Prior authorization / recommended clinical review

Highlighted procedure/services in this code group may require prior authorization per contract agreement; many listed codes are designated MP Criteria and should be submitted for Recommended Clinical Review to avoid post-service review.

• Obtain prior authorization when required by the member's contract for codes in this group.
• Submit for Recommended Clinical Review (predetermination) for MP Criteria-coded services to avoid post-service review.

Unlisted codes — prior authorization may be required

Unlisted procedure codes may require prior authorization per contract agreement; submit prior authorization when applicable to avoid post-service review or claim denial.

• Codes flagged 'Unlisted' (e.g., 15999, 17999, 19499, 20999) may be subject to contract/clinical review.
• When the entry notes 'Prior Authorization may be required per contract agreement,' obtain PA before service.

Prior authorization may be required for unlisted/flagged procedures

Prior authorization may be required per contract agreement for unlisted procedures or those flagged as subject to contract/clinical review; obtain PA when the code entry indicates this requirement.

• For unlisted entries, include supporting documentation and request PA per the member's contract.
• Failure to obtain required PA may result in post-service review or denial.

PA may be required for EIU/unlisted entries when noted

Certain entries identify codes as EIU (not reimbursed) or Unlisted and note that prior authorization may be required per contract; when the entry states PA may be required, providers should obtain authorization prior to service.

• Codes labeled EIU are not reimbursed and not subject to pre-service review, but Unlisted codes with PA notes require pre-service authorization per contract.
• Check the code-specific line for the 'Prior Authorization may be required per contract agreement' phrase and secure PA accordingly.

Prior authorization: unlisted procedures

Unlisted procedures may require prior authorization per contract and are flagged for potential clinical or contract review; submit PA requests with supporting documentation when indicated.

• Unlisted cardiac, vascular, or other system procedure codes (e.g., 33999, 36299, 37799) include ‘‘Prior Authorization may be required per contract agreement.’’
• Include detailed operative reports and justification with PA for unlisted codes.

Prior authorization may be required for unlisted codes

Unlisted procedure codes may require prior authorization per contract agreement; submit prior authorization when applicable to avoid post-service review or denial.

• Examples of unlisted codes that note possible PA: 37799, 38129, 38589, 40799, 40899.
• Providers should check contract-specific PA rules and submit required documentation.

Prior authorization for unlisted codes

Prior authorization may be required for unlisted procedures or codes flagged as 'Unlisted' or subject to contract/clinical review; obtain PA per the member's contract when the code entry indicates it.

• Codes such as 38589, 40799, 40899 and several other unlisted CPTs state PA may be required per contract.
• Submit supporting clinical documentation with PA requests for unlisted codes.

Prior authorization for unlisted procedure codes

Unlisted procedure codes may require prior authorization per contract; submit for clinical review when indicated to avoid post-service review or claim denial.

• Examples: 47399, 47579, 48999, 49329, 49659, 49999, 51999, 53899 are labeled Unlisted and note PA may be required.
• Include detailed operative reports, indications, and justification when requesting PA for unlisted codes.

PA may be required for unlisted/unclassified services

Prior authorization may be required per contract agreement for unlisted procedures and some unclassified services; submit requests for clinical review and PA where noted.

• Some unlisted or unclassified services (examples given in the document) state 'Prior Authorization may be required per contract agreement.'
• Providers should verify member-specific contract requirements and obtain PA before service when applicable.

Recommended clinical review (pre-service) for MP Criteria codes

Submit MP Criteria-coded procedures for Recommended Clinical Review (pre-service/predetermination) to avoid post-service review; many codes in this list are labeled 'MP Criteria' and require recommended clinical review.

• Obtain Recommended Clinical Review for MP Criteria entries prior to service when feasible to reduce risk of retrospective denial.
• Examples include many cardiac, transplant, device, and neurostimulator procedure codes listed as MP Criteria.

Prior Authorization: unlisted and MP Criteria codes

Prior Authorization may be required for unlisted codes and services marked 'Unlisted'; services labeled MP Criteria should be submitted for Recommended Clinical Review to avoid post-service review.

• Unlisted therapeutic radiology and related unlisted codes (e.g., 77299, 77399, 77499) note PA may be required per contract.
• Submit MP Criteria services for Recommended Clinical Review where indicated.

