Prior Authorization ARQ Updates

Date: 11/01/21

We are in the process of adding new codes that became effective 7/1/21 to our systems. As a reminder, all new, re-sequenced and unlisted codes (miscellaneous codes) require prior authorization, regardless of place of service.

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 line of business: https://www.azcompletehealth.com/providers/preauth-check.html

The tables on the following pages include the new codes and provide a reminder that prior authorization is required.

If you have questions regarding the information contained in this update please contact our Provider Customer Service Center at (866) 796-0542 or your Provider Engagement Specialist. If you need contact information for your assigned Provider Engagement, please email AzCHProviderEngagement@azcompletehealth.com.

DID YOU KNOW?

We’ve redesigned the authorization request section in our Secure Provider Portal. The redesign includes the integration of InterQual Connect™.

The web authorization request redesign and InterQual Connect offer improvements and new capabilities:
The web authorization request process was simplified. The Service type drop down was replaced by Provider type, and includes a shorter list of options to choose from.
You are now advised whether or not a service requires authorization or is not covered.
Following the submission of your request, the tool identifies if one or more service lines were not submitted as part of your request and provides the reason for non-submittal, e.g., an authorization is already on file, the service doesn’t require authorization, etc.
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 have the ability to access InterQual Connect and complete a medical review via the portal.

*Medicaid, Marketplace (Ambetter) & Medicare (Allwell)*
Procedure Code	Description	Rule
90626	TICK-BORNE ENCEPH VACC INACTIVATED 0.25ML IM USE	Auth required for all providers
90627	TICK-BORNE ENCEPH VACC INACTIVATED 0.5ML IM USE	Auth required for all providers
90671	PCV15 VACCINE FOR INTRAMUSCULAR USE	Auth required for all providers
90677	PCV20 VACCINE FOR INTRAMUSCULAR USE	Auth required for all providers
90758	ZAIRE EBOLAVIRUS VACCINE LIVE FOR IM USE	Auth required for all providers
A9593	GALLIUM GA-68 PSMA-11 DIAGNOSTIC UCSF 1 MCI	Auth required for all providers
A9594	GALLIUM GA-68 PSMA-11 DIAGNOSTIC UCLA 1 MCI	Auth required for all providers
C1761	CATHETER TRANSLUMINAL IVASC LITHOTRIPSY COR	Auth required for all providers
C9075	INJECTION CASIMERSEN 10 MG	Auth required for all providers
C9076	LISOCABTAGENE MARALEUCEL PER THERAPEUTIC DOSE	Auth required for all providers
C9077	INJECTION CABOTEGRAVIR AND RILPIVIRINE 2 MG/3 MG	Auth required for all providers
C9079	INJECTION EVINACUMAB-DGNB 5 MG	Auth required for all providers
C9080	INJECTION MELPHALAN FLUFENAMIDE HCL 1 MG	Auth required for all providers
C9778	COLPOPEXY VAGINAL MI EXTRAPERITONEAL APPROACH	Auth required for all providers
G0327	COLORECTAL CANCER SCREENING BLOOD-BASED BIOMARK	Auth required for all providers
J0224	INJECTION LUMASIRAN 0.5 MG	Auth required for all providers
J0741	INJECTION CABOTEGRAVIR AND RILPIVIRINE 2 MG/3 MG	Auth required for all providers
J1305	INJECTION EVINACUMAB-DGNB 5 MG	Auth required for all providers
J1426	INJECTION CASIMERSEN 10 MG	Auth required for all providers
J1448	INJECTION TRILACICLIB 1 MG	Auth required for all providers
J1951	INJECTION LEUPROLIDE AC FOR DEPOT SUSP 0.25 MG	Auth required for all providers
J7168	PRT COMPLEX CONC KCENTRA PER IU FIX ACT	Auth required for all providers

*Medicaid, Marketplace (Ambetter) & Medicare (Allwell)*
Procedure Code	Description	Rule
J9247	INJECTION MELPHALAN FLUFENAMIDE 1 MG	Auth required for all providers If used for adult oncology, this service is administered by New Century Health.
J9314	INJECTION ROMIDEPSIN NONLYOPHILIZED 0.1 MG	Auth required for all providers
J9348	INJECTION NAXITAMAB-GQGK 1 MG	Auth required for all providers
J9353	INJECTION MARGETUXIMAB-CMKB 5 MG	Auth required for all providers
M0201	COVID-19 VACCINE ADM INSIDE PATIENT S HOME	Auth required for all providers
M0244	INTRAVENOUS INFUSION CASIRIVIMAB AND IMDEVIMAB	Auth required for all providers
M0246	INTRAVENOUS INFUSION BAMLANIVIMAB AND ETESEVIMAB	Auth required for all providers
M0247	INTRAVENOUS INF SOTROVIMAB INC INF AND P ADM MON	Auth required for all providers
M0248	IV INF SOTROVIMAB INC INF AND POST ADM MON H/RES	Auth required for all providers
Q0244	INJECTION CASIRIVIMAB AND INDEVIMAB 1200 MG	Auth required for all providers
Q0247	INJECTION, SOTROVIMAB, 500 MG	Auth required for all providers
Q5123	INJECTION RITUXIMAB-ARRX BIOSIMILAR 10 MG	Auth required for all providers
0248U	ONC BRAIN SPHRD CLL CUL 12 RX PNL TUMOR RESPONSE	Auth required for all providers
0249U	ONC BRST SEMIQ ALYS 32 PHSPRTN AND PRTN ANALYTE ALG	Auth required for all providers
0250U	ONC SLD ORG NEO TRGT GEN SEQ DNA ALYS 505 GENES	Auth required for all providers
0251U	HEPCIDIN-25 ELISA SERUM OR PLASMA	Auth required for all providers
0252U	FTL ANEUPLOIDY STR CMPRTV ALYS FTL DNA PRDC CNCP	Auth required for all providers
0253U	REPRDTVE MED RNA 238 GEN NXT GEN SEQ ENDMT TISS	Auth required for all providers
0254U	REPRDTVE MED ALYS 24 CHRMSM EMBRY AND MITOCHDRL DNA	Auth required for all providers
0640T	NCNTC NR IFR SPECTRSC FLAP/WND IMG ACQUISJ I AND R	Auth required for all providers
0641T	NCNTC NR IFR SPECTRSC FLAP/WND IMG ACQUISJ ONLY	Auth required for all providers

