To request or status Prior Authorization, call: (855) 463-7275 For more information, go to: www.phxchoice.com Prior Authorization Requirements - Effective January 1, 2016 Overview Prior authorizations are required for: (1) All services rendered by out-of-network providers, irrespective of place of service (POS) or procedures (2) All by-report codes regardless of POS and any professional services, except for hospital based- pathologists, radiologists, and anesthesiologists. (3) All services provided at the following POS: (4) Selected procedures and services (5) For Arizona Medicaid Only: AHCCCS members under the age of 21 with select CRS diagnosis criteria (Refer to pages 161-162) Please refer to the rest of the document for more details on each section. All services provided at the following POS: POS ID Place of Service 12 Patient Home 13 Assisted Living Facility 14 Group Home 16 Temporary Lodging 21 Inpatient Hospital 22 Outpatient Hospital 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Facility 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 51 Inpatient Psychiatric Facility 52 Psychiatric Facility-Partial Hospitalization 54 Intermediate Care Facility/Mentally Retarded 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility 99 Other Place of Service Selected procedures and services: Max Max POS PA units dollar Procedure Services Description Require- allowed amount PA is not required for the following diagnosis codes code ment without allowed PA without PA 21141 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT Accidental dental All 0 0 - 21142 RECONSTRUCTION MIDFACE, LEFORT I; 2 PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT Accidental dental BONE GRAFT All 0 0 - 21143 RECONSTRUCTION MIDFACE, LEFORT I; 3 OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, Accidental dental WITHOUT BONE GRAFT All 0 0 - 21145 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING Accidental dental AUTOGRAFTS) All 0 0 - 21146 RECONSTRUCTION MIDFACE, LEFORT I; 2 PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED UNILATERAL Accidental dental ALVEOLAR CLEFT) All 0 0 - Phoenix Choice 7878 N. 16th. St., Ste. 105 Effective 1/1/2016 Phoenix, Arizona 85020 Page 1 21147 RECONSTRUCTION MIDFACE, LEFORT I; 3 OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED BILATERAL ALVEOLAR CLEFT OR MULTIPLE OSTEOTOMIES) Accidental dental All 0 0 - 21150 RECONSTRUCTION MIDFACE, LEFORT II; ANTERIOR INTRUSION (EG, TREACHER-COLLINS SYNDROME) Accidental dental All 0 0 - 21151 RECONSTRUCTION MIDFACE, LEFORT II; ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES Accidental dental OBTAINING AUTOGRAFTS) All 0 0 - 21154 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); Accidental dental WITHOUT LEFORT I All 0 0 - 21155 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITH Accidental dental LEFORT I All 0 0 - 21244 RECONSTRUCTION OF MANDIBLE, EXTRAORAL, WITH TRANSOSTEAL BONE PLATE (EG, MANDIBULAR Accidental dental STAPLE BONE PLATE) All 0 0 - 21245 RECONSTRUCTION OF MANDIBLE OR MAXILLA, Accidental dental SUBPERIOSTEAL IMPLANT; PARTIAL All 0 0 - 21246 RECONSTRUCTION OF MANDIBLE OR MAXILLA, Accidental dental SUBPERIOSTEAL IMPLANT; COMPLETE All 0 0 - 21247 RECONSTRUCTION OF MANDIBULAR CONDYLE WITH BONE AND CARTILAGE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS) (EG, FOR HEMIFACIAL Accidental dental MICROSOMIA) All 0 0 - 21248 RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL IMPLANT (EG, BLADE, CYLINDER); Accidental dental PARTIAL All 0 0 - 21249 RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL IMPLANT (EG, BLADE, CYLINDER); Accidental dental COMPLETE All 0 0 - A0430 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (FIXED WING) Air Ambulance All 0 0 - A0431 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (ROTARY WING) Air Ambulance All 0 0 - Air Ambulance A0435 FIXED WING AIR MILEAGE, PER STATUTE MILE All 0 0 - Air Ambulance A0436 ROTARY WING AIR MILEAGE, PER STATUTE MILE All 0 0 - AMBULANCE SERVICE, NEONATAL TRANSPORT, BASE Air Ambulance A0225 RATE, EMERGENCY TRANSPORT, ONE WAY All 0 0 - NONCOVERED AMBULANCE MILEAGE, PER MILE (E.G., FOR MILES TRAVELED BEYOND CLOSEST Air Ambulance A0888 APPROPRIATE FACILITY) All 0 0 - 95004 PERCUTANEOUS TESTS (SCRATCH, PUNCTURE, PRICK) WITH ALLERGENIC EXTRACTS, IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT, SPECIFY NUMBER OF TESTS Allergy Testing All 0 0 - Allergy Testing 