bmchp.org | 888-566-0008 BMCHP Prior Authorization HCPCS Code Look-up Tool TO FIND A CODE OR WORD - While holding The Plan requires prior authorization for ALL inpatient services. down the CTRL key, press Many outpatient Medical Services require prior authorization. the F key, type in Code, then press ENTER key ALL services rendered by Out of Network providers require prior authorization with limited exceptions. For Pharmacy inquiries please see the Pharmacy section on BMCHP.org For Behavioral Health, DME, Radiology and Transportation providers, please see our Prior Authorization/Notification Requirements Matrix for authorization details and how to work with our vendors. Please refer to the Provider Manual Section 8: Utilization Management and Prior Authorization for information regarding authorizations. This is not a comprehensive list of every code available. Code updates occur periodically and may be implemented at different intervals than the updates to this code tool. This code tool is only provided as a guide for authorization status and addition or omission of a code does not guarantee payment: 1. This tool cannot confirm member eligibility. 2. This tool cannot confirm member benefits/coverage. Please refer to the Member’s Benefit Documents. 3. This tool cannot confirm payment rules, edits, fee schedules and restrictions that may affect code/claim payment even if authorization is obtained. The plan applies standard industry billing and coding rules to claims. Please refer to the Plan Payment Policies. 4. This code tool cannot confirm provider contract terms. Please reach out to your provider representative. Prior authorization or Plan notification is required for services listed in the Prior Authorization/Notification Requirements Matrix even if a specific code is not listed in the code look-up tool. Please contact the BMCHP Prior Authorization Team at 888-566-0008 and Press 3 for questions related to authorization requirements for codes that may or may not be listed in this tool. Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 1 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies PA REQUIRED for any HCPCS code used w/TMJ DX Codes M26.60-69 UPDATED 9/17/2021 Please review carefully for changes Please review all disclaimers and information on the first page of this code look-up tool before and/or after your code search A0021 AMB SRVC OTSD STATE-MILE TRANSPORT MH QHP SCO Yes No No Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21) A0080 NONEMERG TRNSPRT VOLUN NOT VESTED MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21) A0100 NONEMERGENCY TRANSPORTATION; TAXI MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes No Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21) A0110 NONEMERG TRNSPRT&BUS INTERSTATE MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes No Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21) A0120 NONEMERG TRNSPRT: MINI-BUS MTN/OTH MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes No Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21) A0130 NONEMERG TRNSPRT: WHEELCHAIR VAN MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes No Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21) A0140 NONEMERG TRNSPRT & AIR TRAVEL MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix. A0160 NONEMERGENCY TRANSPORTATIONI MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix. Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 2 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies PA REQUIRED for any HCPCS code used w/TMJ DX Codes M26.60-69 UPDATED 9/17/2021 Please review carefully for changes Please review all disclaimers and information on the first page of this code look-up tool before and/or after your code search A0170 TRNSPRT ANCILLRY: PARK FEE TOLL OTH MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes No Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21) A0180 NONEMERGENCY TRANSPORTATION MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix. A0190 NONEMERGENCY TRANSPORTATION MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix. A0200 NONEMERG TRNSPRT MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix. A0210 NONEMERG TRNSPRT MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix. A0380 BLS MILEAGE MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix. A0382 BLS ROUTINE DISPOSABLE SUPPLIES MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix. A0384 BLS SPCLIZED SRVC DISPBL SPL; DEFIB MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix. A0420 AMB WAITING TIME 1/2 HR INCREMENTS MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix. A0422 AMB OXYGEN&O2 SPL LIFE SUSTAINING MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix. A0425 GROUND MILEAGE PER STATUTE MILE MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix. Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 3 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies PA REQUIRED for any HCPCS code used w/TMJ DX Codes M26.60-69 UPDATED 9/17/2021 Please review carefully for changes Please review all disclaimers and information on the first page of this code look-up tool before and/or after your code search A0426 AMB SRVC ALS NONEMERG TRNSPRT LVL 1 MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21) A0428 AMB SERVICE BLS NONEMERG TRANSPORT MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21) A0433 ADVANCED LIFE SUPPORT LEVEL 2 MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21) A0434 SPECIALTY CARE TRANSPORT MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21) A0435 SPECIALTY CARE TRANSPORT MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix. A0436 SPECIALTY CARE TRANSPORT MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix. A0998 AMBULANCE RSPN&TREATMENT NO MH QHP SCO TRNSPRT Yes Yes No Policy: Ambulance and Transportation Services Ambulance