Arizona Complete Health-Complete Care Plan (Medicaid) & Ambetter (Marketplace) Prior Authorization Updates Effective 5/1/22
Date: 04/01/22
We recently completed a review of the codes listed on pages 2-6 and are noting prior authorization requirement changes effective 5/1/2022.
For other established and non-miscellaneous codes, please use the Pre-Auth Check Tool on our website to confirm if the code(s) requires prior authorization. Prior authorization requirements vary based on the line of business, so please select the applicable Pre-Auth Check Tool by the line of business.
Last year we redesigned the authorization request section in our Secure Provider Portal. The redesign includes the integration of InterQual Connect™ and we encourage you to submit your requests via the portal versus fax!
- The web authorization request process has been simplified. The Service type drop-down is replaced by Provider type and includes a shorter list of options to choose from.
- You are advised whether or not a service requires prior authorization or is not covered.
- If the tool identifies a code included on your request that doesn’t require prior auth or that a prior authorization is already on file for a code, it won’t submit the code onward for clinical review and instead will return a message to you notifying you of why the code was not submitted
- An assigned Authorization ID on submitted web authorization service lines is provided when a request is submitted.
- For a small subset of codes, you also can access InterQual Connect and complete a medical review via the portal.
If you have questions regarding this update, please contact your Provider Engagement Specialist. If you need contact information for your assigned Provider Engagement, please email AzCHProviderEngagement@azcompletehealth.com.
As a reminder, all new, re-sequenced and unlisted codes (miscellaneous codes) require prior authorization, regardless of place of service until otherwise communicated.
Code | Description | Rule |
|---|---|---|
70336 | MRI TEMPOROMANDIBULAR JT | Services administered through NIA www.RADMD.com |
77046 | Magnetic resonance imaging, breast, without contrast material; unilateral | Services administered through NIA www.RADMD.com |
77047 | Magnetic resonance imaging, breast, without contrast material; bilateral | Services administered through NIA www.RADMD.com |
77048 | Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral | Services administered through NIA www.RADMD.com |
78434 | AQMBF PET REST AND PHARMACOLOGIC STRESS | Services administered through NIA www.RADMD.com |
93320 | DOPPLER ECHO CONT WAVE W/SPECTRAL DISPLY; COMPLT | Services administered through NIA www.RADMD.com |
93321 | DOPPLER ECHO CONT WAVE W/SPECTRL DISPLY; F/U-LTD | Services administered through NIA www.RADMD.com |
93325 | DOPPLER ECHO COLOR FLOW VELOCITY MAPPING | Services administered through NIA www.RADMD.com |
93356 | MYOCRD STRAIN IMG SPECKLE TRCK ASSMT MYOCRD MECH | Services administered through NIA www.RADMD.com |
0042T | CERBRL PERFUS ANALY CT W/CONTRST | Services administered through NIA www.RADMD.com |
0698T | QUAN MR ALYS TISS COMPOSITION W/MRI MLT ORGANS | Services administered through NIA www.RADMD.com |
0707T | NJX BONE SUB MATRL INTO SUBCHONDRAL BONE DEFECT | Services administered through NIA www.RADMD.com |
A6511 | COMPRS BRN GARMNT LW TRNK LEG OPN | No auth required for PAR providers |
A9274 | EXT AMB INSULIN DELIVERY SYS | No auth required for PAR providers |
A9278 | EXTERNAL RECEIVER CGM SYS | No auth required for PAR providers |
A9900 | DME SUP/ACCESS/SRV-COMPON/OTH HCPCS | No auth required for PAR providers |
B4082 | NASOGASTRIC TUBING WITHOUT STYLET | No auth required for PAR providers |
