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: https://portal.chcnetwork.org/um- Authorizations-Resources Code Description 17311 MOHS 1 STAGE H/N/HF/G 17312 17312 MOHS ADDL STAGE 17313 MOHS 1 STAGE T/A/L 17314 MOHS ADDL STAGE T/A/L 17315 MOHS SURG ADDL BLOCK 17340 CRYOTHERAPY OF SKIN 67840 REMOVE EYELID LESION 90658 IIV3 VACCINE 3 YRS+ IM 96372 THER/PROPH/DIAG INJ SC/IM 96567 PHOTODYNAMIC TX SKIN 96900 ULTRAVIOLET LIGHT THERAPY 96910 PHOTOCHEMOTHERAPY WITH UV B 96920 LASER TX SKIN < 250 SQ CM 96921 LASER TX SKIN 250 500 SQ CM 96922 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 510-297-0481 or umcod@chcnetwork.org
Dermatology Procedure Codes that do not Require Prior Authorization for Contracted Providers Effective June 1, 2017 Code Description 10040 ACNE SURGERY 10060 DRAINAGE OF SKIN ABSCESS 11056 TRIM SKIN LESIONS 2 TO 4 11057 TRIM SKIN LESIONS OVER 4 11100 BIOPSY SKIN LESION 11101 BIOPSY SKIN ADD ON 11200 REMOVAL OF SKIN TAGS <W/15 11201 REMOVE SKIN TAGS ADD ON 11300 SHAVE SKIN LESION 0.5 CM/< 11301 SHAVE SKIN LESION 0.6 1.0 CM 11302 SHAVE SKIN LESION 1.1 2.0 CM 11307 SHAVE SKIN LESION 1.1 2.0 CM 11308 SHAVE SKIN LESION >2.0 CM 11310 SHAVE SKIN LESION 0.5 CM/< 11311 SHAVE SKIN LESION 0.6 1.0 CM 11312 SHAVE SKIN LESION 1.1 2.0 CM 11313 SHAVE SKIN LESION >2.0 CM 11400 EXC TR EXT B9+MARG 0.5 CM< 11401 EXC TR EXT B9+MARG 0.6 1 CM 11402 EXC TR EXT B9+MARG 1.1 2 CM 11403 EXC TR EXT B9+MARG 2.1 3CM/< 11404 EXC TR EXT B9+MARG 3.1 4 CM 11406 EXC TR EXT B9+MARG >4.0 CM 11420 EXC H F NK SP B9+MARG 0.5/< 11421 EXC H F NK SP B9+MARG 0.6 1 11422 EXC H F NK SP B9+MARG 1.1 2 11423 EXC H F NK SP B9+MARG 2.1 3 11424 EXC H F NK SP B9+MARG 3.1 4 11426 EXC H F NK SP B9+MARG >4 CM 11440 EXC FACE MM B9+MARG 0.5 CM/< 11441 EXC FACE MM B9+MARG 0.6 1 CM 11442 EXC FACE MM B9+MARG 1.1 2 CM 11443 EXC FACE MM B9+MARG 2.1 3 CM 11444 EXC FACE MM B9+MARG 3.1 4 CM 11446 EXC FACE MM B9+MARG >4 CM 11600 EXC TR EXT MAL+MARG 0.5 CM/< 11601 EXC TR EXT MAL+MARG 0.6 1 CM 11603 EXC TR EXT MAL+MARG 2.1 3 CM 11604 EXC TR EXT MAL+MARG 3.1 4 CM 11606 EXC TR EXT MAL+MARG >4 CM 11642 EXC F/E/E/N/L MAL+MRG 1.1 2 11900 INJECT SKIN LESIONS </W 7 11901 INJECT SKIN LESIONS >7
