General prior authorization requirements

Submit Maternal High Risk Assessment. Only one Medical/Pharmacy service may be requested per PA form. The member must be eligible and a member of ACA StandardHealth with Health Choice at the time the covered service is rendered. Authorizations are valid for 90 days from the date issued. All out-of-network providers/facilities require prior authorization for all services.

• Submit Maternal High Risk Assessment as part of PA submission.
• Limit one Medical/Pharmacy service request per PA form.
• Verify member eligibility at time of service.
• Authorizations expire 90 days from issue date.
• Out-of-network providers/facilities require PA for all services.

Prior authorization required for listed services and non‑par providers

Prior authorization is required for the services listed on this grid. Prior authorization is required for all non-participating (out-of-network) providers and hospitals for the listed services.

• Check the PA grid to determine whether a service requires authorization.
• Non-participating providers and hospitals must obtain PA for listed services.

Behavioral health residential PA submission and references

Behavioral health residential care requests must be submitted by fax to 480-760-4732. For PA forms and additional instructions, refer to the online grid and the ACA StandardHealth with Health Choice Provider Manual, Chapter 6: Authorizations and Notifications.

• Fax behavioral health residential care requests to 480-760-4732.
• See the PA grid online and Provider Manual Chapter 6 for authorization forms and details.

PA required for listed procedure codes (e.g., 157xx series)

Prior authorization is required for the specific CPT/procedure codes listed (examples include codes in the 157xx series) and applies to all non‑participating providers and hospitals.

• Review the grid for the full list of CPT/procedure codes requiring PA.
• Obtain PA for listed codes when services are provided by non‑participating providers/facilities.

Procedure codes requiring prior authorization

Prior authorization is required for the procedure codes shown on the grid (examples include 54150, 54160–54164) and is required for all non‑participating providers and hospitals.

• Obtain PA for the listed procedure CPTs before rendering services.
• Non‑participating providers and hospitals must secure PA for these codes.

DME and diabetic supplies: prior authorization and $500 threshold

Durable medical equipment (DME) and diabetic supplies listed (multiple HCPCS/K/E codes such as E0265, E0300, E0460, E0642 and many E/K codes) require prior authorization. Any single DME item with billed charges over $500 requires prior authorization.

• PA required for listed DME/diabetic supply HCPCS and K/E codes on the grid.
• If billed charges for a single DME item exceed $500, submit a PA request.

Specialty and procedure categories requiring PA

The grid includes multiple specialty and procedure categories (Advanced Imaging & Cardiac Imaging, Bariatric Surgery, Behavioral Health, etc.) with associated codes that require prior authorization.

• Refer to the grid sections for Advanced Imaging, Cardiac Imaging, Bariatric Surgery, Behavioral Health and other specialty areas for specific PA code requirements.
• Obtain PA for services in these specialty categories when codes are listed.

Bone growth stimulator HCPCS codes require PA

Prior authorization is required for listed bone growth stimulator HCPCS codes (examples include K1007, K1009, K1015, K0880, A4638, K0885). PA also applies to all non‑participating providers and hospitals.

• Submit PA for bone growth stimulator HCPCS codes shown on the grid.
• Non‑participating providers/facilities must obtain PA for these items.

DME code A9276 and imaging PA provisions; $500 DME rule

PA is required for DME code A9276 and for the listed imaging/procedure codes; additionally, any single DME item with billed charges over $500 triggers a PA requirement.

• Submit PA for A9276 when applicable.
• DME items billed over $500 require prior authorization.

EEG and related neurology codes require PA

Prior authorization is required for neurology EEG testing and related CPT/HCPCS entries (including codes in the 9572x–9572x series). PA is required for the listed EEG codes and associated services.

• Obtain PA for EEG CPT/HCPCS codes listed (e.g., 95721–95726).
• PA is required for listed codes and for services referenced in these entries.

Pain management procedures and injections require PA

A broad set of pain management CPT codes require prior authorization, including injection, infusion and spinal procedure codes (examples: 20552, 20553, 27096, 62320–62327 and related CPTs). This includes initial/new consults, neurotomies, injections, infusions, blocks, pumps/implants and acupuncture.

• Submit PA for the pain management CPTs listed prior to providing services.
• PA covers a wide range of interventional pain procedures and related services as specified.

Prosthetics/Orthotics L‑codes require prior authorization

An extensive set of prosthetics and orthotics L‑codes require prior authorization (sample listed codes include L0112, L0170, L0220, L0456, L0480, L0624, L0638, L1000, L1085, L1250, L1710, etc.). PA is required for the listed L‑codes.

• Refer to the prosthetics/orthotics L‑code lists in the grid and submit PA for those L‑codes.
• Check the grid for the full list of L‑codes requiring authorization.

Place of service and network status PA rules

Prior authorization rules apply by place of service: services at Outpatient Hospital (POS 22) and Ambulatory Surgery Center (POS 24) require PA when listed, and PA is required for out‑of‑network/non‑participating providers and facilities; emergency services are excluded.

• Confirm place of service; obtain PA for listed services at POS 22 and POS 24 when required.
• Out‑of‑network/non‑participating providers and facilities must obtain PA for listed services; emergency services are excluded from PA requirements.

General PA requirement for listed services and non‑par providers

Prior Authorization is required for the services and codes listed throughout this grid; prior authorization is also required for all non‑participating providers and hospitals for these services.

