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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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"PCHP Precert List
...Effective 08/01/08"

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    1-888-672-2277
  • KIDSfirst Member Services
    1-888-814-2352
  • CHIP Perinate
    1-888-814-2352
  • CHIP Perinate Newborn
    1-888-814-2352
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red Synagis® Procedure Update

TEXAS MEDICAID VENDOR DRUG PROGRAM
SYNAGIS® (PALIVIZUMAB) PRIOR AUTHORIZATION REQUEST & PRESCRIPTION FORM pdf .PDF