Important Medical Billing and Coding Updates

Date: 09/29/25

This announcement is to notify you of prior authorization rule updates that will go into effect for Ambetter Health of Delaware effective 10/14/2025.

The following HCPCS code will require prior authorization upon the above effective date above.

H0019 - Behavioral health; long-term residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem

Additionally, the following HCPCS codes will require prior authorization on any billed charges that exceed $500:

• S5000 – is a temporary national code used to identify a generic prescription drug. Part of the HCPCS level II codes, which are codes used for billing and reimbursement for healthcare services and supplies, the S5000 code is specifically used for generic medications that have been prescribed by a healthcare provider.
• S5001 – is a billing and insurance code used for brand name prescription drugs only, prescribed by a healthcare provider. It falls under the category of “miscellaneous medications and therapeutic substances,” as maintained by the Centers for Medicare & Medicaid Services (CMS).

For other established codes, please use the Pre-Auth Check Tools on our website to confirm if the code(s) requires authorization:

We always want to hear from you! If you notice anything missing or have suggestions for additional materials that would support your work, please let us know by submitting feedback through our Provider Feedback Form.

Need Help or Have Questions? Reach out to us through the following channels:

1. Provider Services – 1-877-236-1341, Monday – Friday 8am – 5pm EST
2. General inquiries, email - DE_ProviderEngagement@DelawareFirstHealth.com
3. Contact your dedicated Provider Engagement Account Manager