• Check the PA grid to confirm whether a service or code requires authorization.
• Non‑participating providers and hospitals must obtain PA for listed items.

Prosthetics/Orthotics services require PA

Prosthetics and orthotics services identified by multiple L‑code groups require prior authorization as indicated throughout the grid.

• Submit PA for prosthetics/orthotics L‑codes listed in the grid.
• Refer to the prosthetics/orthotics sections for specific L‑code groupings.

Specific prosthetics/orthotics L‑codes require PA

Prior authorization is required for the prosthetics/orthotics L‑codes listed in the grid (examples include L5984, L3230, L3250, L3251, L3252, L3253, L3265, L6020, L6055).

• Obtain PA for the specific L‑codes shown before ordering or furnishing devices.
• Verify authorization requirements for non‑participating providers/facilities.

Additional prosthetics/orthotics L‑codes require PA

Additional prosthetics/orthotics L‑codes and related device codes (examples include L8046, L8047, L8609, L8610, L8612, L8613, L8659, L8627, 69728) require prior authorization as listed.

• Submit PA requests for the additional L‑codes and related codes indicated on the grid.
• Check the grid for any provider/facility applicability notes.

Rehabilitation therapies and cardiac/pulmonary rehab require PA (60‑visit limit)

Cardiac and pulmonary rehabilitation and other rehabilitation therapy CPT/HCPCS codes require prior authorization; a 60 rehabilitative visit limit per year applies to cardiac & pulmonary rehab.

• Obtain PA for cardiac & pulmonary rehab and listed rehabilitation therapy CPT/HCPCS codes.
• Note the 60‑visit per year limit for cardiac & pulmonary rehabilitation.

Routine office‑based procedures require PA

Routine office‑based procedures listed (examples: 97167, 97168, G0237, G0238, G0422–G0424, S9152) require prior authorization as shown on the grid.

• Submit PA for the routine office‑based procedure CPT/HCPCS codes listed on the grid.
• If a code is not listed on the grid, it does not require authorization unless otherwise specified.

PA for routine office procedures and prosthetics/orthotics

Prior authorization is required for the routine office‑based procedure codes and for the listed prosthetics/orthotics codes when shown together on the grid; PA is required for all non‑participating providers and hospitals.

• When routine office procedures and prosthetics/orthotics L‑codes are listed, secure PA for both as applicable.
• Non‑participating providers/facilities must obtain PA for these listed items.

PA provisions for routine office‑based procedure codes

PA is required for the listed routine office‑based procedure codes; codes not listed on the grid do not require authorization unless otherwise specified in the grid provisions.

• Do not assume authorization is required for codes not present on the PA grid.
• Follow the grid provisions for exceptions and specifics.

Skin substitutes (Q4100–Q4303) require PA

Prior authorization is required for all skin substitute services; PA applies to the listed Q‑codes in the Q4100–Q4303 range.

• Submit PA for skin substitute products coded Q4100 through Q4303.
• PA is required for all skin substitute services listed.

Inpatient admissions require PA and facility notifications

All non‑emergency inpatient admissions (acute, rehabilitation, LTAC, SNF, hospice, observation) require prior authorization. Facilities must notify HCS and fax inpatient notifications to 480-760-4732. For emergency admissions used to evaluate and stabilize, the plan must be notified within 1 calendar day.

• Fax inpatient notifications to 480-760-4732 to notify HCS of admissions.
• For emergency stabilization admissions, notify the plan within one calendar day.

High‑tech imaging and select procedures require PA

High‑tech imaging and select procedures (MRI, MRA, CT, PET, certain ultrasounds, nuclear cardiac stress testing, echocardiography TEE/TTE, cardiac catheterizations, venous ablation) require prior authorization; some services may be considered experimental, investigational, or unproven.

• Obtain PA for high‑tech radiology services and the listed imaging/procedure CPTs.
• Be aware that certain services may be considered EIU and subject to additional review.

All grid codes require PA — use StandardHealth resources

All codes listed on the PA grid require prior authorization from ACA StandardHealth with Health Choice. Visit the StandardHealth website for the PA medical request form and additional PA information.

• Use https://www.standardhealthhc.com to access the PA medical request form and PA guidance.
• Ensure PA is obtained for any code shown on the grid prior to service delivery as required.

Specialty medication PA submission and billing requirements

Provider‑administered specialty medications must have a complete Medical PA request form submitted with supporting documentation to fax 1-877-422-8120. Provider‑administered specialty medications must be billed as a medical claim.

• Submit the complete Medical PA request form and supporting documentation to fax: 1-877-422-8120.
• Bill provider‑administered specialty medications as medical claims after PA is obtained.

Specialty medication code listings for PA and billing

The document contains a reference list of specialty medications and associated HCPCS/J‑ and Q‑codes to be used for authorization and claims processing; consult the list for the exact billing codes required when submitting PAs.

• Use the specialty medication code lists (J‑ and Q‑codes) in the grid when preparing PA submissions and claims.
• Ensure the correct HCPCS/J/Q code is included on the PA request for provider‑administered medications.

Specialty medication code reference (partial)

This section provides a partial reference list of specialty medications and their HCPCS/J‑ and Q‑codes for authorization and billing workflows; use these codes when submitting medical PA requests for specialty agents.

• Refer to the listed J‑ and Q‑codes (e.g., J9299, J9999, J2326) when preparing PA requests for specialty medications.
• Confirm PA and billing requirements per the grid and Provider Manual.