M H OF I 2016 P - Molina Healthcare · 22112 22852 28150 28715 32491 47382 58661 63056 96921 22114...

MOLINA HEALTHCARE OF ILLINOIS

2016 PRIOR AUTHORIZATION CODIFICATION LIST

The Molina Healthcare of Illinois (Molina) Prior Authorization Codification List is reviewed for updates

quarterly, or as deemed necessary to meet the needs of Molina Members and its Provider community.

Codes requiring prior authorization (PA) may be added or deleted. Notification of any and all changes

will be made to Providers with advance notification. Please check the document prior to submitting PA

requests as changes may occur.

All codes listed require authorization, unless otherwise specified.

Authorization is not a guarantee of payment for services. Payment is made in accordance with a

determination of a Member’s eligibility, benefit limitations/exclusions and evidence of medical

necessity during the claim review.

Office visits and/or procedures performed in participating (PAR) Provider offices do not require Prior

Authorization.

Molina Healthcare of Illinois Prior Authorization Codification List

Q2 2016

pg. 1

TABLE OF CONTENTS

Page

Behavioral Health, Mental Health, Alcohol & Chemical Dependency Services 2

Cosmetic, Plastic & Reconstructive Procedures 2

Dental General Anesthesia 2

Durable Medical Equipment (DME) 3

Experimental / Investigation 3

Genetic Counseling & Testing 4-5

Habilitative Therapy 5

Home Health Care / Home Infusion 5

Imaging 5-6

In-Patient (IP) Admissions 6

Long Term Services & Support 6

Neuropsychological and Psychological Testing 6

Non-Par Providers/Facilities 7

Office Based Procedures 7

Out-Patient (OP) Hospital/Ambulatory Surgery Center 7-8

Pain Management 8-9

Pregnancy & Delivery 9

Prosthetics & Orthotics 9

Radiation Therapy & Radiosurgery 9

Sleep Studies 9

Speech Therapy 10

Specialty Pharmacy 10-11

Transplant Services 11

Transportation Services 11

Unlisted/Miscellaneous & Temporary (T) Codes 11-12

Prior Authorization Contact Information 13


Q2 2016

pg. 2

BEHAVIORAL HEALTH, MENTAL HEALTH, ALCOHOL & CHEMICAL DEPENDENCY SERVICES Inpatient, Residential Treatment, Partial Hospitalization, Day Treatment, Electroconvulsive Therapy (ECT). Applied Behavioral Analysis (ABA) for treatment of Autism Spectrum Disorder (ASD)

MEDICARE / MEDICAID MEDICAID ONLY MEDICARE ONLY

0114 0134 0901 0945 H0047

N/A N/A 0124 0144 0912 1002 H2036

0126 0154 0913 90870

0128 0204 0944 H0010

COSMETIC, PLASTIC & RECONSTRUCTIVE PROCEDURES (IN ANY SETTING)


