Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAmeriHealth LA Unlisted Prior Auth | OpenPayer
    Ask Trek AI about this page
    CurrentAmeriHealth Caritas LouisianaPolicy RPC.0115.2100

    Unlisted Procedures

    Customize your policy alerts

    Sign up for amerihealthcaritaslouisiana Policy RPC.0115.2100 alerts

    Get alerted when Policy RPC.0115.2100 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy governs reimbursement for services submitted with unlisted CPT or HCPCS codes by providers billing AmeriHealth Caritas Louisiana on CMS-1500 or UB-04 forms, or their electronic equivalents. It establishes prior authorization, documentation, code-selection, and payment requirements for unlisted procedures.

    Policy Summary
    PayerAmeriHealth Caritas Louisiana
    PolicyUnlisted Procedures
    Policy CodePolicy RPC.0115.2100
    Change TypeAdministrative updateno material clinical or coverage change
    Effective DateN/A
    Last ReviewJan 1, 2025
    Next Review DateDec 1, 202639d
    Key ActionObtain prior authorization before submitting an unlisted procedure code for reimbursement.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    RequiredAuthorization requirement for unlisted procedure codes
    RequiredClaim-submission documentation requirement
    Non-OPPSPayment methodology for unlisted procedures
    No existing codeUse an unlisted code only when no existing code describes the service

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Coverage and Reimbursement Criteria

    Coverage and reimbursement criteria for unlisted procedures

    Unlisted procedure codes are covered when ALL of the following requirements are met:

    ALL of the following

    • Prior authorization is obtained before submitting the unlisted procedure code for reimbursement.
    • Supporting documentation is submitted with the claim and describes the nature, extent, and need for the procedure or service, including the provider's time, effort, and equipment necessary to provide it.
    • No other HCPCS or CPT code exists to accurately reflect the procedure or service submitted for reimbursement.

    Unlisted CPT and HCPCS Codes

    Unlisted CPT and HCPCS procedure codesmixed
    No codes listed

    Provider Billing Requirements

    Prior Authorization

    Obtain prior authorization before billing

    Obtain prior authorization before submitting an unlisted procedure code for reimbursement. Unlisted procedure codes are covered subject to prior authorization and appropriate supporting documentation.

    Documentation Required

    Include supporting documentation with the claim

    Submit supporting documentation with any claim that includes an unlisted procedure code. The documentation must include a definition or description of the nature, extent, and need for the procedure or service, as well as the provider’s time, effort, and equipment necessary to provide the service.

    Unlisted Procedure Code

    Unlisted Procedure Code
    DefinitionAn unlisted procedure CPT code is used when no specific code accurately describes a service or procedure.
    Common useUnlisted codes are often used for new technologies or services that have not yet been approved by the FDA.
    Policy Summary
    PayerAmeriHealth Caritas Louisiana
    PolicyUnlisted Procedures
    Policy CodePolicy RPC.0115.2100
    Change TypeAdministrative updateno material clinical or coverage change
    Effective DateN/A
    Last ReviewJan 1, 2025
    Next Review DateDec 1, 202639d
    Key ActionObtain prior authorization before submitting an unlisted procedure code for reimbursement.
    SourceLink
    On This Page
    Coverage and Reimbursement CriteriaUnlisted CPT and HCPCS CodesProvider Billing RequirementsUnlisted Procedure Code
    Billing Rule

    Use an unlisted code only when no existing code applies

    Use an unlisted procedure code only when no other HCPCS/CPT code exists to reflect the procedure or service being submitted for reimbursement. Selecting an unlisted code when an existing code accurately represents the service may create a reimbursement risk.