News
Ambetter Prior Authorization
Fecha: 11/05/23
Ambetter of Oklahoma 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 of Oklahoma.
Ambetter of Oklahoma 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 www.ambetterofoklahoma.com/provider-resources/manuals-and-forms/pre-auth.html
Effective June 1st, 2023, the following are changes to prior authorization requirements:
Behavioral Health
PA Rule | Services | Procedure Codes |
---|---|---|
No PA Required | Developmental and behavioral screening | 96110, 96112 |
No PA Required | BH counseling | H0007, H2011, S9484 |
Breast reconstruction
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Breast reconstruction | 19300, 19330 |
Cardiovascular
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Vascular embolization | 37799 |
PA Required | Insertion/removal of Cardiac Rhythm Monitor | 33285 |
PA Required | Revascularization | 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231 |
PA Required | External circulatory counterpulsation | G0166 |
No PA Required | Cardiac Rehab | G0422, G0423, S9472 |
DME
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Supplies for home delivery for infant | S8415 |
PA Required | Osteogenesis stimulator | E0749 |
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 | Wireless pressure sensor | C2624 |
PA Required | Electrical Nerve Stimulator | K1023 |
PA Required | Non-Pneumatic Compression | K1024, K1025 |
PA Required | Whirlpool tub Walk In | K1003 |
PA Required | Wheelchairs, power operated vehicles, and accessories | K0813 |
No PA Required if Billed with Breast Cancer Diagnosis | Breast prosthesis | L8031 |
No PA Required | Infusion Pumps | B9002, E0781, K0455 |
No PA Required | Wheelchair and accessories | E2611, K0001 |
No PA Required | Respiratory equipment | E0550, E0565 |
Gastroenterology
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | GI capsule transit and pressure measurement | 91112 |
Home care
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Chore Services | S5120, S5121 |
PA Required | Home Care Services | S5165, S5170, S5175, S9110, S9122, T1022, T1028 |
PA Required | Home therapy | G2168, G2169, S5180, S5181 |
PA Required | Foster Care | S5140, S5141, S5145, S5146 |
PA Required | Respite Care Services- Home | S5150, S5151, S9125 |
PA Required | Attendant and Companion Care Services | S5125, S5126, S5130, S5131, S5135, S5136 |
PA Required | Care Management Home Visit | G0076, G0077, G0078, G0079, G0080, G0081, G0082, G0083, G0084, G0085, G0086, G0087 |
PA Required | Hemodialysis Equipment | A4870, A4890 |
PA Required | Home health skilled nursing visit | 0551 |
PA Required | Pregnancy Home Services | S9208, S9209, S9211, S9212, S9213, S9214 |
Hospice
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Physician Services and Care in Hospice | 0657, Q5010 |
Laboratory
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Genetic analysis/studies | 81235, 81263, 81265, 81267, 81268, 81270, 81275, 81310, 81315, 88237, 88377 |
Orthopedic
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Procedures lower extremities | 28285, 28299 |
PA Required | TLSO Orthotics | L0464 |
PA Required | Endoscopy Wrist | 29848 |
PA Required | Sacroiliac Injection | 27096, G0260 |
PA Required | Spine Procedures | 62264, 62350, 62362, 63650, 63655, 63685 |
PA Required | Trigger Point Injection | 20552, 20553 |
Pain management
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Nerve Block | 64490, 64491, 64492, 64493, 64494, 64495 |
PA Required | Neurostimulators on Nerves | 64555, 64561, 64566, 64590 |
PA Required | Destruction by Neurolytic Agent | 64620, 64624, 64625, 64633, 64634, 64635,64636, 64640, 64650, 64680, 64681 |
No PA Required | Transversus abdominis plane (TAP) block | 64486, 64488 |
No PA Required | Destruction by neurolytic agent | 64632 |
Professional services
PA Rule | Services | Procedure Codes |
---|---|---|
No PA Required | Hospitalist Services | S0310 |
PA Required | Plan of Care Management | G0162 |
PA Required | Respite Care Services not in home | H0045 |
PA Required | Nursing Assessment | T1001 |
Radiology Treatments
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required
| Ablation of liver tumor | 47382 |
PA Required
| Stereotactic radiosurgery | 77372, 77373, G0339, G0340 |
Skin substitute
PA Rule | Services | Procedure Codes |
---|---|---|
PA Required | Skin substitute products | Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226 |
Sleep Medicine
PA Rule | Services | Procedure Codes |
---|---|---|
No PA Required | Sleep medicine testing | 95800, 95806 |