15775 15822 15837 19324 30430

N/A N/A

15776 15823 15838 19325 30435

15780 15824 15839 19328 30450

15781 15825 15847 19330 30460

15782 15826 15876 19340 30462

15783 15828 15877 19342 67904

15788 15829 15878 19350 67906

15789 15832 15879 19355 67908

15792 15833 17380 19396

15793 15834 19300 30400

15820 15835 19316 30410

15821 15836 19318 30420

DURABLE MEDICAL EQUIPMENT (DME) MEDICARE / MEDICAID MEDICAID ONLY MEDICARE ONLY

A7025 E0984 E2311 E2616 K0837 E0481

N/A

A9900 E0986 E2312 E2617 K0838 S1034

E0194 E0988 E2313 E2620 K0839 S1035

E0255 E1002 E2321 E2621 K0840 S1036

E0256 E1003 E2322 E2622 K0841 S1037

E0260 E1004 E2325 E2623 K0842

E0261 E1005 E2326 E2624 K0843

E0265 E1006 E2327 E2625 K0848

E0266 E1007 E2328 E2626 K0849

E0277 E1008 E2329 E2627 K0850

E0292 E1010 E2330 E2628 K0851

E0293 E1014 E2340 E2629 K0852

E0294 E1020 E2341 E2630 K0853

E0295 E1029 E2342 E2631 K0854


Q2 2016

pg. 3

DURABLE MEDICAL EQUIPMENT (DME) E0296 E1030 E2343 K0008 K0855

N/A

E0297 E1035 E2351 K0009 K0856

E0300 E1036 E2361 K0010 K0857

E0301 E1161 E2366 K0011 K0858

E0302 E1225 E2367 K0012 K0859

E0303 E1226 E2368 K0014 K0860

E0304 E1227 E2369 K0108 K0861

E0328 E1230 E2370 K0606 K0862

E0329 E1232 E2373 K0800 K0863

E0371 E1233 E2374 K0801 K0864

E0372 E1234 E2375 K0802 K0868

E0373 E1235 E2376 K0806 K0869

E0462 E1236 E2377 K0807 K0870

E0483 E1237 E2378 K0808 K0871

E0691 E1238 E2397 K0813 K0877

E0692 E1296 E2500 K0814 K0878

E0693 E1298 E2502 K0815 K0879

E0694 E1310 E2504 K0816 K0880

E0747 E1399 E2506 K0820 K0884

E0748 E1700 E2508 K0821 K0885

E0749 E2201 E2510 K0822 K0886

E0760 E2202 E2511 K0823 K0890

E0762 E2203 E2605 K0824 K0891

E0764 E2204 E2606 K0825 K0900

E0782 E2227 E2607 K0826 V2530

E0783 E2228 E2608 K0827 V2531

E0784 E2291 E2609 K0828

E0785 E2292 E2611 K0829

E0786 E2293 E2612 K0830

E0849 E2294 E2613 K0831

E0855 E2295 E2614 K0835

E0983 E2310 E2615 K0836

EXPERIMENTAL/INVESTIGATIONAL MEDICARE/MEDICAID MEDICAID ONLY MEDICARE ONLY

0019T 0178T 0238T 0300T 0360T 0329T

N/A

0042T 0179T 0249T 0301T 0361T 0330T

0051T 0180T 0253T 0302T 0362T 0331T

0052T 0184T 0254T 0303T 0363T 0332T

0053T 0195T 0255T 0304T 0364T 0333T


Q2 2016

pg. 4

EXPERIMENTAL/INVESTIGATIONAL 0054T 0196T 0264T 0306T 0366T

N/A

0055T 0198T 0265T 0307T 0367T

0058T 0200T 0266T 0308T 0368T

0071T 0201T 0267T 0309T 0369T

0072T 0202T 0268T 0310T 0370T

0075T 0205T 0269T 0312T 0371T

0076T 0206T 0270T 0313T 0372T

0085T 0207T 0271T 0314T 0373T

0095T 0208T 0272T 0315T 0374T

0098T 0209T 0273T 0316T 0392T

0100T 0210T 0274T 0317T 0393T

0101T 0211T 0275T 0335T 82017

0102T 0212T 0278T 0336T 83987

0106T 0213T 0281T 0337T 84145

0107T 0214T 0282T 0338T 86316

0108T 0215T 0283T 0339T 86343

0109T 0216T 0285T 0340T

0110T 0217T 0286T 0342T

0111T 0218T 0287T 0347T

0159T 0219T 0288T 0348T

0163T 0220T 0289T 0349T

0164T 0221T 0290T 0350T

0165T 0222T 0291T 0351T

0169T 0228T 0292T 0352T

0171T 0229T 0293T 0353T

0172T 0230T 0294T 0354T

0174T 0231T 0295T 0355T

0175T 0234T 0296T 0356T

0188T 0235T 0297T 0357T

0189T 0236T 0298T 0358T

0190T 0237T 0299T 0359T

0191T 0263T 0305T 0365T

GENETIC COUNSELING & TESTING Exception(s): Prenatal diagnosis of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations

MEDICARE / MEDICAID MEDICAID

ONLY MEDICARE ONLY

81201 81226 81291 81323 81408 81435 83006

N/A N/A 81203 81227 81292 81325 81410 81436 88369

81211 81228 81294 81355 81411 81440 88373


Q2 2016

pg. 5

GENETIC COUNSELING & TESTING Exception(s): Prenatal diagnosis of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations

81212 81229 81297 81401 81417 81455 84999*

N/A N/A

81213 81246 81298 81402 81425 81460 0004M

81214 81265 81300 81403 81426 81465 0006M

81215 81266 81313 81404 81427 81470 0007M

81216 81280 81317 81405 81430 81471 0008M

81217 81282 81319 81406 81431 81519 0010M

81222 81287 81321 81415 81445 88374

81223 81295 81400 81416 81450 88377

* Including Oncotype DX

HABILITATIVE CARE


ONLY MEDICARE

ONLY

92507 92508 92606 N/A N/A

HOME HEALTH CARE/HOME INFUSION After initial evaluation plus six (6) visits for outpatient and home settings


G0151 G0155 G0158 G0161 G0164

N/A

0023 043X

G0152 G0156 G0159 G0162 G0299 032X 044X

G0153 G0157 G0160 G0163 G0300 033X 055X

034X 056X

027X 057X

029X 060X

042X 062X

HYPERBARIC THERAPY


ONLY MEDICARE

ONLY

G0277 99183 N/A N/A

IMAGING - Advanced & Specialty


ONLY MEDICARE

ONLY

C8900 70470 71260 72192 73723 75573 78647

N/A

S8042 C8901 70480 71270 72193 73725 75574 78710

C8902 70481 71275 72194 74150 75635 78811

C8903 70482 71550 72195 74160 76376 78812

https://www.encoderpro.com/epro/hcpcsHandler.do?_k=102*C8907&_a=viewDetail







Q2 2016

pg. 6

IMAGING - Advanced & Specialty C8904 70486 71551 72196 74170 77084 78813

N/A

C8905 70487 71552 72197 74174 78205 78814

C8906 70488 71555 72198 74175 78206 78815

C8907 70490 72125 73200 74176 78320 78816

C8908 70491 72126 73201 74177 78451 G0288

C8909 70492 72127 73202 74178 78452

C8910 70496 72128 73206 74181 78453

C8911 70498 72129 73218 74182 78454

C8912 70540 72130 73219 74183 78459

C8913 70542 72131 73220 74185 78466

C8914 70543 72132 73221 74261 78468

C8918 70544 72133 73222 74262 78469

C8919 70545 72141 73223 74263 78472

C8920 70546 72142 73225 75557 78473

C8931 70547 72146 73700 75559 78481

C8932 70548 72147 73701 75561 78483

C8933 70549 72148 73702 75563 78491

C8934 70551 72149 73706 75565 78492

C8935 70552 72156 73718 75572 78494

C8936 70553 72157 73719 78496 76377

70336 70554 72158 73720 78607 76380

70450 70555 72159 73721 78608 77058

70460 71250 72191 73722 78609 77059

IN-PATIENT ADMISSIONS

All Acute Hospital, Skilled Nursing Facility (SNF), Rehabilitation and Long Term Acute Care (LTAC) Facility in-patient admissions require Prior Authorization


ALL CODES ALL CODES ALL CODES

LONG TERM SERVICES & SUPPORT


N/A ALL CODES N/A

NEUROPSYCHOLOGICAL & PSYCHOLOGICAL TESTING


95951 96103 96120 95957

N/A N/A 95956 96116 96125

96101 96118 95950

96102 96119 95953










Q2 2016

pg. 7

NON-PAR PROVIDERS/FACILITIES All Out of Network Office Visits, Procedures, Labs, Diagnostic Studies and Inpatient stays require Prior Authorization, except for: • Emergency Department Services and/or Urgent Care Services • Family Planning, Routine Women’s Health and Routine Obstetrical Services • Professional fees associated with ER visits and Ambulatory Surgery Center (ASC) or in-patient stays • Local Health Department (LHD) services • Other services based on State requirements • Urgent Care

OFFICE Visits & Office BASED PROCEDURES DO NOT REQUIRE AUTHORIZATION (Participating Providers)

REQUIRE AUTHORIZATION (Non-Participating Providers)

