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 Continued on next page MDwise Marketplace, Inc. is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise.org/providers 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 Continued on next page MDwise Marketplace, Inc. is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise.org/providers 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 Continued on next page MDwise Marketplace, Inc. is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise.org/providers 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 Continued on next page MDwise Marketplace, Inc. is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise.org/providers 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 Continued on next page MDwise Marketplace, Inc. is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise.org/providers 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 Continued on next page MDwise Marketplace, Inc. is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise.org/providers 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. Continued on next page MDwise Marketplace, Inc. is a Qualified Health Plan issuer in the Health Insurance Marketplace MDwise.org/providers 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
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