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Parkland
Community Health Plans, Inc
Medicaid
Prior-Authorization List for Participating Providers
Effective
August 1, 2008
Parkland Medicaid
Prior-Authorization list for participating
providers for 2008:
Applies
to: Parkland HEALTHfirst, KIDSfirst, CHIP Perinate and CHIP Perinate Newborn
The August
1, 2008 Prior-Authorization list supersedes all Prior-Authorization lists
ALL
TEXAS
REFERRAL/AUTHORIZATION FORMS MUST BE SIGNED BY
THE PCP OR ORDERING PHYSICIAN
THAT HAS A VALID REFERRAL FROM THE PCP.
PROCEDURE DESCRIPTION |
PROCEDURE CODES |
Inpatients |
|
Hospitalizations/inpatient
admissions
- All elective admissions to a facility including
acute, skilled, hospice, rehabilitation and partial hospitalization for
any medical, surgical, obstetrical, or behavioral health condition.
- All inpatient facility to facility transfers – The transferring facility is
responsible for obtaining pre-certification prior to the transfer to the
new facility
- All non-elective admission notification is
required. Please submit clinical
information for medical necessity for admission and level of care within
two business days of the admission date.
|
|
In-office Specialty
Care Referrals |
|
Any
non-urgent referral for out of network specialists office visits, regardless
of specialty |
|
Any
Provider other than the member’s PCP of record on the date of service |
|
All
Dermatology services |
10040 -
19499 Surgery Skin
30620
Septal/intranasal dermatoplasty
36400 -
36550 Surgery (Venous)
85007 -
85048 hematology and coagulation
99201 -
99215 Office and other outpatient service 99241 - 99245 Office and other
outpatient consultations |
Podiatry
(except for services related to diabetic foot care – Diabetes must be primary
diagnoses) |
All
Related Codes Except for services related to diabetes 250.x |
All
Neuropsych evaluations |
|
Obstetrical
and Perinatology - Notification required after the first visit to ensure
member is screened for
OB case management |
|
Diagnostic Testing |
|
Genetic
testing for those over the age of 1 year |
83890 -
84999 Pathology and Lab/Chemistry, 86805 - 86849 Tissue Typing
88230 -
88299 Cytogenic Studies
99201 -
99215 Office and other outpatient services, 99241 - 99245 Office and other
outpatient consultations
S3820, S3822, S3823 Brach Genetic Testing |
Ambulance |
|
Non-emergent Ambulance
Transportation – Air or Ground |
|
Home Health Care |
|
Skilled
Nursing |
|
Rehabilitation/Physical,
Occupational, Speech therapy |
|
Private
Duty Nursing |
|
Infusion
Therapy |
|
Home
Health Aide/ Personal Care Assistant |
|
Medical Injectables – In office,
outpatient setting, or home (including but not limited to): |
|
Growth
Hormone |
J2170,
J2940, J2941, Q0515, S9558, 83003, |
IVIG |
J1561,
J1562, J1566, J1567, J1568, J1569, J1572
90281,
90283, 90284, 90399 |
Synagis® |
C9003; J1565; S9562, 90378; 90379; |
Remicade |
|
17 Alpha
Hydrozyprogesterone Caproate (17P) |
|
Pain
management – intrathecal, epidural, trigger point injections, facet
injections, joint injections, etc. |
|
Intrathecal
Baclofen Pump |
|
Transplants |
|
All
transplant work-ups and procedures |
|
Outpatient Rehabilitation/Habilitatation/Therapies
– excluding initial evaluation |
|
Physical
Therapy |
|
Occupational
Therapy |
|
Speech
Therapy |
|
Respiratory
Therapy |
|
Outpatient Procedures |
|
Removal
of premalignant, malignant lesions |
11600-11646 |
Dental/Oral Maxillofacial/Craniofacial |
|
General dental anesthesia |
|
Orthognathic surgery procedures/osteotomies |
21120, 21121, 21122, 21123, 21125,
21127, 21141, 21142, 21143, 21145, 21146, 21147,
21150, 21151, 21154, 21159, 21193, 21194, 21195, 21196,
21198, 21199, 21206, 21208, 21209, 21210, 21215
D codes:
D7940,D7941, D7943, D7944, D7945, D7946, D7947, D7948,
D7949, D7950, D7995, D7996 |
TMJ |
|
Cosmetic Procedures (including but not limited to): |
|
Reconstructive
repairs, injection of filling material (including collagen) |
11950,
11951, 11952, 11954 |
Excision
of skin |
15831-15839 |
Removal
of Benign lesion |
11400-11446 |
Otoplasty |
69300,
69399 |
Breast
Reconstruction |
19350,
19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380,
19396, S2066, S2067, S2068 |
Reconstructive
repair of pectus excavatum or carinatum |
21740,
21742, 21743 |
Reduction
Mammoplasty/Gynecomastia |
19316,
19318, 19324, 19325, 19328, 19330, 19340, 19342 |
Lipectomy |
15876,
15877, 15878, 15879 |
Venous
Ligation |
36475,
36476, 36478, 36479, 37204, 37700, 37718, 37722, 37735, 37760, 37765, 37766, 37780, 37785,
75894 |
Sclerotherapy |
36468,
36469, 36470, 36471 |
Rhinoplasty |
30120,
30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30620 |
Blepharoplasty |
15820,
15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906,
67908, 67916, 67917, 67923, 67924, 67950 |
Canthopexy |
21282 |
Canthoplasty |
67950 |
Cervicoplasty |
15819 |
Rhytidectomy |
15824,
15825, 15826,15828, 15829 |
Gastroplasty/gastric
bypass |
43631,
43632, 43633, 43634, 43644, 43645,
43659, 43770, 43771, 43772, 43773, 43774, 43842,
43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999, 49999 |
Uvulopalatopharyngoplasty
(UP3 or LAUP) |
42145,
42140, 42299 |
Circumcision
in children over 1 year of age |
54152,
54161 |
Abortion |
59840-59857,
59866 |
Durable Medical Equipment,
Supplies, Prosthetics, Orthotics |
|
All
requests where the total amount of the request is greater than $1,000 (including
but not limited to): |
|
Hospital
Beds |
|
Electric
Scooter |
|
Customized
Braces/Orthotics |
|
Upper
Limb Prosthetics |
|
Lower
Limb Prosthetics |
|
Wheelchairs |
|
Cranial
Molding Helmets |
|
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