*Medicaid, Marketplace (Ambetter) & Medicare (Allwell)*
Procedure Code	Description	Rule
0642T	NCNTC NR IFR SPECTRSC FLAP/WND I AND R ONLY	Auth required for all providers
0643T	TRANSCATHETER L VENTR RESTORATION DEVICE IMPLTJ	Auth required for all providers
0644T	TCAT RMVL/DEBULK ICAR MASS SUCTION DEVICE PERQ	Auth required for all providers
0645T	TCAT IMPLANTATION CORONARY SINUS REDUCTION DEV	Auth required for all providers
0646T	TTVI/RPLCMT PROSTC VLV PERQ W/R HRT CATH AND ANGRPH	Auth required for all providers
0647T	INSJ GASTROSTOMY TUBE PERQ W/MAGNETIC GASTROPEXY	Auth required for all providers
0648T	QUAN MR ALYS TISS COMPOSITION W/O MRI SAME SESS	Auth required for all providers
0649T	QUAN MR ALYS TISS COMPOSITION W/MRI	Auth required for all providers
0650T	PRGRMG DEV EVAL SCRMS PHYS/QHP REMOTE	Auth required for all providers
0651T	MAGNETICALLY CONTROLLED CAPSULE ENDOSCOPY W/I AND R	Auth required for all providers
0652T	EGD FLEXIBLE TRANSNASAL DX W/COLLJ SPEC BR/WA	Auth required for all providers
0653T	EGD FLEXIBLE TRANSNASAL W/BIOPSY SINGLE/MULTIPLE	Auth required for all providers
0654T	EGD FLEXIBLE TRANSNASAL W/INSJ INTRAL TUBE/CATH	Auth required for all providers
0655T	TRANSPERINEAL FOCAL LASER ABLTJ MAL PRST8 TISS	Auth required for all providers
0656T	ANTERIOR VERTEBRAL BODY TETHERING <7VRT SEGMENTS	Auth required for all providers
0657T	ANTERIOR VERTEBRAL BODY TETHERING 8+VRT SEGMENTS	Auth required for all providers
0658T	ELECTRICAL IMPEDENCE SPECTROSCOPY 1+SKIN LESIONS	Auth required for all providers
0659T	TCAT INTRA-C NFS SUPERSAT O2 W/PERQ C REVSC AMI	Auth required for all providers
0660T	IMPLTJ ANT SGM IO NBIODEGRADABLE RX ELUTING SYS	Auth required for all providers
0661T	RMVL AND RIMPLTJ ANT SGM IO NBIODGRD RX ELUT IMPLT	Auth required for all providers
0662T	SCALP COOLING 1ST MEASUREMENT AND CAP CALIBRATION	Auth required for all providers
0663T	SCALP COOLING PLACEMENT MNTR AND REMOVAL OF DEVICE	Auth required for all providers

*Medicaid, Marketplace (Ambetter) & Medicare (Allwell)*
Procedure Code	Description	Rule
0664T	DONOR HYSTERECTOMY OPEN FROM CADAVER DONOR	Auth required for all providers
0665T	DONOR HYSTERECTOMY OPEN FROM LIVING DONOR	Auth required for all providers
0666T	DONOR HYSTERECTOMY LAPS/ROBOTIC FROM LIV DONOR	Auth required for all providers
0667T	DONOR HYST RCP UTER ALGRFT TRNSPLJ CDVR/LIV	Auth required for all providers
0668T	BACKBENCH PREP CDVR/LIV DONOR UTERINE ALLOGRAFT	Auth required for all providers
0669T	BCKBNCH RCNSTJ CDVR/LIV DON UTER ALGRFT VEN ANST	Auth required for all providers
0670T	BCKBNCH RCNSTJ CDVR/LIV DON UTER ALGRFT ART ANST	Auth required for all providers