MDwise HIP Prior Authorization and Drug List

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

2016 MDwise HIP Medical Services that Require Prior Authorization

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

2016 MDwise HIP Medical Services that Require Prior Authorization

MDwise Hoosier Care Connect Medical Services that Require Prior Authorization

Drug Name. J0129 Injection, abatacept (Orencia ), 10 mg Effective 01/01/2014. J0178 Injection, aflibercept (Eylea ), 1 mg Effective 04/01/2015

Provider Administered Drug Program (PADP) and Physician Administered Drug VPSS List

2017 MDwise HIP Medical Services that Require Prior Authorization

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

BCBS AZ ADV PLUS * CLASSIC * PREMIER For use with members associated with the BHN Network Prior Authorization List 2015

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

PA Category Name Code(s) Additional Notes ABA 0364T 0365T 0366T 0367T 0373T 0374T H G0396. Applied Behavioral Analysis stage 3*

2018 MDwise HIP Medical Services that Require Prior Authorization

2018 MDwise HIP Medical Services that Require Prior Authorization

Oregon CPT Preapproval Grid

2018 MDwise HIP Medical Services that Require Prior Authorization

Prior Authorization List Effective February 2, 2015

Jan 30, Dear Provider:

Oregon CPT Preapproval Grid

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

January 2016 Topic of the Month

2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization

2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization

PA Category Name Code(s) Additional Notes ABA. Applied Behavioral Analysis stage 3*

Provider Alert. November 30, 2017

MedStar Medicare Choice Pharmacy Services

SPECIALTY PHARMACY Master Clinical Drug List

UnitedHealthcare Notification/Prior Authorization Requirements Effective October 1, 2016

Louisiana Revised Prior Authorization Requirements

Outpatient Specialty Referral Request Types

National Accounts Utilization Management Requirements New York based Accounts

Pre-authorization Form

UnitedHealthcare Notification/Prior Authorization Requirements Effective July 1, 2017

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

Injectable Drugs Requiring Pre-Service Approval

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

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

New Billing Guidelines for Home Infusion, Enteral and Parenteral Therapies Home Infusion Fee Schedule Effective July 1, 2009

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

Prior treatment with non-biologic Disease- Modifying Antirheumatic. Not to be used in combination with another biologic DMARD

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

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

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

New York Essential Plan cost-sharing matrix

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

INJECTABLE MEDICINES. Resources, Links or Additional Information. J Code Brand Names Generic names Prior Authorization or Restrictions

April 4, 2016 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST

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

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

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

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

Medical Pre-Authorization and Notification Requirements

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

Premera Blue Cross Medicare Advantage Plans Medical Policy Updates

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

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

MetroPlus Health Plan SCHEDULE OF BENEFITS MetroPlus Gold

NEIGHBORHOOD HEALTH PARTNERSHIP HMO SUMMARY OF BENEFITS

sad EFFECTIVE DATE: POLICY LAST UPDATED:

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

HealthyBlue Living SM

MEDICAL SCHEDULE OF BENEFITS

MOLINA HEALTHCARE MEDICARE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 01/01/2018

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

2016 Rochester Regional Health PPO Medical Plan Summary

sad EFFECTIVE DATE: POLICY LAST UPDATED:

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

UnitedHealthcare SignatureValue TM Focus Offered by UnitedHealthcare of California

Pharmacy and Medical Guideline Updates

Medical Policies and Clinical Utilization Management Guidelines

Billing for Infusion Services in an Outpatient Neurology Clinic. Christine Mann, MBA Director of Infusion Services Dent Neurologic Institute

MOLINA HEALTHCARE MEDICARE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 01/01/2018

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

April 8, 2018 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST

Arkansas State Specific UM Statistics for Prior Authorizations

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

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

Your 2010 Medical Benefit Chart PFFS Plan Xerox Effective 01/01/2010

PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION

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

Position Statement Treatments that primarily affect the appearance are considered medically necessary only in the following circumstances:

LABORATORY PROCEDURES IMAGING/RADIOLOGY PROCEDURES THERAPY GVH EMERGENCY DEPARTMENT PROCECURES

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

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

Pennslyvania Green (Plan 028) 2018 Medical Benefits

PHC TAR REQUIREMENTS

sad EFFECTIVE DATE: POLICY LAST UPDATED:

Schedule of Benefits PPO MASSACHUSETTS

Medication Policy Manual. Policy No: dru408. Topic: Site of Care Review Date of Origin: July 10, 2015

2018 Anthem Blue Cross HMO*

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

Medical Policies and Clinical Utilization Management Guidelines update

not require PA. review. MHT

January 29, Dear Provider:

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

Medical Services Requiring Prior Approval

Individual Market Schedule of Benefits

Transcription:

MDwise HIP Prior Authorization and Drug List Services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services With the exception of ER, Ambulance, Urgent Care Center services, Immunizations, Family planning services, chiropractic services, podiatry, and ologists, except if service is otherwise listed on PA list. Facility to facility ambulance transport (nonemergent transport) A0426 & A0428 Air Ambulance A0430, A0431, A0435, A0436 Elective/emergent/urgent medical, surgical inpatient admissions and observation stays Inpatient Rehabilitation POS 21, 22, 24, 51, 61 Skilled nursing facility services POS 31 Subacute admission POS 21 POS 21 or 61 and accommodation codes 024, 931-932 POS 21 or POS 61. Revenue code 024 Transplants Accidental dental services (other than ER) Bariatric Surgery excluding the work up/evaluation for transplant POS 21 - For outpatient need to have the following: S9975, Solid: Heart/lung 33930-33945 liver - 47133-47147, pancreas - 48550-48556, Bone Marrow: 38240-38242 Heart valve tissue transplants: 33933, 33944 Stem cell: 38204-38232 Pancreas: 48550-48556 Intestine: 44132-44137, 44715-44721 D0100-D0999. Please contact Dentaquest for prior authorization of dental services 43644-43645, 43770 43775, 43842 43848, 43886 43888 or 43999 Cochlear Implants surgery (See DME for device) 69930 General anesthesia for dental procedures D9210 - D9248 Hysterectomy 51925, 58150 58294, 58541 58544, 58548 58554, 58570-58573, 58951 58956 Mastectomy reconstructive surgery Same as breast reconstruction below

Maxillofacial surgeries/tmj -including Arthroplasty, Arthroscopy, Reconstruction, Discectomy (with or without disc replacement), trigger point injections, Arthrocentesis, and mandibular orthopedic repositioning appliances (MORA) 21010, 21025-21026, 21050, 21060, 21070, 21073, 21116, 21193-21196, 21240-21249, 21255, 29800, 29804, S8262 Non-cosmetic reconstructive surgery Included in potentially cosmetic Potentially cosmetic procedures in addition to other procedures listed separately: blepharoplasty, septoplasty/rhinoplasty, port wine stain removal, otoplasty, breast reconstruction, breast enlargement, breast reduction/mammoplasty, mammoplasty for gynecomastia, breast implant removal, excision of excess skin due to weight loss including panniculectomy/abdominoplasty, lipectomy or excess fat removal, varicose vein treatment, cleft lip/palate surgery, congenital craniofacial anomaly surgery, surgical treatment of congenital chest wall deformity (pectus excavatum), breast congenital anomaly (i.e. polymastia) 11200-11201, 11920-11922, 11950-11954, 15775-15776, 15780-15839, 15847, 15876-15879, 17106-17108, 19300-19307, 19316-19396, 21740-21743, 30400-30462, 30520, 36468-36471, 37785,37799, 40650-40761, 42200-42281, 54660, 67900-67975, 69300, S2066-S2068 Breast congenital anomaly (i.e. polymastia) Included in Breast Reconstruction Breast enlargement (same as Augmentation) Same as Augmentation above Congenital craniofacial anomaly surgery Included in Maxillofacial above Tonsillectomy & Adenoidectomy 42820-42836 Uvulopalatoplasty including laser assisted 42145 Vision surgery - Laser in-situ keratomileusis (LASIK), laser epithelial keratomileusis (LASEK), Photorefractive Keratectomy (PRK), Photostigmatic keratectomy (PARK/PRK-A), Epikeratoplasty S0800, S0810, S0812, 65767 Home health services POS 12 with the following codes, G0151, G0152, G0153, G0155, 99600, 99600 TE, 99600 TD, 99601, 99602, 92610, S9349, S9127, 97001, 97003, 92521-24 - Initial evaluation codes for PT, OT, ST in home and all subsequent therapy visits in home requires PA.

Home IV infusion S9349 Tocolytics, 96601-99602 Home oxygen Hospice (inpatient and outpatient) Nutritionals and Supplements, Enteral/Parenteral Nutrition and services Outpatient ST/OT/PT Outpatient cardiac rehab Outpatient Pulmonary rehab CORF- comprehensive outpatient rehabilitation facilities, regardless of total claim cost A4615- A4616, A7046, E0424-E0455, E0460-E0461, E0463, E1352-E1392, E1405-E1406, K0738 All POS 34, For POS 12, the following should pend: 651, 652, 655 and 656 with HCPCS codes Q5001-Q5010 B4034 -B9998 97002, 97004, 97010-97546, 97750-97762, 92507-92508, 92520-92526 G0422 - G0423 99 HX 93797-93798 99 CP 943 G0237 - G0239 99 HX G0424 - G0424 99 HX G0237-G0239, 948, G0424 Included in PT, OT, ST including all POS 62 Cochlear Implants (device) L8614- L8619 Durable Medical equipment all DME and supplies >$500 (total claim) including rental or purchase requires prior authorization ALL DME codes Electric breast pump, rental or purchase of $500 or more per claim Hearing Aids V5030 - V5263, V5267 Orthotics L0100-L4631 Prosthetics of $500 or more per claim L5000 L9900 TENS (see pain management) A4556 - A4558 99 HX A4595 A4630 - A4630 99 HX E0720 - E0720 99 HX E0730 - E0731 99 HX