OUT-PATIENT (OP) HOSPITAL/AMBULATORY SURGERY CENTER MEDICARE / MEDICAID

10040 22551 27442 28261 29828 36478 54360 58950 63087

20930 22552 27443 28262 29848 36479 54401 58951 63088

21120 22554 27445 28264 29873 36514 54405 58952 63090

21121 22556 27446 28270 29874 37191 57288 58953 63091

21122 22558 27447 28272 29875 37700 57289 58954 63101

21123 22585 27486 28280 29876 37718 58150 58956 63102

21125 22586 27487 28285 29877 37722 58152 58957 63103

21127 22590 28005 28286 29879 37735 58180 58958 64553

21137 22595 28008 28288 29880 37760 58200 58970 64568

21138 22600 28010 28289 29881 37761 58210 58974 64569

21139 22610 28011 28290 29882 37765 58240 58976 64570

21141 22612 28035 28292 29883 37766 58260 59070 64590

21142 22614 28060 28293 29884 37780 58262 59072 64595

21143 22630 28062 28294 29885 37785 58263 59074 65771

21145 22632 28080 28296 29886 38204 58267 59076 65772

21146 22633 28090 28297 29887 38207 58270 62370 69717

21147 22634 28092 28298 29888 38208 58275 63001 69718

21150 22800 28100 28299 29889 38209 58280 63003 69930

21151 22802 28102 28300 29891 38210 58285 63005 90867

21154 22804 28103 28302 29892 38211 58290 63011 90868

21155 22808 28104 28304 29893 38212 58291 63012 90869

21159 22810 28106 28305 29894 38213 58292 63015 91122

21160 22812 28107 28306 29895 38214 58293 63016 93229

21172 22818 28108 28307 29897 38215 58294 63017 95909


Q2 2016

pg. 8

OUT-PATIENT (OP) HOSPITAL/AMBULATORY SURGERY CENTER 21175 22819 28110 28308 29898 43773 58543 63020 95911

21240 22830 28111 28309 29899 43774 58544 63030 95912

21242 22840 28112 28310 29914 43775 58545 63035 95913

21243 22841 28113 28312 29915 43842 58546 63040 95965

21270 22842 28114 28313 29916 43843 58548 63042 96567

21280 22843 28116 28315 30465 43845 58550 63043 96570

21282 22844 28118 28320 30520 43846 58552 63044 96571

21295 22845 28119 28322 30540 43847 58553 63045 96900

21296 22846 28120 28340 30545 43848 58554 63046 96902

22100 22847 28122 28341 31295 43881 58570 63047 96904

22101 22848 28124 28344 31296 43882 58571 63048 96910

22102 22849 28126 28345 31297 45499 58572 63050 96912

22103 22850 28130 28360 31660 47380 58573 63051 96913

22110 22851 28140 28705 31661 47381 58660 63055 96920

22112 22852 28150 28715 32491 47382 58661 63056 96921

22114 22855 28153 28725 33251 47600 58662 63057 96922

22116 22856 28160 28730 33254 47605 58672 63064

22206 22857 28171 28735 33261 47610 58673 65775

22207 22861 28173 28737 33265 47612 58700 67900

22208 22862 28175 28740 33266 47620 58720 67901

22210 22864 28200 28750 36460 52441 58740 67902

22212 22865 28202 28755 36468 52442 58750 67903

22214 23412 28208 28760 36470 52649 58752 67909

22216 25447 28210 28890 36471 53850 58760 67950

22220 26499 28220 29806 36475 53852 58770 69714

22222 27120 28222 29807 36476 53860 58940 69715

22224 27122 28225 29819 38232 58321 59899 63066

22226 27125 28226 29820 43644 58322 61863 63075

22505 27130 28230 29821 43645 58323 61864 63076

22526 27132 28232 29822 43647 58345 61867 63077

22527 27134 28234 29823 43648 58350 61868 63078

22532 27137 28238 29824 43653 58356 61885 63081

22533 27138 28240 29825 43770 58540 61886 63082

22534 27440 28250 29826 43771 58541 62369 63085

22548 27441 28260 29827 43772 58542 58943 63086

PAIN MANAGEMENT PROCEDURES Except trigger point injections. [Acupuncture is not a Medicare covered benefit]


G0260 62362 63664 64487 64495 N/A 97810


Q2 2016

pg. 9

PAIN MANAGEMENT PROCEDURES Except trigger point injections. [Acupuncture is not a Medicare covered benefit]

