CurrentAspirus ArisePolicy N/A

Authorization and Notification Requirements

Defines prior authorization and notification requirements for inpatient and outpatient services for Aspirus Health Plan providers, including codes, timing, forms, and contact information.

Policy Summary

PayerAspirus Arise

PolicyAuthorization and Notification Requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization or submit required notification with supporting clinical documentation before the service to avoid denial of claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14 daysallowable time for non-urgent authorization decision

24 hoursrequired notification timeframe for inpatient admissions

72 hoursdischarge summary submission timeframe

InterQualmedical necessity criteria source named

Medicare NCD/LCDcoverage determination sources referenced

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Medical Necessity Criteria Source

Services covered when medical necessity is met per referenced criteria sources

InterQual/Medicare-based Criteria: Appropriate subset of InterQual criteria or the applicable Medicare NCD/LCD must be met based on the requested procedure or item

Examples: InterQual LOC Rehabilitation; InterQual Medicare Procedures; InterQual Medicare Durable Medical Equipment; InterQual Molecular Diagnostics; Medicare NCD/LCD will be chosen based on requested service

Authorization is not required for breast reconstruction associated with breast cancer. This is listed under the policy's authorization exceptions for cosmetic/reconstructive surgeries; providers do not need to request prior authorization for those breast reconstruction procedures when they are associated with breast cancer.

Codes and Code Groups Requiring Authorization

Back (Spine) Surgery CodesCPTCovered

22533
22534
22558
22585
22586
22612
22614
22630
22632
22633

1–10 of 21

1/3

Bariatric Surgery CodesCPTCovered

43644
43645
43770
43773
43775
43842
43845
43846
43847
43848

Durable Medical Equipment (DME) CodesHCPCSCovered

E0483	High Frequency Chest Wall Oscillation System
E0652	Pneumatic Compression Device
E0748	Osteogenesis stimulator, electrical, non-invasive, spinal applications
E0749	Osteogenesis stimulator, electrical, surgically implanted
E0764	Functional Neuromuscular Stimulator (rental only item)
E0766	Electrical Stimulation Device

Genetic/Molecular Diagnostic CodesCPTCovered

0037U
81162
81163
81164
81165
81166
81167
81210
81212
81215

1–10 of 51

1/6

Cranial Nerve Stimulation CodesCPTCovered

64553
64568
64569
64582

Spinal Cord Stimulation CodesCPTCovered

63650
63655
63663
63664
63685

TMS and Vein Procedure CodesCPTCovered

90867
90868
90869
36465
36466
36468
36470
36471
36473
36474

1–10 of 18

1/2

Wheelchair Accessories HCPCS CodesHCPCSCovered

E0986
E1002
E1003
E1004
E1005
E1006
E1007
E1008
E1009
E1010

1–10 of 31

1/4

Wheelchair Rental Codes (K-codes)HCPCSCovered

K0800
K0801
K0802
K0806
K0807
K0808
K0812
K0813
K0814
K0815

1–10 of 51

1/6

Cosmetic Procedure CodesCPTCovered

11960
15780
15781
15782
15783
15786
15787
15830
15832
15833

1–10 of 74

1/8

Wheelchair rental authorization duration

Authorization duration for wheelchair rentalsAll months must be authorized.

Authority to determine rental vs. purchaseAspirus Health Plan or its authorizing delegate reserves the right to determine rental vs. purchase.

Codes requiring authorization (rental)K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0890, K0891

Codes requiring authorization (purchase)K0005 - K0007, E1161, all power-operated vehicles and power wheelchairs

Prior Authorization, Notification, and Documentation Requirements

Denial Risk

Failure to obtain authorization

Failure to obtain prior authorization for services that require it may result in a denied claim. Providers are responsible for verifying member eligibility and benefit coverage prior to rendering services and obtaining any required prior authorization or network exception in advance.

Allow up to 14 calendar days for non-urgent authorization decisions.
All services are subject to member eligibility and benefit coverage.
If you are not able to obtain services in your network, you may submit a network exception request prior to services.
Providers may request a copy of the criteria used to make a medical necessity determination on Aspirus Health Plan's Authorization page.

Documentation Required

Submission and discharge documentation

Submit the appropriate prior authorization or notification request form with supporting clinical documentation by fax or e‑mail per instructions on the form. For inpatient notifications, notify within 24 hours of admission where required and send a discharge summary within 72 hours of discharge. Concurrent review may be required for additional inpatient days.

Notification for acute inpatient, mental health, and substance use disorder admissions: within 24 hours of admission; fax acute inpatient medical admissions to 715.787.7316; fax inpatient mental health and substance use disorder admissions to 715.787.7314.
Discharge summary required within 72 hours of discharge.
Aspirus Health Plan requires concurrent review for additional inpatient rehabilitation days.

Prior Authorization

Drug prior authorization and formulary note

Certain medical injectable drugs require prior authorization per the Medical Drug Policy library. Drugs covered under the pharmacy benefit are listed on the formulary available on the Formulary page. Refer to the Medical Drug Policy and formulary for prior authorization requirements and coverage details before ordering or administering medical injectable drugs.

Medical Drug Policy library lists injectable drugs requiring prior authorization.
Formulary indicates drugs covered under the pharmacy benefit and is available on the Formulary page.

Background and References

This policy uses established external medical-necessity sources to determine coverage. Medical necessity determinations for procedures, durable medical equipment, and diagnostics will follow InterQual criteria (appropriate InterQual subset selected for the requested service) and applicable Medicare National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). Providers should supply documentation that aligns with those referenced criteria when submitting authorization requests.