Prior authorization may be required for Unlisted codes

Certain unlisted procedure codes are designated 'Unlisted' and note that prior authorization may be required per contract agreement; providers should obtain prior authorization where contractually required.

• Examples: 81599, 84999, 85999, 86486, 86849, 87799, 87899, 87999, 88299 are labeled Unlisted and may require PA.
• Provide clinical justification and operative details when requesting PA for these unlisted laboratory or assay procedures.

Prior Authorization may be required for listed unlisted codes

Certain unlisted procedure codes may require prior authorization or contract/clinical review per contract agreement; obtain PA when indicated.

• Unlisted codes such as 89398, 90399, 91299, 92499 carry 'Prior Authorization may be required' language.
• Confirm member contract and submit PA with supporting documentation for unlisted codes.

Prior authorization for unlisted cardiovascular & vascular diagnostic codes

Unlisted cardiovascular and unlisted noninvasive vascular diagnostic study codes may require prior authorization per contract agreement; submit prior authorization when indicated.

• Examples: 93799, 93998, 94014 are noted as Unlisted and may require PA.
• Obtain PA and provide procedure details for unlisted cardiovascular/vascular diagnostic studies.

Submit for Recommended Clinical Review (Predetermination)

Submit for Recommended Clinical Review (Predetermination) to avoid post-service review for procedures/services reviewed against Medical Policy Criteria.

• MP Criteria-designated procedures should be submitted for recommended clinical review prior to service when feasible.
• Predetermination reduces the risk of post-service denials.

Denial triggers from code group labels

Services listed as 'Not a benefit,' 'Non Covered,' or designated EIU may trigger claim denial if billed; verify coverage and do not expect pre-service review to change EIU or Non Covered status.

• EIU-labeled procedures are not reimbursed by the Plan and are not subject to pre-service review.
• Non Covered services are not covered by the Plan and are not subject to pre-service review; billing these may be denied.

EIU (excluded from reimbursement)

Procedures designated EIU are not reimbursed by the Plan; submission for pre-service review is not applicable and claims may be denied for reimbursement.

• Examples in the list show EIU entries (e.g., 20560, 20561, 20985) with the note 'Procedure/service not reimbursed by the Plan. Not subject to pre-service review.'
• Do not expect PA to authorize EIU-designated services for payment.

EIU-designated non-reimbursed services

Procedures labeled EIU: 'Procedure/service not reimbursed by the Plan' are not reimbursed and therefore would be denied if billed to the Plan.

• Examples: 22526, 22586, 22837, 22838, 22867 are flagged EIU and will not be reimbursed.
• EIU items are not subject to pre-service authorization to obtain reimbursement.

MP Criteria — recommended clinical review

Procedures marked 'MP Criteria' are reviewed against Medical Policy Criteria; submit for Recommended Clinical Review to avoid post-service review and potential denial.

• MP Criteria entries require supporting clinical documentation aligned with the referenced Medical Policy Criteria.
• Failure to submit recommended clinical review may result in retrospective review and denial.

EIU (Excluded/Not reimbursed) triggers denial risk

Codes designated EIU are not reimbursed by the Plan and therefore may trigger denial if billed for reimbursement.

• EIU designation indicates non-reimbursement; check the EIU/CPCP policy but plan will not pay for EIU services.
• Providers should not expect pre-service review to overturn EIU status for payment.

Unlisted codes may trigger review/denial

Unlisted procedure codes may be subject to contract/clinical review and prior authorization per contract; lacking required review/authorization may result in denial or post-service adjustments.

• Examples include many unlisted CPTs across specialties; check the code line for PA language.
• Provide thorough documentation and obtain PA when required to reduce denial risk.

Unlisted codes may trigger review/denial risk

Unlisted procedure/service not specifically defined or classified may be subject to contract/clinical review; prior authorization may be required per contract agreement and may be necessary to avoid denial.

• Services coded with unlisted procedure codes may be denied without appropriate review/authorization.
• Submit PA and detailed clinical documentation for unlisted procedures when the code entry indicates PA may be required.

EIU (Excluded/Investigational/Unreimbursed) codes

Codes designated EIU (e.g., select lab and diagnostic tests) are labeled 'Procedure/service not reimbursed by the Plan' and therefore are subject to denial if billed.

• Examples: 83695, 83698, 83701 and other EIU laboratory codes are not reimbursed.
• Do not submit PA to request payment for EIU-designated services; these are excluded by policy.