opinion 99201 99205, 99211 99215, 99241 99245 P5 Specialty Referral Extension 99211 99215 P4 ADSMs = active duty service members TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Last Updated 09/27/2018. HH0618x013 (10/18) Page 1

Physical Health Outpatient Authorization Request Types ABA Initial Assessment 0359T, T1023 P153 ABA Outcome Measures T1023 P154 ABA Tiered Provider 0359T, 0364T 0365T, 0368T 0369T, 0370T,0360T 0361T, T1023 P151 Acupuncture 97810 P163 Adjunctive Dental* P127 Air Ambulance Services A0430 A0431 P116 Allergy Services 95004, 95017 95117 P9 Ambulance Services A0999 P10 Audiology 92550, 92552 92557, 92563 92588 P11 BMPR1A 81479 P133 BRCA1/BRCA2 81211 81217 P129 Breastfeeding Counseling 99401 99404 P159 Cardiac Rehabilitation 93797 93798 P12 CFTR 81220 81224 P135 Chiropractic Care 98940 98943 P14 Colonoscopy 45300 45392 P43 Custodial Care Home 99600 P165 Cytogenomic Constitutional Microarry Analysis 81228 81229, 81406 P136 Dental Anesthesia 41899, 00170 P101 Dental/Adjunctive Dental Svc Data Entry D9310 P22 Diabetic Education G0108 G0109 P23 Diabetic Eye Exam 92082, 92250, 99203 99204 P114 Dialysis 90935 P60 ECHO Respite Care 99600 P47 Emergency Room Visit 99281 99285 P44 Global OB 59400 59622 P76 Global OB ICD-10 59400 59622 P126 Hippotherapy S8940 P124 Home Health Infusion Therapy* 99601 99602 *generic request type (can also enter codes manually) P28 Home Health PPS or Corp-Nursing 0023, G0151 G0153, G0299 G0300 P26 Hospice 0651 0657, 0551, 0561, 0571 P46A Hourly Skilled Nursing 99347 P48 Injection, Epidural (Cervical or Thoracic) 62320 62321, 77003 P30 Injection, Epidural (Lumbar or Sacral) 62322 62323, 77003 P31 Injection, Facet Joint (Cervical or Thoracic) 64490 94492 P32 Injection, Facet Joint (Lumbar or Sacral) 64493 64495 P33 Page 2

Physical Health Outpatient Authorization Request Types (continued) Injection, HPV 90649 P29 Integrated Disability Evaluation 99456 P111 Maternity Ultrasounds 76801 76817 P34 Non-USFDA LDTs Demo* P162 Nutritional Counseling 97802 97804, G0270 G0271 P24 Observation Stay G0378 G0379 P35 Occupational Therapy Post Op Care 97165, 97167 97168, 97010 97024, 97028 97036, P36B Occupational Therapy Acute Injuries 97165, 97167 97168, 97010 97024, 97028 97036, P36A Occupational Therapy Long Term 97165, 97167 97168, 97010 97024, 97028 97036, Conditions P36C Opioid Replacement Therapy (ORT) 0912 0913 P152 Osteopathic Manipulation 98925 98929 P37 Outpatient Infusion Therapy or Medication Administration* P115 Outpatient PH Medical Procedure* (duration of 180 days) P106 Outpatient PH Surgical Procedure* (duration of 180 days) P105 Physical and Occupational Therapy Acute Injuries Physical and Occupational Therapy Long-Term Conditions Physical and Occupational Therapy Post- Op Care Physical Therapy Long-Term Conditions Physical Therapy Post-Op Care Physical Therapy Acute Injuries Pulmonary Rehabilitation G0237 G0238 P13 Pulmonary Rehabilitation Pre/Post Transplant 97161 97163, 97110 P59 Sleep Study 95810 95811 P40 Sleep Study (Under 6 Years Old) 95782 95783 P123 SMN1/SMN2 81400 81401, 81403, 81405 P148 Smoking Cessation 96152 96153 P62 Speech Therapy Post-Op Care 92521 92524, 92507 P39B Speech Therapy Acute Injuries 92521 92524, 92507 P39A Speech Therapy Long-Term Conditions 92521 92524, 92507, 92610, 92526 P39C Synagis 90378 P67 Terminal Leave Blanket Authorization 99201 99215, 90791 90792, 99201 99205 P128 Trigger Point Injections 20552 20553 P41 Urgent Care 99201 99205 P45 *= generic request type P125A P125C P125B P38C P38B P38A Page 3

Behavioral Health Outpatient Authorization Request Types (continued) Continuing Outpatient Therapy (BH) 90791 90792, 90832 90853, 99201 99205, 99211 99215, 90785 P50 Electroconvulsive Therapy (BH) 90791 90792, 90870 P64 IOP Psych (BH) S9480 P156 IOP Substance Abuse (BH) H0015 P157 Medication Assistant Treatment (BH)* P167 Medication Management (BH) 99201 99215 P51 Neuro Psychological Testing (BH) 90791 90792, 96118 96120 P53 Observation Stay (BH) G0379 P75 PHP Psych Full Day (BH) 0913 P71 PHP Psych Half Day (BH) 0912 P73 PHP Substance Abuse Full Day (BH) 0913 P72 PHP Substance Abuse Half Day (BH) 0912 P74 Psychological Testing (BH) 090791 90792, 96101 96103 P52 Transcranial Magnetic Stimulation (BH) 090791 90792, 90867 90869 P166 BH = behavioral health, *= generic request type Durable Medical Equipment Request Types The associated CPT codes, number of visits, and duration of the authorization will populate based on the request type selected. ASV (Adaptive Servo-Ventilation Machine) Purchase and Supplies E0471, E0562, A7027 A7039, A7046, A4604 P168P ASV Rental and Supplies E0471, E0562, A7027 A7039, A7046, A4604 P168R BiPap Purchase and Supplies E0562, E0470, A7030 A7039, A7046 P17P BiPap Rental and Supplies E0562, E0470, A7030 A7039, A7046 P17R Breast Pump and Supplies Heavy Duty Hospital Grade E0604, A4281 A4286, A9999 P160 Breastfeeding Pump and Supplies E0602 E0603, A4281 A4286, A9999 P158 Commode (3 in 1) E0163 P57 CPAP Purchase and Supplies E0601, E0562, A7027-A7039, A7046, A4604 P16P CPAP Rental and Supplies E0601, E0562, A7027 A7039, A7046, A4604 P16R CPAP Supplies Only A7027 A7039, A7046, A4604 P155 CPM Machine Knee E0935 P54 CPM Machine Other E0936 P65 DME Purchase and Med Supplies Generic P108 DME Rental and Med Supplies Generic P107 Insulin Pump Purchase and Pump Supplies E0784, A4222, A4231-A4232 P15P Insulin Pump Rental and Pump Supplies E0784, A4222, A4231-A4232 P15R LVAD L9900 P61 Personal Incontinence Supplies A4520, T4521 T4536, T4539, T4543 P161 Page 4

Durable Medical Equipment Request Types (continued) Prosthetics and Orthotics Generic Rolling Walker E0143 P56 Synthetic Sheepskin Pad E0188 P55 TENS Unit Purchase E0720 E0730, A4595 P113 TENS Unit Rental E0720 E0730, A4595 P112 P109 Wheelchair (Custom) Purchase, Manual Wheelchair (Custom) Purchase, Power E0990, E0950, E0955, E0960, E0971, E0973, E0974, E0978, E2604, K0004, K0040, K0108 E0950, E0955, E0960, E0960, E0973, E0974, E0978, E2313, E2321, E2363, E2367, E2376, E2604, K0836, K0040, K0108 P19 P20 Wheelchair Rental Basic K0001, E0990 P18 Wound Vacuum E2402, A6550, A7000, A4221, A4222 P21 *= generic request type Inpatient Authorization Request Types Description Included CPT, NDC, HCPCS Codes Request Type Bariatric Surgery Laparoscopic Roux-en-Y (Inpatient PH) 43644 P97 Bariatric Surgery Laproscopic Banding (Inpatient PH) 43770 43774 P98 Bariatric Surgery Open Roux-en-Y (Inpatient PH) 43846 P100 Bariatric Surgery Vertical Banding (Inpatient PH) 43842 P99 BH Admit (Inpatient) 99221 P81 Chemical Dependency (BH CD) Detoxification 99221 P83 Chemical Dependency (BH CD) Rehabilitation 99221 P84 C-Section Delivery (Inpatient) 59514 P80 Custodial Care (Inpatient) 99324 P164 Double Lung Transplant (Inpatient PH ) 32852 32584 P89 Heart Lung Transplant (Inpatient PH) 33935 P90 Heart Transplant (Inpatient PH) 33945 P94 Intestinal Transplant (Inpatient PH) 44135 44136 P93 Islet Cell Transplant (Inpatient PH) 48160 P92 Kidney Transplant (Inpatient PH) 50360, 50365, 50380 P86 Liver Transplant (Inpatient PH) 47135 47136 P87 Long Term Acute Care (Inpatient PH) 99221 P104 Medical Admit (Inpatient PH) 99221 P77 Pancreas Transplant (Inpatient PH) 48554 P91 Rehabilitation Acute (Inpatient PH) 99221 P103 Residential Treatment Center (BH Inpatient) 99221 P82 Single Lung Transplant (Inpatient PH) 32851 P88 Skilled Care (Inpatient PH) 0022 P102 Stem Cell Transplant Allogeneic (Inpatient PH) 38240 P95 Stem Cell Transplant Autologous (Inpatient PH) 38241 P96 Surgical Admit (Inpatient PH)* P78 Vaginal Delivery (Inpatient) 59409 P79 BH = behavioral health, PH = physical health, *= generic request type Page 5

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback