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Firstcare STAR Prior Authorization List Effective January 1, 2021

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Firstcare STAR Prior Authorization List Effective January 1, 2021 FirstCare STAR Prior Authorization List Effective January 1, 2021 FirstCare Health Plans STAR Medicaid in-network providers are encouraged to log in1 to the Provider Portal to verify member eligibility2 status and utilize the Authorization Code Look-up to submit new authorization requests, view authorization status, and view prior authorization requirements. Alternately, complete the Essential Information to Initiate an Authorization3 on the FirstCare Authorization Request Form and submit the Complete Authorization Request4 via fax. PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE. 5 Effective Prior Authorization Medical Policy Date Prior Authorization is required for ALL SERVICES provided by NON-CONTRACTED providers except for use of out- 261 01/21/13 of-network benefits in PPO and POS products, unless required per listing below6 Notification required for admission to these facilities/services and will be subject to admission review concurrent review:7 1/21/13 1. Contracted hospitals for medical, surgical, and behavioral health services 1. MCG5, 250 2. Contracted hospice programs (applies to inpatient and outpatient programs) 2. MCG5 Notification required for DISCHARGE from all facilities n/a 01/21/13 Prior Authorization required for admission to facilities/programs listed below: 5 1. Long-term Acute Care (LTAC) hospitals, 1. MCG 01/21/13 2. Inpatient Rehabilitation hospitals 2. MN-248 3. Behavioral health/substance abuse residential, partial hospitalization, intensive outpatient programs (IOP) 3. TMPPM, MCG5 8 5 Effective Category Code Code Description Medical Policy Date Anesthesia for Dental Anesthesia for intraoral procedures, including biopsy; not otherwise 00170 267 6/23/2014 Procedures specified Cosmetic, Plastic, and 11950 Subcutaneous injection of filling material (eg, collagen); 1 cc or less MN-043 11/1/2019 Reconstructive Surgery Cosmetic, Plastic, and 11951 Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc MN-043 11/1/2019 Reconstructive Surgery Cosmetic, Plastic, and 11952 Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc MN-043 11/1/2019 Reconstructive Surgery Cosmetic, Plastic, and 11954 Subcutaneous injection of filling material (eg, collagen); over 10.0 cc MN-043 11/1/2019 Reconstructive Surgery Cosmetic, Plastic, and Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, 15780 263 11/1/2019 Reconstructive Surgery general keratosis) Cosmetic, Plastic, and 15781 Dermabrasion; segmental, face 263 1/21/2013 Reconstructive Surgery Cosmetic, Plastic, and 15782 Dermabrasion; regional, other than face 263 11/1/2019 Reconstructive Surgery Cosmetic, Plastic, and 11/1/2019 15783 Dermabrasion; superficial, any site (eg, tattoo removal) 263 Reconstructive Surgery FCHP 12201 Page 1 of 52 FirstCare STAR Prior Authorization Effective January 1, 2021 8 5 Effective Category Code Code Description Medical Policy Date Cosmetic, Plastic, and 15786 Abrasion; single lesion (eg, keratosis, scar) 263 11/1/2019 Reconstructive Surgery Cosmetic, Plastic, and 15788 Chemical peel, facial; epidermal 263 1/21/2013 Reconstructive Surgery Cosmetic, Plastic, and 15789 Chemical peel, facial; dermal 263 1/21/2013 Reconstructive Surgery Blepharoplasty 15820 Blepharoplasty, lower eyelid; MCG5 1/21/2013 Blepharoplasty 15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad MCG5 1/21/2013 Blepharoplasty 15822 Blepharoplasty, upper eyelid; MCG5 1/21/2013 Blepharoplasty 15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid MCG5 1/21/2013 Cosmetic, Plastic, and Excision, excessive skin and subcutaneous tissue (includes lipectomy); 15830 TMPPM 1/21/2013 Reconstructive Surgery abdomen, infraumbilical panniculectomy Excision, excessive skin and subcutaneous tissue (includes lipectomy), Cosmetic, Plastic, and 15847 abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial TMPPM 1/21/2013 Reconstructive Surgery plication) (List separately in addition to code for primary procedure) Cosmetic, Plastic, and 15876 Suction assisted lipectomy; head and neck MN-043 11/1/2019 Reconstructive Surgery Cosmetic, Plastic, and 15877 Suction assisted lipectomy; trunk MN-043 11/1/2019 Reconstructive Surgery Cosmetic, Plastic, and 15878 Suction assisted lipectomy; upper extremity MN-043 11/1/2019 Reconstructive Surgery Cosmetic, Plastic, and 15879 Suction assisted lipectomy; lower extremity MN-043 11/1/2019 Reconstructive Surgery Cosmetic, Plastic, and Destruction of cutaneous vascular proliferative lesions (eg, laser 17106 MN-043 11/1/2019 Reconstructive Surgery technique); less than 10 sq cm Cosmetic, Plastic, and Destruction of cutaneous vascular proliferative lesions (eg, laser 17107 MN-043 11/1/2019 Reconstructive Surgery technique); 10.0 to 50.0 sq cm Cosmetic, Plastic, and Destruction of cutaneous vascular proliferative lesions (eg, laser 17108 MN-043 11/1/2019 Reconstructive Surgery technique); over 50.
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