MMP Services That Require Prior Auth List 10-01-2018.Xlsx
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Effective: 9/13/2018 Revised: 10/01/2018 Medicare-Medicaid Plan (MMP) Services that require Prior Authorization List HAP must be notified when the member is admitted for all inpatient hospitalizations, even if you have obtained a prior authorization for the procedure to be performed. • HAP members must receive care from contracted providers. • Any service listed below, when provided by a non-contracted provider, requires prior authorization from HAP. To determine if a procedure is a covered benefit and meets criteria, providers must utilize HAP's online Member Eligibility Application (MEA) and the Benefit Administration Manual (BAM). It is imperative that you verify benefit coverage prior to rendering service, as failure to do so may result in denial of payment and Members must be held harmless. The information contained in the Services that require Prior Authorization List is protected by copyright laws. Duplication should occur only with permission from the HAP Corporate Office. Providers shall not modify, translate, decompile, disclose, create nor attempt to create any derivative work in the Services that require Prior Authorization List. Treating providers are solely responsible for medical advice and treatment of Members. HAP’s Benefit Coverage Policies and Procedure Reference Lists apply to all HAP lines of business offered through any HAP affiliate including insured and self-funded plans except for the following: These Benefit Coverage Policies and Procedure Reference Lists do not apply to lines of business offered through HAP affiliates ASR and Midwest Health Plan. HAP continuously reviews and monitors all procedures to determine any potential changes of coverage that would affect current procedure lists. Otherwise, the Services that require Prior Authorization list will be reviewed and updated on a monthly basis. Always check the list on the HAP website, as it is the most current list and printed copies may be incomplete or outdated. If you would like to suggest additional services to be added to the Services that require Prior Authorization list, please contact us and we will take your request into consideration for the next scheduled revision. Any suggestions or questions should be directed in writing to: Sr Project Consultant (T14 - 4th floor) EMAIL to: [email protected] Health Alliance Plan or 2850 West Grand Boulevard Detroit, MI 48202 Key: * Specific coverage criteria or limitations/restrictions apply. Refer to BAM for more information. ExGEN Services that are “carved out” of the Genesys delegation. All other services that are indicated as "ExGEN" are processed by the HAP Referral INFO Informational/reportingM t T F code - icode th not t separatelyi ipayable th i ti t t RMT di tl b lli 313 664 8950 ti #1 b it th t li RMT Submit request for authorization via CareAffiliate. Please select appropriate Request Type based on the type of service/place of service that care is Product Line Key: MMP Medicare-Medicaid Plan Services that require Prior Authorization List Code Description Prior Auth Key Rider Requirement Product Lines Required 00100 ANESTHESIA FOR PROCEDURES ON No MMP SALIVARY GLANDS, INCLUDING BIOPSY 00102 ANESTHESIA FOR PROCEDURES No MMP INVOLVING PLASTIC REPAIR OF CLEFT LIP 00103 ANESTHESIA FOR RECONSTRUCTIVE No MMP PROCEDURES OF EYELID (eg, blepharoplasty, 00104 ANESTHESIA FOR No MMP ELECTROCONVULSIVE THERAPY 00120 ANESTHESIA FOR PROCEDURES ON No MMP EXTERNAL, MIDDLE AND INNER EAR INCLUDING 00124 ANESTHESIA FOR PROCEDURES ON No MMP EXTERNAL, MIDDLE AND INNER EAR INCLUDING 1 of 571 Revised: 10/01/2018 Services that require Prior Authorization List Code Description Prior Auth Key Rider Requirement Product Lines Required 00126 ANESTHESIA FOR PROCEDURES ON No MMP EXTERNAL, MIDDLE AND INNER EAR INCLUDING 00140 ANESTHESIA FOR PROCEDURES ON No MMP EYE; NOT OTHERWISE SPECIFIED 00142 ANESTHESIA FOR PROCEDURES ON No MMP EYE; LENS SURGERY 00144 ANESTHESIA FOR PROCEDURES ON No MMP EYE; CORNEAL TRANSPLANT 00145 ANESTHESIA FOR PROCEDURES ON No MMP EYE, VITREORETINAL SURGERY 00147 ANESTHESIA FOR PROCEDURES ON No MMP EYE; IRIDECTOMY 00148 ANESTHESIA FOR PROCEDURE ON No MMP EYE; OPHTHALMOSCOPY 00160 ANESTHESIA FOR PROCEDURES ON No MMP NOSE AND ACCESSORY SINUSES; not otherwise 00162 ANESTHESIA FOR PROCEDURES ON No MMP NOSE AND ACCESSORY SINUSES; radical 00164 ANESTHESIA FOR PROCEDURES ON No MMP NOSE AND ACCESSORY SINUSES; biopsy, soft 00170 ANESTHESIA FOR INTRAORAL No MMP PROCEDURES, INCLUDING BIOPSY; NOT OTHERWISE SPECIFIED (UNITS: 5) 00172 ANESTHESIA FOR INTRAORAL No MMP PROCEDURES, INCLUDING BIOPSY; repair of cleft palate 00174 ANESTHESIA FOR INTRAORAL No MMP PROCEDURES, INCLUDING BIOPSY; EXCISION OF 00176 ANESTHESIA FOR INTRAORAL No MMP PROCEDURES, INCLUDING BIOPSY; RADICAL SURGERY 00190 ANESTHESIA FOR PROCEDURES ON No MMP FACIAL BONES OR SKULL; not otherwise 00192 ANESTHESIA FOR PROCEDURES ON No MMP FACIAL BONES OR SKULL; radical surgery 00210 ANESTHESIA FOR INTRACRANIAL No MMP PROCEDURES; not otherwise specified 00211 Anesthia for intracranial procedures; No MMP craniotomy or craniectomy for evacuation of hematoma 00212 Anesthesia for intracranial procedures; No MMP subdural taps 00214 Anesthesia for intracranial procedures; No MMP burr holes, including 00215 Anesthesia for intracranial procedures; No MMP cranioplasty or elevation of 00216 Anesthesia for intracranial procedures; No MMP vascular procedures 00218 Anesthesia for intracranial procedures; No MMP procedures in sitting position 00220 Anesthesia for intracranial procedures; No MMP cerebrospinal fluid shunting 00222 Anesthesia for intracranial procedures; No MMP electrocoagulation of 00300 Anesthesia for all procedures on the No MMP integumentary system, muscles and 2 of 571 Revised: 10/01/2018 Services that require Prior Authorization List Code Description Prior Auth Key Rider Requirement Product Lines Required 00320 Anesthesia for all procedures on No MMP esophagus, thyroid, larynx, trachea and 00322 Anesthesia for all procedures on No MMP esophagus, thyroid, larynx, trachea and 00326 Anesthesia for all procedures on the No MMP larynx and trachea in children less 00350 Anesthesia for procedures on major No MMP vessels of neck; not otherwise 00352 Anesthesia for procedures on major No MMP vessels of neck; simple ligation 00400 Anesthesia for procedures on the No MMP integumentary system on the 00402 extremities, anterior trunk and perineum; No MMP reconstructive procedures on 00404 extremities, anterior trunk and perineum; No MMP radical or modified radical 00406 Anesthesia for procedures on the No MMP integumentary system on the 00410 Anesthesia for procedures on the No MMP integumentary system on the 00450 Anesthesia for procedures on clavicle and No MMP scapula; not otherwise 00454 Anesthesia for procedures on clavicle and No MMP scapula; biopsy of clavicle 00470 Anesthesia for partial rib resection; not No MMP otherwise specified 00472 Anesthesia for partial rib resection; No MMP thoracoplasty (any type) 00474 Anesthesia for partial rib resection; radical No MMP procedures (eg, pectus 00500 Anesthesia for all procedures on No MMP esophagus 00520 Anesthesia for closed chest procedures; No MMP (including bronchoscopy) not 00522 Anesthesia for closed chest procedures; No MMP needle biopsy of pleura 00524 Anesthesia for closed chest procedures; No MMP pneumocentesis 00528 Anesthesia for closed chest procedures; No MMP mediastinoscopy and diagnostic 00529 Anesthesia for closed chest procedures; No MMP mediastinoscopy and diagnostic 00530 Anesthesia for permanent transvenous No MMP pacemaker insertion 00532 Anesthesia for access to central venous No MMP circulation 00534 Anesthesia for transvenous insertion or No MMP replacement of pacing 00537 Anesthesia for cardiac electrophysiologic No MMP procedures including 00539 Anesthesia for tracheobronchial No MMP reconstruction 00540 Anesthesia for thoracotomy procedures No MMP involving lungs, pleura, 00541 Anesthesia for thoracotomy procedures No MMP involving lungs, pleura, 00542 Anesthesia for thoracotomy procedures No MMP involving lungs, pleura, 00546 Anesthesia for thoracotomy procedures No MMP involving lungs, pleura, 00548 Anesthesia for thoracotomy procedures No MMP involving lungs, pleura, 00550 Anesthesia for sternal debridement No MMP 3 of 571 Revised: 10/01/2018 Services that require Prior Authorization List Code Description Prior Auth Key Rider Requirement Product Lines Required 00560 of chest; without pump oxygenator No MMP 00561 Anesthesia for procedures on heart, No MMP pericardial sac, and great vessels 00562 Anesthesia for procedures on heart, No MMP pericardial sac, and great vessels 00563 Anesthesia for procedures on heart, No MMP pericardial sac, and great vessels 00566 Anesthesia for direct coronary artery No MMP bypass grafting without pump 00567 Anesthesia for direct coronary artery No MMP bypass grafting; with pump oxygenator 00580 Anesthesia for heart transplant or No MMP heart/lung transplant 00600 Anesthesia for procedures on cervical No MMP spine and cord; not otherwise 00604 Anesthesia for procedures on cervical No MMP spine and cord; procedures with 00620 Anesthesia for procedures on thoracic No MMP spine and cord; not otherwise 00625 ANESTHESIA FOR PROCEDURES ON No MMP THE THORACIC SPINE AND CORD,2- LUNG 00626 ANESTHESIA FOR PROCEDURES ON No MMP THE THORACIC SPINE AND CORD,1- LUNG 00630 Anesthesia for procedures in lumbar No MMP region; not otherwise specified 00632 Anesthesia for procedures in lumbar No MMP region; lumbar sympathectomy 00635 Anesthesia for procedures in lumbar