Code Description 12031 INTMD RPR S/A/T/EXT 2.5 CM/< 12032 INTMD RPR S/A/T/EXT 2.6 7.5 12041 INTMD RPR N HF/GENIT 2.5CM/< 12051 INTMD RPR FACE/MM 2.5 CM/< 12052 INTMD RPR FACE/MM 2.6 5.0 CM 13100 CMPLX RPR TRUNK 1.1 2.5 CM 13101 CMPLX RPR TRUNK 2.6 7.5 CM 13102 CMPLX RPR TRUNK ADDL 5CM/< 13121 CMPLX RPR S/A/L 2.6 7.5 CM 13122 CMPLX RPR S/A/L ADDL 5 CM/> 13131 CMPLX RPR F/C/C/M/N/AX/G/H/F 13132 CMPLX RPR F/C/C/M/N/AX/G/H/F 13151 CMPLX RPR E/N/E/L 1.1 2.5 CM 13152 CMPLX RPR E/N/E/L 2.6 7.5 CM 14000 TIS TRNFR TRUNK 10 SQ CM/< 14001 TIS TRNFR TRUNK 10.1 30SQCM 14020 TIS TRNFR S/A/L 10 SQ CM/< 14021 TIS TRNFR S/A/L 10.1 30 SQCM 14040 TIS TRNFR F/C/C/M/N/A/G/H/F 14060 TIS TRNFR E/N/E/L 10 SQ CM/< 14301 TIS TRNFR ANY 30.1 60 SQ CM 15260 SKIN FULL GRAFT EEN & LIPS 17000 DESTRUCT PREMALG LESION 17003 DESTRUCT PREMALG LES 2 14 17004 DESTROY PREMAL LESIONS 15/> 17108 DESTRUCTION OF SKIN LESIONS 17110 DESTRUCT B9 LESION 1 14 17111 DESTRUCT LESION 15 OR MORE 17260 DESTRUCTION OF SKIN LESIONS 17261 DESTRUCTION OF SKIN LESIONS 17262 DESTRUCTION OF SKIN LESIONS 17264 DESTRUCTION OF SKIN LESIONS 17266 DESTRUCTION OF SKIN LESIONS 17273 DESTRUCTION OF SKIN LESIONS 17280 DESTRUCTION OF SKIN LESIONS 17281 DESTRUCTION OF SKIN LESIONS 17282 DESTRUCTION OF SKIN LESIONS 17311 MOHS 1 STAGE H/N/HF/G 17312 17312 MOHS ADDL STAGE 17313 MOHS 1 STAGE T/A/L 17314 MOHS ADDL STAGE T/A/L 17315 MOHS SURG ADDL BLOCK 17340 CRYOTHERAPY OF SKIN 54056 CRYOSURGERY PENIS LESION(S) 54060 EXCISION OF PENIS LESION(S) 54100 BIOPSY OF PENIS
Code Description 67840 REMOVE EYELID LESION 81025 URINE PREGNANCY TEST 87101 SKIN FUNGI CULTURE 87210 SMEAR WET MOUNT SALINE/INK 88304 TISSUE EXAM BY PATHOLOGIST 88305 TISSUE EXAM BY PATHOLOGIST 88312 SPECIAL STAINS GROUP 1 88313 SPECIAL STAINS GROUP 2 88321 MICROSLIDE CONSULTATION 88342 IMMUNOHISTO ANTB 1ST STAIN 88346 IMMUNOFLUOR ANTB 1ST STAIN 88350 IMMUNOFLUOR ANTB ADDL STAIN 90658 IIV3 VACCINE 3 YRS+ IM 95004 PERCUT ALLERGY SKIN TESTS 95044 ALLERGY PATCH TESTS 96372 THER/PROPH/DIAG INJ SC/IM 96567 PHOTODYNAMIC TX SKIN 96900 ULTRAVIOLET LIGHT THERAPY 96910 PHOTOCHEMOTHERAPY WITH UV B 96920 LASER TX SKIN < 250 SQ CM 96921 LASER TX SKIN 250 500 SQ CM 96922 LASER TX SKIN >500 SQ CM 99070 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
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 510 297 0220 6/1/2017 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
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 510 297 0220 6/1/2017 AAH: Submit CHME DME Prior Authorization (PA) form to CHME: Phone: 1 800 906 0626; fax: 650 357 8551; email: 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
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 510 297 0220 6/1/2017 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