News

Ambetter Prior Authorization Change Summary

Date: 05/19/23

Ambetter from Meridian (Ambetter) requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Ambetter products offered by Ambetter.

Ambetter is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.

For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on our website at https://www.ambettermeridian.com/provider-resources/manuals-and-forms/pre-auth.html.

Effective August 1st, 2023, the following are changes to prior authorization requirements:

Behavioral Health

PA Rule	Services	Procedure Codes
No PA Required	Counseling and crisis intervention	H0004, H2011, S9484
No PA Required	Alcohol and/or drug services	H0005, H0007, H0014, S9475

Breast reconstruction

PA Rule	Services	Procedure Codes
PA Required except with breast cancer diagnosis	Breast reconstruction, prosthesis	19316, 19318, 19325, 19328, 19340, 19342, 19350, 19370, 19371, 19499, L8031

Cardiovascular

PA Rule	Services	Procedure Codes
PA Required	Revascularization	37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37799
PA Required	External counterpulsation	G0166
PA Required	Wireless pressure sensor	C2624
PA Required	Insertion/removal of Cardiac Rhythm Monitor	33285
No PA Required	Transesophageal/Transthoracic Echocardiography	C8921, C8922, C8923, C8924, C8924, C8925, C8926, C8927, C8928, C8929, C8930
No PA Required	Cardiac Rehab	S9472

DME and Supplies

PA Rule	Services	Procedure Codes
PA Required	Wheelchairs, power operated vehicles, and accessories	E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613, E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2624
PA Required	Osteogenesis stimulator	E0749
PA Required	Supplies for home delivery	S8415
No PA Required	Respiratory equipment	E0550, E0565
No PA Required	Infusion pumps and supplies	B9002, E0781, K0455
No PA Required	Wheelchair and accessories	K0001, E2611
No PA Required	Vision supplies	S0515

Gastroenterology

PA Rule	Services	Procedure Codes
PA Required	GI capsule transit and pressure measurement	91112

Home Health Services

PA Rule	Services	Procedure Codes
PA Required	Home nursing visit	Rev code: 551
PA Required	Chore services, attendant/companion care	S5120, S5121, S5125, S5126, S5135, S5136, S5140, S5141, S5145, S5146
PA Required	Unskilled respite care	S5150, S5151
PA Required	Home delivered meals and prep, laundry service	S5170, S5175
PA Required	Attendant and homemaker services, companion	T1020
PA Required	Nursing assessment/evaluation	T1001
No PA Required	Home dialysis (ESRD)	90966, S9335, S9339
No PA Required	Prenatal home visit	99500
No PA Required	Home nursing visit	G0490
No PA Required	Post-discharge home care and care plan oversight	G2001, G2002, G2003, G2004, G2005, G2006, G2007, G2008, G2009, G2013, G2014, G2015
No PA Required	Coordinated Care Home Monitoring	G9006
No PA Required	BPCI home visit	G9187
No PA Required	Remote in-home visits	G9978, G9979, G9980, G9981, G9982, G9983, G9984, G9985, G9986, G9987
No PA Required	Practitioner home visit	S0270, S0272, S0273
No PA Required	Medical home program	S0280, S0281
No PA Required	Home visit, wound care	S9097, S9098
No PA Required	Diabetic Mgmt. Nurse Visit	S9460
No PA Required	Home infusion therapy	Q2052, S5035, S5036, S9347
No PA Required	Home care training	S5108, S5109, S5110, S5111, S5115, S5116, G0248

Laboratory

PA Rule	Services	Procedure Codes
PA Required	Genetic analysis/studies	81235, 81263, 81265, 81267, 81268, 81270, 81275, 81310, 81315, 88237, 88277
No PA Required	Blood and blood products	P9010, P9011, P9016, P9021, P9022, P9051, P9054, P9056, P9057, P9058

Orthopedic

PA Rule	Services	Procedure Codes
PA Required	Procedures lower extremities	28285, 28299
PA Required	Endoscopic wrist surgery	29848

Orthotics

PA Rule	Services	Procedure Codes
1 per calendar year then PA Required	Diabetic insert	A5514, L3330

Pain management

PA Rule	Services	Procedure Codes
PA Required	Injection, anesthetic agent or steroid	20552, 27096, 62264, 64490, 64491, 64492, 64493, 64494, 64495
No PA Required	Transversus abdominis plane (TAP) block	64486, 64488
No PA Required	Nerve block	64632

Preventive

PA Rule	Services	Procedure Codes
No PA Required	Developmental and behavioral screening	96110, 96112

Professional services

PA Rule	Services	Procedure Codes
No PA Required	Medication administration	G0068, G0069, G0070, T1502, T1503

Radiology Treatments

PA Rule	Services	Procedure Codes
PA Required	Radiation therapy services	77372, 77373, G0339, G0340
PA Required	Indium in-111 ibritumomab, dx	A9542

Screenings & Assessments

PA Rule	Services	Procedure Codes
No PA Required	Comprehensive environmental lead investigation	T1029

Surgical procedures

PA Rule	Services	Procedure Codes
PA Required	Neurostimulators	64555, 64561, 64566, 64590, 64620, 64624, 64625, 64633, 64634, 64635, 64636, 64640, 64650, 64680, 64681

PA Rule

Services

Procedure Codes

PA Required

Neurostimulators

64555, 64561, 64566, 64590, 64620, 64624, 64625, 64633, 64634, 64635, 64636, 64640, 64650, 64680, 64681