E0265 | HOSP BED TOTAL ELEC W/ANY RAILS W/MATTRESS | No auth required for PAR providers |
E0303 | HOSP BED/HVY DTY/X-TRA WIDE/WGHT CP>350 PDS/LESS OR = 600 /W MATT | No auth required for PAR providers |
E0482 | COUGH STIMULATING DEVICE | No auth required for PAR providers |
E0635 | PATIENT LIFT ELECTRIC W/SEAT/SLING | No auth required for PAR providers |
E0651 | PNEUMATIC COMPRESS SEGMENTAL WO GRADIENT PRESS | No auth required for PAR providers |
E0935 | PASSIVE MOTION EXERCISE DEVICE | No auth required for PAR providers |
E0958 | MANUAL WHEELCHIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACH | No auth required for PAR providers |
E0986 | MAN W/C PUSH-RIM POWR SYSTEM | No auth required for PAR providers |
E1030 | WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED | No auth required for PAR providers |
E1140 | WHEELCHAIR DETACH ARMS (DESK FULL) DETACH FOOT | No auth required for PAR providers |
E1150 | WHEELCHAIR DETACH ARMS (DESK FULL) DETACH LEG | No auth required for PAR providers |
E1226 | MANUAL WHEELCHAIR ACCESSORY, FULLY RECLINING BACK, EACH | No auth required for PAR providers |
E1240 | LITE WHEELCHAIR DETACH ARM DETACH ELEV LEGREST | No auth required for PAR providers |
E1800 | DYN ADJUS ELBOW EXTENSION/FLEXION DEVICE | No auth required for PAR providers |
E1805 | DYN ADJUS WRIST EXTENSION/FLEXION DEVICE | No auth required for PAR providers |
E2203 | MANUAL WHELLCHAIR/N-STNDRD SEAT FRAME DEPTH, 20 TO LESS THAN 22 INCHES | No auth required for PAR providers |
K0002 | Standard Wheelchair | No auth required for PAR providers |
K0004 | HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR | No auth required for PAR providers |
K0006 | HEAVY-DUTY WHEELCHAIR | No auth required for PAR providers |
K0007 | EXTRA HEAVY-DUTY WHEELCHAIR | No auth required for PAR providers |
K0739 | REPAIR/SVC DME NON-OXYGEN EQ | No auth required for PAR providers |
L0637 | LUMBAR SACRAL ORTHOSIS SAGGITAL-CORONAL PANEL PREFAB | No auth required for PAR providers |
L1005 | TENSION BASED SCOLIOSIS ORTHOSIS AND ACCESSORY PADS | No auth required for PAR providers |
L1640 | HO ABDUCTION STATIC PELVIC BAND SPREAD BAR CUFFS | No auth required for PAR providers |
L1844 | KNEE ORTHOS 1 UPRT THI&CALF CSTM | No auth required for PAR providers |
L1932 | AFO RIGD ANT TIBL TOT CARB FIBER/EQUL MATL PRFAB | No auth required for PAR providers |
L1971 | AFO, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED | No auth required for PAR providers |
L1990 | AFO 2 UPRIGHT FREE PLANTAR SOLID STIRRUP | No auth required for PAR providers |
L2020 | KAFO UPRIGHT FREE KNEE/ANKLE SOLID STIRRUP | No auth required for PAR providers |
L2330 | ADD LOW EXT LACER MOLDED TO PT MODEL | No auth required for PAR providers |
L2340 | ADD LOW EXT PRETIBIAL SHELL MOLD TO PT MODEL | No auth required for PAR providers |
L2570 | ADD LOW EXT PELV HIP JNT CLEVIS TYPE 2 POS JNT | No auth required for PAR providers |
L3905 | WRIST HAND ORTHOSIS INCLS ONE OR MORE NONTORSION JOINTS CUSTOM | No auth required for PAR providers |
L3915 | WRIST HAND ORTH INCL 1 OR MORE NONTORS JOINT(S), ELAST BANDS,TURNBUCK | No auth required for PAR providers |
L3916 | WHO NONTORSION JNTS PRE OTS | No auth required for PAR providers |
L3960 | SEWHO ABDUCT POSITION AIRPLANE DESIGN | No auth required for PAR providers |
L5645 | ADD LOW EXT BELOW KNEE FLEX INNER EXT FRAME | No auth required for PAR providers |
L5812 | ADD KNEE/SHIN 1 AXIS FRICTION SWING STANCE PHASE | No auth required for PAR providers |
L5848 | ADDITION TO ENDOSKELETAL KNEE-SHIN SYST, FLUID STANCE EXT, DAMPEN | No auth required for PAR providers |