95012 NITRIC OXIDE EXPIRED GAS DETERMINATION All 0 0 - 95017 ALLERGY TESTING, ANY COMBINATION OF PERCUTANEOUS (SCRATCH, PUNCTURE, PRICK) AND INTRACUTANEOUS (INTRADERMAL), SEQUENTIAL AND INCREMENTAL, WITH VENOMS, IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT, SPECIFY NUMBER OF TESTS Allergy Testing All 0 0 - 95018 ALLERGY TESTING, ANY COMBINATION OF PERCUTANEOUS (SCRATCH, PUNCTURE, PRICK) AND INTRACUTANEOUS (INTRADERMAL), SEQUENTIAL AND INCREMENTAL, WITH DRUGS OR BIOLOGICALS, IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT, SPECIFY NUMBER OF Allergy Testing TESTS All 0 0 - 95024 INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC EXTRACTS, IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT, Allergy Testing SPECIFY NUMBER OF TESTS All 0 0 - Phoenix Choice 7878 N. 16th. St., Ste. 105 Effective 1/1/2016 Phoenix, Arizona 85020 Page 2 95027 INTRACUTANEOUS (INTRADERMAL) TESTS, SEQUENTIAL AND INCREMENTAL, WITH ALLERGENIC EXTRACTS FOR AIRBORNE ALLERGENS, IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT, SPECIFY NUMBER OF TESTS Allergy Testing All 0 0 - 95028 INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC EXTRACTS, DELAYED TYPE REACTION, INCLUDING READING, SPECIFY NUMBER OF TESTS Allergy Testing All 0 0 - 95044 PATCH OR APPLICATION TEST(S) (SPECIFY NUMBER Allergy Testing OF TESTS) All 0 0 - 95052 PHOTO PATCH TEST(S) (SPECIFY NUMBER OF TESTS) Allergy Testing All 0 0 - Allergy Testing 95056 PHOTO TESTS All 0 0 - Allergy Testing 95060 OPHTHALMIC MUCOUS MEMBRANE TESTS All 0 0 - Allergy Testing 95065 DIRECT NASAL MUCOUS MEMBRANE TEST All 0 0 - 95070 INHALATION BRONCHIAL CHALLENGE TESTING (NOT INCLUDING NECESSARY PULMONARY FUNCTION TESTS); WITH HISTAMINE, METHACHOLINE, OR Allergy Testing SIMILAR COMPOUNDS All 0 0 - 95071 INHALATION BRONCHIAL CHALLENGE TESTING (NOT INCLUDING NECESSARY PULMONARY FUNCTION TESTS); WITH ANTIGENS OR GASES, SPECIFY Allergy Testing All 0 0 - 95076 INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTION OF TEST ITEMS, EG, FOOD, DRUG OR OTHER SUBSTANCE); INITIAL 120 MINUTES Allergy Testing OF TESTING All 0 0 - 95079 INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTION OF TEST ITEMS, EG, FOOD, DRUG OR OTHER SUBSTANCE); EACH ADDITIONAL 60 MINUTES OF TESTING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Allergy Testing All 0 0 - 95115 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF Allergy Testing ALLERGENIC EXTRACTS; SINGLE INJECTION All 0 0 - 95117 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS Allergy Testing All 0 0 - 95120 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN THE OFFICE OR INSTITUTION OF THE PRESCRIBING PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING PROVISION OF ALLERGENIC EXTRACT; SINGLE Allergy Testing INJECTION All 0 0 - 95125 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN THE OFFICE OR INSTITUTION OF THE PRESCRIBING PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING PROVISION OF ALLERGENIC EXTRACT; 2 OR MORE Allergy Testing INJECTIONS All 0 0 - 95130 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN THE OFFICE OR INSTITUTION OF THE PRESCRIBING PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING PROVISION OF ALLERGENIC EXTRACT; SINGLE STINGING INSECT VENOM Allergy Testing All 0 0 - 95131 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN THE OFFICE OR INSTITUTION OF THE PRESCRIBING PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING PROVISION OF ALLERGENIC EXTRACT; 2 STINGING INSECT VENOMS Allergy Testing All 0 0 - Phoenix Choice 7878 N. 16th. St., Ste. 105 Effective 1/1/2016 Phoenix, Arizona 85020 Page 3 95132 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN THE OFFICE OR INSTITUTION OF THE PRESCRIBING PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING PROVISION OF ALLERGENIC EXTRACT; 3 STINGING INSECT VENOMS Allergy Testing All 0 0 - 95133 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN THE OFFICE OR INSTITUTION OF THE PRESCRIBING PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING PROVISION OF ALLERGENIC EXTRACT; 4 STINGING INSECT VENOMS Allergy Testing All 0 0 - 95134 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN THE OFFICE OR INSTITUTION OF THE PRESCRIBING PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING PROVISION OF ALLERGENIC EXTRACT; 5 STINGING INSECT VENOMS Allergy Testing All 0 0 - 95144 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS