Prior Authorization List and Quick Reference Guide

Transcription

Prior Authorization List and Quick Reference Guide
Prior Authorization List and Quick Reference Guide
Certain services provided to MDwise Marketplace members require prior authorization. Requests for authorization
should be submitted to the delivery system of the member. Authorization requests must be submitted on the MDwise
Marketplace prior authorization form, which can be found online at MDwise.org/forms. Please make certain to send
the prior authorization form to the appropriate member delivery system. The delivery system’s prior authorization fax
number is located on the top of the prior authorization form. For additional delivery system contact information please
see the MDwise Marketplace Quick Contact Guide at MDwise.org/quickcontact.
Network providers will receive confirmation of authorization decisions via an authorization letter, which will be sent
either by fax or mail. The authorization letter will include an authorization identification number, authorization decision,
number of days/visits and the duration approved. Prior authorizations that result in a denial will be communication via a
denial letter, which will be sent via fax or mail and includes the rationale for the denial, the criteria applied, the right to
peer review and the process to initiate an internal appeal.
Detailed response timelines for prior authorization can be found in the MDwise Marketplace Provider Manual at
MDwise.org/providers.
MDwise Marketplace Services that Require PA
This reference document is to provide general information for services that require prior authorization for MDwise
Marketplace and should not be considered all inclusive. Please see the MDwise Marketplace Reimbursement Manual at
MDwise.org/providers for more information.
Important: MDwise Marketplace requires prior authorization for any non-emergency service provided by a noncontracted provider or facility. Non-contracted providers must contact the member’s delivery system so that provider
enrollment information can be obtained to complete enrollment for reimbursement for services authorized.
Category
Description
Any service that will be provided by a
Non-participating
non-participating practitioner or facility
All medical, surgical, inpatient admissions
and observation stays, including acute
Inpatient
hospital; non-routine OB inpatient
admissions, inpatient and day rehab, and
transitional, and skilled nursing facility.
OP observations (includes observation in
Observation
emergency room)
Details
Maternity admissions for normal vaginal delivery
or cesarean section do not require prior
authorization
720, 760, 762, 99217–99220, 99226, 99235,
G0378
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Category
Surgical
Therapy
Description
Details
Laryngoplasty: 31580–31590
Uvulopalatoplasty or any type of
palatopharyngoplasty: 42145
Tonsillectomy and adenoidecomty (T&A):
42820–42836
OP procedures and surgeries
Myringotomy: 69420–69421
Excision of benign lesions: 11400–11471
Hysterectomy: 51925, 58150–58294, 58541–
58544, 58548–58554, 58570–58573, 58951–
58956
11200–11201, 11920–11922, 11950–11954,
15775–15776,15780–15839, 15847, 15876–15879,
17106–17108, 19300, 19316–19396, 21740–
Potentially cosmetic and reconstructive
21743, 30400–30462, 30520, 36468–36471,
surgeries
37785, 40650–40761, 42200–42281, 54660,
67900–67975, 69300, or diagnosis 757.32 or
757.33
Heart/lung: 33930–33945
Liver: 47133–47147
Pancreas:48550–48556
Transplants: All solid organ, bone
Intestine: 44132–44137, 44715–44721
marrow/stem cell transplants includes
Bone Marrow: 38240–38242
the evaluation, work-up and travel
Heart valve tissue: 33933, 33944
accommodations
Stem cell: 38204–38215, 38230–38232 and
Transplant related Lodging, meals and
transportation: S9975
Comprehensive Outpatient Rehabilitation Services provided at a comprehensive outpatient
Facility (CORF)
rehabilitation facility
Physical therapy revenue codes: 420–423, 429,
97002, 97004, 97010–97546, 97750–97762
Speech/occupational/physical therapy
Speech therapy revenue codes: 430–433, 439
(after initial evaluation)
Occupational therapy revenue codes: 440–443,
449, 92507–92508, 92520–92526
G0422–G0423, 93797–93798 and revenue code
Cardiac rehabilitation
943
Pulmonary rehabilitation
G0237–G0239, G0424 and revenue code 948
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Category
Description
Durable medical equipment (DME) and
supplies over $500 billed charges per
claim including insulin pumps, breast
pumps and continuous positive airway
pressure (CPAP) devices, whether rented
or purchased, replacement or repair
unless otherwise indicated in this list.
DME and medical Diabetic shoes with custom mold or
supplies
compression mold or deluxe
Enteral and parenteral nutrition
Nutritional counseling after the first/initial
visit
Prosthetics over $500 billed charges per
claim
Orthotics regardless of billed charges
Home health care
Home and OP infusion therapy, includes
tocolytics. All prior authorization requests
for tocolytics must be referred to an MD
Home
to determine medical necessity.
