MDwise Hoosier Care Connect Medical Services that Require Prior Authorization

Transcription

1 MDwise Hoosier Care Connect Medical Services that Require Prior Authorization Certain Indiana Health Coverage Programs (IHCP) services require prior authorization (PA) for members enrolled in the Hoosier Care Connect program. Providers should submit PA requests to MDwise. This reference document was designed to provide general information for services that require PA in the Hoosier Care Connect program. This reference should not be considered all-inclusive. Note: the HCC network remains open until further notice. Medical Services that Require PA in Hoosier Care Connect Category Description Details Non-Participating These do not apply while the network is open. Inpatient Surgical Any service that will be provided by a non-participating practitioner or facility All Medical, surgical, inpatient admissions including acute hospital; non-routine OB inpatient admissions, inpatient and day rehab, and transitional, and skilled nursing facility. Outpatient procedures/surgeries ALL- Exception is self-referral services: Chiropractic services Eye care services, except surgical services Podiatric services Psychiatric services Family planning services Abortions Emergency services Immunizations Diabetes self-management services Behavioral health services Maternity admissions for normal vaginal delivery or C-Section do not require prior authorization Laryngoplasty Uvulopalatoplasty or any type of palatopharyngoplasty Excision of Benign lesions *Prior authorization would not be required for if the following diagnosis/symptom is the reason for the excision: Carcinoma in situ Personal history of malignant melanoma V10.82 Personal history of other malignant neoplasm of skin V10.83 Cellulitis or abscess Hysterectomy 51925, , , , , Rev. August 2016

2 Category Description Details Potentially cosmetic and reconstructive surgeries , , , , , 15847, , , 19300, , ,30520, , 37785, , , 54660, , 69300, or diagnosis or S2066 S2068, , , Rhinoplasty Cochlear Implant Surgical Weight Reduction Surgery Transplants - All solid organ, bone marrow/stem cell transplants, including the evaluation Roux-en-Y , Gastroplasty Gastric banding sleeve , Gastrectomy , , Duodenal switch , 43645, 43775, 43844, Heart/lung Liver Pancreas Intestine , Bone Marrow Stem cell , Heart valve tissue , Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy T Replacement or repair of thoracic unit of a total replacement heart system (artificial heart) T Replacement or repair of implantable component or components of total replacement heart system (artificial heart), excluding thoracic unit T

3 Category Description Details Therapy The initial evaluation does not require prior auth. Prior authorization is required for PT or OT exceeding the 12 hours or visits per discipline within 30 calendar days. No PA required for ST for the first 12 visits or hours within a calendar year. PT - Revenue codes , 429, and 97002, 97004, , OT - Revenue codes , 439 ST - Revenue codes , 449, and , Durable Medical Equipment and supplies of $500 or more per claim, whether rented or purchased, unless otherwise indicated in this PA list, Electric breast pumps (rental or purchase)of $500 or more, Repair or replacement of DME of $500 or more Orthopedic shoes including heels, lifts, and wedges as well as diabetic shoes diabetic shoes with custom mold or compression mold/deluxe diabetic shoes All DME unless otherwise indicated below A5500 A5513 Enteral and Parenteral Nutrition B4034 B9998 DME and Medical Supplies Prosthetics over $500 billed charges per claim Hearing aid purchase and replacement of hearing aids less than 5 years after purchase Wearable ventricular assist and cardioverter defibrillator devices including but not limited to LifeVest Orthotics regardless of billed charges L5500 L9900 Left and Right ear- V5030, V5040, V5050, V5060, V5070, V5080, V5095, V5100, V5120, V5130, V5140, V5150, V5170, V5180, V5190, V5210, V5220, V5230, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5263, V5267 Bilateral- V5100, V5120, V5130, V5140, V5150, V5248, V5249, V5250, V5251, V5252, V5253, V5258, V5259, V5260, V5261 E0617, K0606 L0100 L4631

4 Category Description Details Home Health Care Home Hospice Chemotherapy DOES NOT require prior authorization Home and OP Infusion Therapy, includes Tocolytics. All prior authorization requests for tocolytics must be referred to an MD to determine medical necessity PICC line placement for hyperemesis gravidarum Home Oxygen including supplies, home oxygen tent, and oxygen concentrators regardless of billed charges Home Hospice Services and Tocolytics - S with diagnosis 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 Genetic testing (all requests for genetic testing require MD review) 80502, , 88230, 88262, 88289, 88291, Diagnostics Clinical Trials CT Scans: (maxillofacial, cervical, thoracic and lumbar spine, thorax, abdomen, pelvis, 3D CT scans) MRIs - head/brain, cervical, thoracic and lumbar spine, chest, abdomen, pelvis, lower extremity, needle guided MRIs, 3D MRIs MRA PET Scans Single Photon Emission Computer Tomography (SPECT) Diagnosis code V70.7, or Modifier Q1, Q0, or HCPCs S9988, S9990, S , , , , , , Revenue codes - 611,612, 615, 616 and , , , , , , , , , 73225, 71555, , 73725, , 72198, 72159, (billed under MRI revenue codes) , 404, G0219 G0235, 78459, , , , 78607, 78647, 78710, , 78205, 78803, (billed on CT revenue codes) Routine OB ultrasounds greater than 2 per pregnancy with the following diagnosis: O003.xx and O00.0-O03.9, O24.31, O O24.319

5 Category Description Details Ambulance Ambulance - Facility to facility and/or nonemergent transfers Ambulance - Fixed Wing Air (a retrospective review of rotary wing air ambulance) Pain Management services/procedures listed below, Office place of service only A0426, A0428 A0430, A0435 A0431, A0436 TENS unit including electrodes, batteries, etc. regardless of billed charges A4556 A4558, A4595, A4630, E0720, E0730 E0731, A4290 Pain Management Facet Joint and/or Facet Joint Nerve Injection Epidural Steroid Injection Anesthesia for Facet Joint and Epidural Injection , , 72275, Neurostimulator , , 64561, E0744 E0749, E0762, E0766, L8679 L8695 Hyperbaric Oxygen Hyperbaric Oxygen 413, A4575, C1300, G0277, Dental Chiropractic TMJ Behavior Health Dental - Emergency procedures/services including general anesthesia to treat dental emergencies for children 6 years of age and younger Chiropractic Spinal Manipulation for members less than 5 years old 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 below D0100 D , and , , 21050, 21060, 21070, 21073, 21116, , , 21255, 29800, 29804, S8262 and diagnosis , , 715.1, , , , , , ,

6 Behavioral Health Services that Require PA in Hoosier Care Connect MDwise BH contracted providers - outpatient prior authorization requirements for Hoosier Care Connect. Service Type Psychiatric Diagnostic Interview CPT code or (Interactive Interview) Therapy Services CPT code: Psytx Office 30 min Psytx Office 45 min Psytx off. 60 min Family medical psychotherapy Family Psytx conjoint Group Psychotherapy Medication Management , new patient, office , existing patient, office PA is not required for CPT codes , , , (contracted providers only) Therapy visits with E/M: Interactive Psytx w/medical EM 60 min PA Requirements 1 unit per member, per billing provider, per rolling 12-months allowed with no PA. 2 units are allowed without PA when member is separately evaluated both by a physician, an advanced practice nurse or HSPP and another mid-level practitioner. No PA is required for contracted providers. Interactive Complexity (CPT code 90785) is an add-on code to this CPT group and does not require a separate authorization. PA not required Interactive Complexity (CPT code 90785) is an add-on code to this CPT group and does not require a separate authorization. For non-contracted IHCP phsychiatrists, PA required after 30 visits PA is not required. Multi-Family Group Therapy PA not required. Psychoanalysis Requires PA Office Patient Visits and Consultations: New patient visits Established patient visits Psychological Testing: Psychological Testing, per hour of the Psychologist or Physicians time, face to face time Psychological Testing administered by technician, per hour of time face to face Developmental Test, Extensive Neurobehavioral Status, Neurobehavioral Test by Psych Neuropsychological testing per hour of technician time, face to face PA is not required. Requires PA Please note: If PA is given for the PA would also apply to If PA is given for the PA would also apply to CPT Code Developmental Test, w/interpretation & Report does not require a PA.

7 Service Type PA Requirements Electroconvulsive Therapy ECT Health and Behavior Assessment: PA is required for persons with Autism Spectrum Disorder Diagnosis. Authorizations are to be given in accordance with treatment plan which can only be required every 6 months Assess health/behavior, subsequent Intervene health/behavior, initial Intervene health/behavior, group Intervene health/behavior, family W/E&M Health/behavior family, no intervention Requires PA. Anesthesia (CPT code 00104) and outpatient facility (i.e., observation room) may also be provided. If ECT authorized, anesthesia/ anesthesia provider and facility service to be authorized. Does not require PA except when used with ASD diagnosis for ABA services. PA is required for persons with Autism Spectrum Disorder Diagnosis (ICD-9 codes 299.0, 299.8, ICD-10 codes F84.0 or F84.9). Authorizations are to be given in accordance with treatment plan which can only be required every 6 months. Cognitive Skills Development Requires PA. Screening & Brief Intervention Services (SBI) - Drug/Alcohol Abuse: Alcohol &/or SA structured SBI min Alcohol &/or SA SBI greater than 30 min PA not required for one or per member, per contracted billing provider. PA is required for non-contracted providers, except if provided as emergency service. SBI services are not typically billed by behavioral health clinics as screening and interventions are already include in behavioral health assessment/treatment CPT codes. Partial Hospitalization Services H0035 Partial Hospitalization Services Smoking Cessation Treatment Services S9075 Smoking Cessation Treatment Services Requires PA PA is not required. Benefit maximum - one 12-week course of treatment per member per calendar year. Non-contracted BH providers - outpatient prior authorization requirements. *Except for the following self-referral services for any non-contracted IHCP enrolled Psychiatrist, all outpatient BH services provided by non-contracted behavioral health providers require PA. This includes observation stays. Service Type Self-Referral Services for non-contracted IHCP Psychiatrist: Psychiatric Diagnostic Interview Interactive Psychiatric Diagnostic Interview Individual Psychotherapy Psychoanalysis Family/Group Psychotherapy Health/Behavior Assessment Codes PA Requirements Members may see any non-contracted IHCP enrolled psychiatrist for 20 visits, per rolling 12 months without PA. Per billing provider, this includes (in combination): 90791, 90792, , , & PA is required for additional visits. See NOTE below for authorization application guideline.

8 Behavioral Health Professional Services During Medical/Surgical Stay Service Type Diagnostic Interview CPT codes or PA Requirements PA is not required per inpatient episode of care. Inpatient Services: With the exception of emergency admissions, prior authorization is required for any psychiatric admission stay, including admissions for substance abuse and nursing facility stays. Please note: For services requiring authorization, authorizations provided for a higher level code may be applied to the claim submitted by that provider with a lower level code, rather than denying the lower level code for no authorization. For example, in the event an authorization is given for a more involved visit, i.e., 90837, but in turn, a claim is submitted with CPT code or 90834, the claim would be paid on the authorization rather than denied for no authorization.

9 Medical Benefit Drugs that Require Prior Authorization Therapeutic Category Brand Name Generic Name Applicable Code(s) Botulinum Toxins Botox onabotulinumtoxin A J0585 Dysport abobotulinumtoxin A J0586 Myobloc rimabotulinumtoxin B J0587 Xeomin incobotulinumtoxin A J0588 Endocrine Agents Enzyme Replacement Therapy Hormonal Modifiers Immune Globulins H.P. Acthar corticotropin J0800 Makena hydroxyprogesterone caproate None Cerezyme imiglucerase J1786 Elelyso taliglucerase J3060 Lumizyme alglucosidase alfa J0221 Myozyme alglucosidase alfa J0220 Vimizim elosulfase alfa None VPRIV velaglucerase J3385 Eligard, Lupron leuprolide J9217, J9218, J1950 Sandostatin octreotide J2354 Sandostatin LAR octreotide J2353 Trelstar LA triptorelin J3315 Zoladex goserelin J9202 Bivigam immune globulin, human J1556 Carimune immune globulin, human J1566 Flebogamma / Flebogamma DIF immune globulin, human J1572 GamaSTAN S/D immune globulin, human J1460 Gammagard S/D immune globulin, human J1566 Gammaplex immune globulin, human J1557 Privigen immune globulin, human J1459 Gammagard Liquid immune globulin, human J1569 Hizentra immune globulin, human J1559 Gamunex-C immune globulin, human J1561 Gammaked immune globulin, human J1561 Octagam immune globulin, human J1568 Hyqvia immune globulin, human with recombinant hyaluronidase, None

10 Therapeutic Category Brand Name Generic Name Applicable Code(s) Immuno-modulators for Inflammatory Conditions Miscellaneous Immunomodulators Immuno-modulators for Multiple Sclerosis Metabolic Bone Disease Osteoarthritis Pulmonary Arterial Hypertension (PAH) Agents Respiratory Agents Actemra tocilizumab J3262 Benylsta belimumab J0490 Entyvio vedolizumab None Orencia abatacept J0129 Remicade infliximab J1745 Rituxan rituximab J9310 Simponi Aria golimumab J1602 Ilaris canakinumab J0638 Soliris eculizumab J1300 Sylvant siltuximab None Tysabri natalizumab J2323 Aredia pamidronate J2430 Boniva ibandronate J1740 Reclast zoledronic acid J3488 Prolia, Xgeva denosumab J0897 Zometa zoledronic acid J3487 Euflexxa sodium hyaluronate J7323 Gel-One sodium hyaluronate J7326 Hyalgan, Supartz sodium hyaluronate J7321 Monovisc sodium hyaluronate None Orthovisc sodium hyaluronate J7324 Synvisc, Synvisc-One sodium hyaluronate J7325 Flolan epoprostenol J1325 Veletri epoprostenol J1325 Aralast NP proteinase inhibitor J0256 Glassia proteinase inhibitor J0257 Prolastin, Zemaira proteinase inhibitor J2357 Xolair omalizumab J2315 Submit PA requests for MDwise Hoosier Care Connect members to: MDwise Hoosier Care Connect Prior Authorization Unit P.O. Box Indianapolis, Indiana Providers are encouraged to fax PA requests involving MDwise Hoosier Care Connect members to or locally to HCCP0022 (3/15) HCCO0005 (3/15) HIPO0001(4/15) APP0229 (12/15) MDwise 1200 Madison Avenue Suite 400 Indianapolis, IN Fax: (317) MDwise.org