27096 62367 63685 64488 64600

N/A

62310 62368 63688 64489 64633

62311 63650 64479 64490 64634

62350 63655 64480 64491 64635

62351 63661 64483 64492 64636

62360 63662 64484 64493 64640

62361 63663 64486 64494 77003

PREGNANCY & DELIVERY

NOTIFICATION ONLY

PROSTHETICS & ORTHOTICS MEDICARE / MEDICAID MEDICAID ONLY MEDICARE ONLY

L0480 L1640 L1860 L2000 L2090 L8692

N/A

L0482 L1680 L1900 L2005 L2106

L0484 L1685 L1904 L2010 L2108

L0486 L1700 L1907 L2020 L2126

L0452 L1710 L1920 L2030 L2128

L0622 L1720 L1940 L2034 L2232

L0640 L1730 L1945 L2036 L2800

L0700 L1755 L1950 L2037 L4631

L0710 L1834 L1960 L2038 L6026

L1000 L1840 L1970 L2050 L7259

L1005 L1844 L1980 L2060 S1040

L1110 L1846 L1990 L2080

RADIATION THERAPY & RADIO SURGERY


77520 77523 G0339 G6015 G6017 N/A N/A

77522 77525 G0340 G6016

SLEEP STUDIES

Allow one sleep study per calendar year without authorization


95800 95803 95806 95808 95811 N/A N/A

95801 95805 95807 95810


Q2 2016

pg. 10

SPEECH THERAPY After initial evaluation plus six (6) visits for outpatient and home settings

GN Modifier is required when billing Speech Therapy Services for Medicaid services

* Refer to the State of Illinois therapy fee schedule guidelines mandating Provider billing practices


92507 92508 (*92507) 92526 (*92507)

N/A N/A 92606 (*92507)

SPECIALTY Pharmacy * No PA required when used for intravitreal injection (67028) for ocular diagnoses


ONLY MEDICARE

ONLY

90281 J0596 J1566 J2505 J7193 J8520 J9301

N/A N/A

90283 J0597 J1568 J2507 J7194 J8530 J9302

90284 J0598 J1569 J2597 J7195 J8562 J9306

90378 J0637 J1571 J2724 J7196 J8655 J9307

90378 J0638 J1572 J2778 J7197 J9043 J9308

A9542 J0695 J1573 J2783 J7198 J8700 J9310

A9543 J0714 J1575 J2793 J7199 J8999 J9315

C9132 J0717 J1595 J2796 J7200 J9010 Q0515

C9137 J0725 J1599 J2820 J7201 J9015 J9351

C9138 J0775 J1602 J2860 J7205 J9019 J9354

C9257* J0800 J1640 J2941 J7309 J9032 J9357

C9293 J0850 J1645 J3060 J7310 J9035* J9371

C9399 J0875 J1650 J3090 J7311 J9039 J9400

C9470 J0881 J1652 J3110 J7312 J9042 J9600

C9471 J0882 J1675 J3240 J7313 J9047 L8605

C9472 J0885 J1725 J3262 J7316 J9050 Q2028

C9473 J0888 J1743 J3285 J7321 J9098 Q2043

C9474 J0890 J1744 J3315 J7323 J9160 Q2050

C9475 J0895 J1745 J3357 J7324 J9202 Q3025

J0129 J0897 J1786 J3380 J7325 J9207 Q3026

J0178 J1290 J1826 J3385 J7326 J9212 Q3027

J0180 J1300 J1830 J3396 J7327 J9213 Q3028

J0202 J1322 J1833 J3487 J7330 J9214 Q4074

J0205 J1324 J1930 J3489 J3355 J9215 Q4101

J0207 J1325 J1931 J3490 J3365 J9216 Q4139

J0220 J1438 J1950 J3590 J7504 J9217 Q4145

J0221 J1442 J2170 J7178 J7505 J9218 Q4149

J0256 J1446 J2278 J7180 J7506 J9219 Q5101

J0257 J1447 J2323 J7181 J7510 J9225 S0122


Q2 2016

pg. 11

SPECIALTY Pharmacy * No PA required when used for intravitreal injection (67028) for ocular diagnoses

