News
Ambetter Prior Authorization
Fecha: 05/04/23
Ambetter from Sunflower Health Plan 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 Sunflower Health Plan.
Ambetter from Sunflower Health Plan 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 the Online Prior Authorization Tool on our website.
Effective June 1, 2023, the following are changes to prior authorization requirements:
Audiology
PA Rule | Services | Procedure Codes |
---|---|---|
No PA Required | Hearing aid, assistive hearing devices, supplies | V5267 |
Behavioral Health
PA Rule | Services | Procedure Codes |
---|---|---|
No PA Required | Behavioral health counseling | S9484 |
No PA Required | Developmental and behavioral screening | 96110, 96112 |
No PA Required | Alcohol and/or drug services | H0004, H0005, H0007, H0014, S9475 |
No PA Required | Crisis intervention services | H2011 |
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 | Insertion/removal of Cardiac Rhythm Monitor | 33285 |
PA Required | Revascularization | 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231 |
PA Required | Unlisted procedure | 37799 |
PA Required | Wireless pressure sensor | C2624 |
PA Required | External counterpulsation | G0166 |
No PA Required | Catheter | C2623 |
No PA Required | Cardiac rehab program | G0422, G0423, S9472 |
Diagnostic and Therapeutic Radiology services
PA Rule | Services | Procedure Codes |
---|---|---|
No PA Required | Indium In-111 ibritumomab tiuxetan | A9542 |
No PA Required | Ablation Liver Tumor | 47382 |
No PA Required | Radiation therapy | 77372, 77373, G0339, G0340 |
No PA Required | Radiolabeled item | C9898 |
DME & Supplies
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Osteogenesis stimulator | E0749 |
PA Required | Supplies for home delivery of infant | S8415 |
PA Required | Personal care items | S5199 |
No PA Required | Infusion pumps and supplies | B9002, E0781, K0455 |
No PA Required | Respiratory equipment | E0550, E0565 |
No PA Required | Wheelchair and accessories | E2611, K0001 |
Ears, Nose, and Throat
PA Rule | Services | Procedure Codes |
---|---|---|
No PA Required | Otorhinolaryngologic Services | 92611 |
No PA Required | Dysphagia screening | V5364 |
Home Care
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Home health skilled nursing visit | 0551 |
PA Required | Repair/maintenance for home hemodialysis equipment | A4870, A4890 |
PA Required | Home Care Management Services | G0087 |
PA Required | Home therapy | G2168, G2169 |
PA Required | Unskilled respite care | S5150, S5151 |
PA Required | Home modifications, meals, laundry | S5175 |
PA Required | In-home telemonitoring | S9110 |
PA Required | Nursing assessment/evaluation | T1001 |
No PA Required | End Stage Renal Disease services | 90966, S9335, S9339 |
No PA Required | Prenatal home visit | 99500 |
No PA Required | Home visits post-discharge and care plan oversight | G2001, G2003, G2004, G2005, G2006, G2007, G2008, G2009, G2013, G2014, G2015 |
No PA Required | Coordinated care – home monitoring | G9006 |
No PA Required | Remote in-home visits | G9978, G9979, G9980, G9981, G9982, G9983, G9984, G9985, G9986, G9987 |
No PA Required | Services, supplies and accessories used in the home | Q2052 |
No PA Required | Management of patient home care | S0271, S0273, S0274 |
No PA Required | Medical home program | S0280, S0281 |
No PA Required | BPCI home visit | G9187 |
No PA Required | Home care training | S5108, S5109, S5110, S5111, S5115, S5116 |
No PA Required | Home visit – wound care and phototherapy services | S9097, S9098 |
No PA Required | Home infusion therapy | S5035, S5036, S9347 |
Hospice
PA Rule | Services | Procedure Codes |
---|---|---|
No PA Required | Physician supervision | G0182 |
No PA Required | Counseling Services | G9473, G9474, G9475, G9476, G9477, G9478, G9479, S0255 |
Laboratory
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Genetic analysis/studies, surgical pathology procedures | 81235, 81263, 81265, 81267, 81268, 81270, 81275, 81310, 81315, 88237, 0089U |
Nutrition
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Medical food nutritionally complete (oral) | S9433 |
Orthopedic
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Procedures lower extremities | 28285, 28299 |
PA Required | Endoscopy wrist | 29848 |
Orthotics and Prosthetics
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Lower extremity orthotics | L1851, L1852 |
No PA Required | Lower extremity orthotics | L2112 |
Pain management
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required unless | Injection, anesthetic agent or steroid | 62320, 62321, 62322, 62323, 62325, 62327, 64400, 64405, 64415, 64417, 64418, 64420, 64421, 64430, 64445, 64447, 64448, 64450, 64451, 64454, 64479, 64480, 64483, 64484, 64505, 64510, 64517, 64520, 64530 |
No PA Required | Transversus abdominis plane (TAP) block | 64486, 64488 |
No PA Required | Nerve block | 64632 |
Professional services
PA Rule | Services | Procedure Codes |
---|---|---|
No PA Required | Inpatient telehealth | G0459 |
No PA Required | Drug infusion services | G0068, G0069, G0070 |
Skin substitute
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Skin substitute products and injectables | Q4114, Q4130, Q4137, Q4139, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226 |
Surgical
PA Rule | Services | Procedure Codes |
---|---|---|
No PA Required | Complex repair of eyelids, nose and ears | 13153 |
Transplant
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Small intestine and liver allografts | S2053 |