L5856 | ADD LOW EXT PROS KNEE-SHIN SYS SWING&STANCE PHSE | No auth required for PAR providers |
L5950 | ADD ABOVE KNEE ULTRA LIGHT MATERIAL | No auth required for PAR providers |
L6200 | ELBOW DISARTIC MOLDED OUTSIDE LOCK HINGE FOREARM | No auth required for PAR providers |
L6624 | UPPER EXTREMITY ADDITION, FLEXION/EXTENSION AND ROTATION WRIST UNIT | No auth required for PAR providers |
L6881 | AUTO GRASP FEATURE, ADDTN TO UP LIMB ELECTRIC PROSTHETIC TERMINAL | No auth required for PAR providers |
L6686 | UP EXT ADD SUCTION SOCKET | No auth required for PAR providers |
L6688 | UP EXT ADD FRAME SOCKET ABOVE ELBOW | No auth required for PAR providers |
L6698 | ADD UP EXT PROS ELB LOCK MECH EXCL SCKT INSRT | No auth required for PAR providers |
L8690 | AUDITORY OSSEOINTEGRATED DEVICE, INC INTERNAL & EXTERNAL COMPONENTS | No auth required for PAR providers |
L8691 | AO D EXT SP EXCL TRNDCR/ACTR RPL EA | No auth required for PAR providers |
L9900 | ORTHO/PROSTH SUPP ACCES &/OR SERV | No auth required for PAR providers |
S8092 | ELECTRON BEAM COMPUTED TOMOGRAPHY | Services administered through NIA www.RADMD.com |
V2531 | CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS | No auth required for PAR providers |
V2624 | POLISHING/RESURFACING OF OCULAR PROSTHESIS | No auth required for PAR providers |
V2627 | SCLERAL COVER SHELL | No auth required for PAR providers
|
Code | Description | Rule |
75565 | CARD MRI VEL FLW MAP ADD-ON | Services administered through NIA www.RADMD.com |
78496 | CARD BLD POOL IMAG-GATED-1 STUDY-REST-1ST PASS | Services administered through NIA www.RADMD.com |
93320 | DOPPLER ECHO CONT WAVE W/SPECTRAL DISPLY; COMPLT | Services administered through NIA www.RADMD.com |
93352 | New NIA reviewed codes that need to be listed Vendor | Services administered through NIA www.RADMD.com |
93356 | ADMIN ECG CONTRAST AGENT | Services administered through NIA www.RADMD.com |
0042T | CERBRL PERFUS ANALY CT W/CONTRST | Services administered through NIA www.RADMD.com |
0698T | QUAN MR ALYS TISS COMPOSITION W/MRI MLT ORGANS | Services administered through NIA www.RADMD.com |
0707T | NJX BONE SUB MATRL INTO SUBCHONDRAL BONE DEFECT | Services administered through NIA www.RADMD.com |
E0471 | RSPRTRY DVCE/BI-LVL PRESS CPLTY/W BCKP RATE FTRE/W NNINVSV INTRFC | No auth required for PAR providers |
E0486 | ORAL DEVICE/APPLIANCE TO REDUCE UP/AIRWAY COLLAPSIBILITY ADJUSTABLE OR | Auth required for all providers |
E0550 | HUMIDIFIER DURABLE SUPPLEMENTAL W/IPPB/OXYGEN | No auth required for PAR providers |
E1802 | DYN ADJUSTBL FORARM PRON/SUPIN DEVC | No auth required for PAR providers |
E2510 | SPEECH GEN DVC/SYNTH SPEECH, PERMITTING MLTPL METH OF MSGE FRMLTN | No auth required for PAR providers |
E2599 | ACCESSORY FOR SPEECH GENERATIONG DEVICE, NOT OTHERWISE CLASSIFIED | No auth required for PAR providers |
E2611 | GEN WC BACK CUSHN WDTH < 22 IN HT MOUNT HARDWARE | No auth required for PAR providers |
E2620 | PSTN WC BACK CUSHN PLANAR LAT SUPP WDTH <22 IN | No auth required for PAR providers |
E2622 | ADJ SKIN PRO W/C CUS WD<22IN | No auth required for PAR providers |
E2624 | ADJ SKIN PRO/POS CUS<22IN | No auth required for PAR providers |
L1851 | KO SINGLE UPRIGHT PREFAB OTS | Auth required for all providers |
L1852 | KO DOUBLE UPRIGHT PREFAB OTS | Auth required for all providers |
L5984 | ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESIS, AXIAL ROTATION UNIT | No auth required for PAR providers |
S8092 | ELECTRON BEAM COMPUTED TOMOGRAPHY | Services administered through NIA www.RADMD.com |
As a reminder, all new, re-sequenced and unlisted codes (miscellaneous codes) require prior authorization, regardless of place of service until otherwise communicated.