J0364 J1458 J2325 J7182 J7513 J9226 S0126

J0401 J1459 J2353 J7183 J7516 J9228 S0128

J0480 J1460 J2354 J7185 J7525 J9245 S0132

J0485 J1556 J2355 J7186 J7527 J9261 S0157

J0490 J1557 J2357 J7187 J7639 J9262 S0145

J0585 J1559 J2425 J7189 J7682 J9267 S0148

J0586 J1560 J2426 J7190 J7686 J9271

J0587 J1561 J2502 J7191 J7999 J9293

J0588 J1562 J2503 J7192 J8499 J9299

TRANSPLANT SERVICES Including Solid Organ and Bone Marrow

Corneal Transplants do not require authorization


38205 44721 47146 50323 50380 48160

N /A

38206 47133 47147 50325

38230 47135 48550 50327

38240 47140 48551 50328

38241 47141 48552 50329

38242 47142 48554 50340

38243 47143 48556 50360

44715 47144 50300 50365

44720 47145 50320 50370

TRANSPORTATION SERVICES PA required for non-emergent ambulance (ground)

Post service Authorization request accepted per State guidelines

Transportation that is non-emergent and non-ambulance requires 3-day notice and is coordinated through Secure Transportation - see page 13


A0430 A0431 N/A N/A

UNLISTED/MISCELLANEOUS CODES Molina requires standard codes when requesting authorization. Should an unlisted or miscellaneous code be used, medical necessity documentation and rationale must be prior authorized


01999 44899 67399 86486 B9999 T5999

N/A 15999 44979 67599 86849 E0769

17999 45399 67999 86999 E0770

19105 45499 68399 87999 E2599


Q2 2016

pg. 12

UNLISTED/MISCELLANEOUS CODES Molina requires standard codes when requesting authorization. Should an unlisted or miscellaneous code be used,

medical necessity documentation and rationale must be prior authorized

19499 46999 69399 88399 L0999

20999 47379 69799 88749 L1499

21299 47399 69949 89240 L2999

21499 47579 69979 89398 L3649

22899 47999 76497 90399 L3999

22999 48999 76498 90749 L5999

23929 49329 76499 90899 L7499

24999 49999 76999 91299 L8039

25999 51999 77799 92499 L8499

27899 53899 78099 92700 L8699

28899 54699 78199 93799 Q0507

29999 55559 78299 94799 Q0508

30999 55899 78499 95199 Q0509

31299 58578 78599 96999 V2199

31899 58579 78699 97039 V2399

33999 58679 78799 97139 V2799

37799 58999 78999 97799 V5299

40799 59897 79999 99429

40899 59898 81099 99499

41599 60659 81479 A4649

43659 60699 81599 A4913

43999 64999 85999 A9999

44238 66999 88099 J7599

44799 67299 88199 K0898

45999 68899 88299 K0899


Q2 2016

pg. 13

PRIOR AUTHORIZATION CONTACT INFORMATION

Prior Authorizations 8 a.m. – 5 p.m.

Phone: (855) 866-5462

Fax: (866) 617-4971

Radiology Authorizations

Phone: (855) 714-2415

Fax: (877) 731-7218

NICU Authorizations

Phone: (855) 714-2415

Fax: (877) 731- 7218

Pharmacy Authorizations

Medicaid Phone: (855) 866-5462

Medicaid Fax: (855) 365-8112

MMP Phone: (877) 901-8181

MMP Fax: (866) 290-1309

Behavioral Health Authorizations

Phone: (855) 866-5462

Fax: (866) 617-4971

Transplant Authorizations:

Phone: (855) 714-2415

Fax: (877) 731-7218

Member Services

Integrated Care Program Phone: (855) 766-5462

Family Health Plan Phone: (855) 687-7861

MMP Phone: (877) 901-8181

TTY:711

Provider Services

Phone: (855) 866-5462

24 Hour Nurse Advice Line

English: (888) 275-8750 [TTY: (866) 735-2929]

Spanish: (866) 648-3537 [TTY: (866) 833-4703]

Vision Care

Phone: (844) 456-2724

Dental


MMP Phone: (855) 701-0433

Transportation


MMP Phone: (844) 644-6353

ILUM1605.1

M H OF I 2016 P - Molina Healthcare · 22112 22852 28150 28715 32491 47382 58661 63056 96921 22114...

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