Home oxygen including supplies, home
oxygen tent and oxygen concentrators
regardless of billed charges
Hospice
Hospice services (inpatient or outpatient)
Details
All DME unless otherwise indicated below.
A5500–A5513
B4034–B9998
97802–97804, G0270–G0271
L5500–L9900
L0100–L4631
96601–99602
Tocolytics: S9349
A4615–A4616, A7046, E0424–E0455, E0460–
E0461, E0463, E1352–E1392, E1405–E1406,
K0738
Revenue codes 651, 652, 655 and 656 with
HCPCS codes Q5001–Q5010
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Category
Description
Genetic testing (all requests for genetic
testing require an MD review)
Clinical trials
Diagnostics
Details
72090, 77072, 80502, 81228–81229, 81265–
81266, 81331, 81400–81408, 88230, 88262,
88289, 88291, 88367
Diagnosis code V70.7, or Modifier Q1, Q0, or
HCPCs S9988, S9990, S9991
CT scan: maxillofacial, cervical, thoracic
and lumbar spine, thorax, abdomen,
pelvis, 3D CT scan
76977, 77078–77083 and 78350–78351, G0130
MRI: head, brain, cervical, thoracic and
lumbar spine, chest, abdomen, pelvis,
lower extremity, 3D MRI
Revenue codes: 611,612, 615, 616, 71250–71275,
71550–71552, 72125–72133, 72141–72158,
73718–73723, 72191–72194, 74150–74178 ,
74181–74183, 72195–72197, C8900, C8901,
C8902, C8909 – C8920, C8914, S8037, S8042,
S8042 HR, S8042 KX, S8042 NU, S8042 SS76376–
76377, 77058–77059, 73700–73706, 70551–70559
MRA
PET scans
Single photon emission computer
tomography (SPECT)
74185, 73225, 71555, 70544–70546, 73725,
70547–70549, 72198, 72159, 73725 (billed under
MRI revenue codes)
340–349, 404, G0219–G0235, 78459, 78491–
78492, 78608–78609, 78811–78816
78320, 78607, 78647, 78710, 78071–78072,
78205, 78803, 78807 (billed on CT revenue
codes)
Radiation therapy including: intraoperative
radiation therapy, (IORT), intensity
modulated radiation therapy (IMRT),
32553, 77261–77790, C1728, C2634–C2699,
proton beam radiotherapy (PBRT),
G0173, G0251
neutron beam therapy, brachytherapy,
stereotactic radiosurgery
Bone density study for members
G0130, 76977, 77078–77082, 78350–78351
under 65 years of age
76801–76817 with the following diagnosis:
Routine OB ultrasounds greater than two V22.0–V22.2, V23.0–V23.9, V28.3–V28.4,
per pregnancy
630.00–633.91, 634.00–634.92, 640.00–676.94,
677–679.14, 764.00–764.99
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Category
Description
Ambulance: facility to facility and/or nonemergent transfers
Ambulance
Ambulance: fixed-wing air (a retrospective
review of rotary-wing air ambulance)
Pain management services/procedures
listed below, office place of service only
Transcutaneous electrical nerve
stimulation (TENS) unit including
electrodes, batteries, etc. regardless of
billed charges
Pain management Trigger point injection
Facet joint and/or facet joint nerve
injection
Epidural steroid injection anesthesia for
facet joint and epidural injection
Neurostimulator
Hyperbaric
Oxygen
Hyperbaric Oxygen
Diabetic education if more than 10 hours
Diabetic services within the first calendar year of diagnosis
and supplies
or more than two hours for subsequent
years
Vision surgery as indicated are to be filed
Vision
with the vision carrier
Dental: emergency procedures/services
including general anesthesia to treat
Dental
dental emergencies for children six years
of age and younger
Podiatry: all covered services after the
initial visit or routine foot care.
Podiatry
Please refer to the individual member
policy for podiatry services that are
considered non-covered.