Bone Density study for members under 65 years of age Botox Injections Chiropractic Clinical trials for cancer treatment Dialysis Genetic testing Hyperbaric oxygen PET Scan- All MRA- ALL G0130 - G0130 99 HX 76977-76977 99 CP 77078-77086 99 CP 78350-78351 99 CP J0585-J0588 Please refer to Drugs that Require Prior Authorization below Prior Authorization is required for all services billed by the Chiropractor Provider Specialty (150). Chiropractor services are only prior authorized based on medical necessity. Rev codes 082x, 083x, 084x-, 085x 81228, 81229, 88230, 88367, 88291, 80502, 88262, 88289, 88230, 72090, 77072 413 99183 C1300, A4575, E0446 404, 78608-78609, 78811-78816, 78459, 78491-78492, G0219-G0235 74185, 73225, 71555, 70544-70546, 73725, 70547-70549, 72198, 72159, 72159, 73725 MR Spectroscopy 76390 MRI- Abdomen 74181-74183 MRI - Pelvis 72195-72197 MRI - Lower Extremity 73718-73723 MRI- 3D 76376-76377 MRI - Brain 70551-70559 MRI - Chest 71550-71555 MRI - Cervical, Thoracic, lumbar spine 72141-72158 MRI - Breast 77058-77059

CT scan - Cervical, Thoracic, lumbar spine 72125-72133 CT scan - Thorax 71250-71275 CT scan - Abdomen 74150-74178 CT scan - Maxillofacial 70486-70488 CT Scan - Pelvis 72191-72194 3D CT scans 77061-77063, 76376-76377 Podiatry (also described as routine foot care per HIP 2.0 benefit plans), after initial visit All services require PA after initial E&M office visit code or the INITIAL ROUTINE FOOT CARE (codes 11055, 11056, 11057, 11719, 11720, 11721) visit. Pulse generator 61885-61886 The following radiation therapy requires prior auth: Proton Beam, IMRT, Neutron Beam 32553, 77261-77790, C1728, C2634-C2699, G0173, G0251 Vision training therapy 92065 Routine OB Ultrasounds PICC line insertion for OB services (i.e. hyperemesis gravidarum) Pain management- including trigger point injection, facet joint and/or facet joint nerve injection, Epidural steroid injection, transcutaneous electric nerve stimulator Sacral nerve, Neuro or Spinal Cord stimulator Behavioral Health, more than 2 OB ultrasounds require prior auth the following require prior authorization (TENS) 76801-76817 with Diagnosis codes V22.0-V22.2, V23.0-V23.9, V28.3-V28.4, 630.00-633.91, 634.00 634.92, 640.00 676.94, 677 679.14, 764.00 764.99 36569 with diagnosis of 643-643.8, 640.0-643.9 20552-20553, 61850-61888, 62310-62311, 64550-64581, 64479-64484, 64490-64495, 76942, 77002, 77003, 77021,72275, E0744-E0749, E0762, E0766, L8679-L8695, A4290 64553 64565 (for implant) 43647, 43881 (for electrodes) PA requirements as outlined in HIP BAP 18

Drugs that require Prior Authorization Therapeutic Category Brand Name Generic Name Applicable Code(s) Blood Modifiers Botulinum Toxins Enzyme Replacement Therapy Hormonal Modifiers Immuno-modulators for Inflammatory Conditions Immuno-modulators for Multiple Sclerosis Metabolic Bone Disease Aranesp darbepoetin alfa J0881, J0882 Epogen, Procrit epoetin alfa J0885, J0886 Leukine sargramostim J2820 Neulasta pegfilgrastim J2505 Neumega oprelvekin J2355 Neupogen filgrastim J1440, J1441 Botox onabotulinumtoxin A J0585 Dysport abobtulinumtoxin A J0586 Myobloc rimabotulinumtoxin B J0587 Xeomin incobotulinumtoxin A J0588 Cerezyme imiglucerase J1786 Elelyso taliglucerase J3060 VPRIV velaglucerase J3385 Eligard, Lupron leuprolide J9217, J9218, J1950 Sandostatin octreotide J2354 Sandostatin LAR octreotide J2353 Supprelin LA histrelin J9225, J9226 Synarel nafarelin J3490 Trelstar LA triptorelin J3315 Zoladex goserelin J9202 Actemra tocilizumab J3262 Benylsta belimumab J0490 Entyvio vedolizumab None Orencia abatacept J0129 Remicade infliximab J1745 Rituxan rituximab J9310 Simponi Aria golimumab None Tysabri natalizumab J2323 Aredia pamidronate J2430 Boniva ibandronate J1740 Reclast zoledronic acid J3488 Prolia, Xgeva denosumab J0897 Zometa zoledronic acid J3487

Therapeutic Category Brand Name Generic Name Applicable Code(s) Euflexxa sodium hyaluronate J7323 Gel-One sodium hyaluronate J7326 Osteoarthritis Hyalgan, Supartz sodium hyaluronate J7321 Monovisc sodium hyaluronate None Orthovisc sodium hyaluronate J7324 Synvisc, Synvisc-One sodium hyaluronate J7325 Respiratory Agents Prolastin, Zemaira proteinase inhibitor J2357 Xolair omilzumab J2315 Toxicologic Agent Vivitrol naltrexone J2315 HIP2P0014 (2/15)

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