Chiropractic spinal manipulation for
Chiropractic
members less than five years old
Details
A0426, A0428
A0430, A0435
A4556–A4558, A4595, A4630, E0720,
E0730–E0731
20552–20553, 76942, 77002, 77021
64490-64495
62310–62311, 64479–64484, 64479–64480,
64483–64484, 72275, 77003
64550–64581, 61850–61888, 64561, 64581
E0744–E0749, E0762, E0766, L8679–L8695
A4575, C1300, G0277, 99183
G0108–G0109 with diagnosis codes
249.00–249.51, 250.00–250.93, 648.00–648.04,
648.80–648.84
S0800, S0810, S0812, 65767
D0100–D0199
99201–99215, 11055–11057, 11719–11721
98940, 98941 and 98942
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Category
Temporomandibular joint
(TMJ)
Behavior health
Description
Temporomandibular joint (TMJ) services
including: arthroplasty, arthroscopy,
reconstruction, discectomy (with or
without disc replacement), mandibular
orthopedic repositioning appliances
(MORA), trigger point injections,
arthrocentesis. Treatment plan/services
ordered for TMJ may also be a service
that is included on the prior authorization
list (e.g., physical therapy, DME or
prosthetic greater than $500)
Behavior health/mental health/substance
abuse, please refer to the Behavior Health
Policy
Category and Description
Therapeutic
Category
Blood modifiers
Medications/injectables
Medications as listed (covered
under the medical benefit)
Botulinum toxins
Enzyme
replacement
therapy
Hormonal
modifiers
Details
21010, 21025–21026, 21050, 21060, 21070,
21073, 21116, 21193–21196, 21240–21249,
21255, 29800, 29804, S8262 and diagnosis
524.60–524.64, 524.69, 715.1, 715.28, 715.38,
718.18 , 718.28, 718.38 , 719.18, 996.77–996.78
Brand Name
Generic Name
Aranesp
Epogen, Procrit
Leukine
Neulasta
Neumega
Neupogen
Botox
Dysport
Myobloc
Xeomin
Cerezyme
Elelyso
VPRIV
Eligard, Lupron
Sandostatin
Sandostatin LAR
Supprelin LA
Synarel
Trelstar LA
Zoladex
darbepoetin alfa
epoetin alfa
sargramostim
pegfilgrastim
oprelvekin
filgrastim
onabotulinumtoxin A
abobtulinumtoxin A
rimabotulinumtoxin B
incobotulinumtoxin A
imiglucerase
taliglucerase
velaglucerase
leuprolide
octreotide
octreotide
histrelin
nafarelin
triptorelin
goserelin
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Category and Description
Medications/injectables
Medications as listed (covered
under the medical benefit)
Therapeutic
Category
Brand Name
Generic Name
Immunomodulators for
inflammatory
conditions
Actemra
Benylsta
Entyvio
Orencia
Remicade
Rituxan
Simponi Aria
tocilizumab
belimumab
vedolizumab
abatacept
infliximab
rituximab
golimumab
Immunomodulators for
multiple sclerosis
Tysabri
natalizumab
Aredia
Boniva
Reclast
Prolia
Xgeva
Zometa
Euflexxa
Gel-One
Hyalgan, Supartz
Monovisc
Orthovisc
Synvisc, Synvisc-One
Prolastin,
Zemaira
Xolair
pamidronate
ibandronate
zoledronic acid
Vivitrol
naltrexone
Metabolic bone
disease
Osteoarthritis
Respiratory agents
Toxicologic agent
denosumab
zoledronic acid
sodium hyaluronate
sodium hyaluronate
sodium hyaluronate
sodium hyaluronate
sodium hyaluronate
sodium hyaluronate
proteinase inhibitor
omilzumab
Authorization Appeals
Members and providers have the right to request an internal appeal of an adverse authorization determination. Internal
appeals must be filed with MDwise within 180 calendar days of the adverse determination. Standard or non-expedited
appeals can be requested in writing and mailed to MDwise Marketplace Medical Management at MDwise Marketplace,
P.O. Box 441099, Indianapolis, IN 46244-1099.
Non-expedited appeals will be resolved within 30 calendar days for pre-service authorization decisions and within 45
calendar days for post-service decisions (where the member has already received services).
An expedited internal appeal can be requested by calling MDwise Marketplace Medical Management at
1-855-417-5615. Expedited appeals will be resolved within 48 hours or less.
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If the original decision is upheld, the provider and member have the right to request an external review by an
Independent Review Organization (IRO) within 120 calendar days of the decision. A non-expedited external review
will be resolved no later than 15 business days after receiving the request. Expedited external reviews will be resolved
within 72 hours.
More information on appeals can be found in the MDwise Marketplace Provider Manual at MDwise.org/providers.
Members can be directed to MDwise Marketplace Customer Service at 1-855-417-5615 for additional directions and
assistance regarding their appeal rights.
Rev. Feb 2015
MDwise Marketplace, Inc. is a Qualified Health Plan issuer in the Health Insurance Marketplace
MDwise.org/providers