Provider responsibilities: verify PA, eligibility and benefits

Ordering/prescribing provider is responsible to determine which specific codes require prior authorization; verify eligibility and benefits prior to rendering services. Payment is contingent on member eligibility at time of service; non‑participating providers must submit prior authorization for most services. For the complete CPT/HCPCS listing, use the Ambetter Online Prior Authorization Tool.

• Determine which codes require prior authorization before scheduling.
• Verify member eligibility and benefits prior to rendering services.
• Non‑participating providers must submit PA for most services.
• Reference full code listing on the Ambetter Online Prior Authorization Tool.

Ambetter PA requirement overview (CMS‑0057‑F)

Ambetter Health requires prior authorization as a condition of payment for many services and publishes PA requirements in accordance with CMS Final Rule 0057‑F; prior authorization is a physician‑initiated process to verify medical necessity in advance.

• PA is required for many services as a condition of payment.
• PA requirements are published per CMS Final Rule 0057‑F.

Vascular & interventional procedure codes require PA

The listed vascular and select interventional CPT/HCPCS/T procedure codes require prior authorization effective 12/31/2025; providers must obtain PA before reimbursement will be approved for codes such as 37220–37248 series, select 364xx thrombectomy/infusion codes, 37700 series, S2202, and multiple T‑codes shown in the list.

• Examples include 37220, 37221, 37224–37239, 37243, 37246–37248.
• Includes listed 36465–36483 and 37700, 37718, 37722, 37735, 37760–37785, S2202, and multiple T codes (e.g., 0042T, 0174T, 0623T–0721T).

MRI/MRA procedure codes require PA

Magnetic resonance imaging (MRI/MRA) procedure codes enumerated in the list require prior authorization effective 12/31/2025; obtain PA for the specific CPT/T/HCPCS codes (e.g., 70450, 70460, 70470, 71250–71275, 72125–72133, 73200–73225, 73700–73725, 74150–74178, 75571–75580, and numerous T‑codes and additional MRI codes shown).

• Examples include 70450, 70460, 70470, 70480–70498 series.
• Also includes 71250–71275, 72125–72133 and related MRI/MRA codes and listed T‑codes (0743T, 0807T–0880T, etc.).

Imaging, nuclear medicine, dialysis & selected DME require PA

Mammography, diagnostic ultrasound, nuclear medicine/PET, standard x‑ray, dialysis/nephrology, and selected DME procedure codes in the document require prior authorization effective 12/31/2025; obtain PA for the specific codes listed (e.g., 0351T–0354T, 0422T, 0694T; 0689T–0690T; 0331T/0332T and numerous nuclear medicine codes; 0347T–0350T; and listed DME codes).

• Mammography examples: 0351T, 0352T, 0353T, 0354T, 0422T, 0694T.
• Nuclear medicine/PET examples: 0331T, 0332T, 78414–78499 series.
• Standard X‑ray and radiography examples: 0347T–0350T, 0749T–0750T, 77011, 77014.
• DME examples: listed A‑ and E‑series codes (see chunks 20–21).

Enteral/Parenteral, Orthotics/Prosthetics & DME codes require PA

Extensive lists of enteral/parenteral therapy, orthotics, prosthetics, DME and related codes require prior authorization effective 12/31/2025; providers must obtain PA for the specific E‑, K‑, L‑, B‑, and other device and supply codes listed in the policy.

• Enteral & parenteral examples: B9004, B9006, S9433 and other codes in chunk 24.
• Extensive orthotics/prosthetics and DME codes listed (see chunks 24–25 for full code lists).

Home health & community services codes require PA

Home infusion, home nursing, non‑hospital based care, and supplemental/state‑waiver service codes require prior authorization effective 12/31/2025; obtain PA for the specific G‑, T‑, Q‑, and S‑codes listed for home health and community services.

• Home infusion examples: G0076–G0087, G0166.
• Home nursing and nonhospital care examples: G0299, G0300, G0493–G0496, T1000–T1031, and listed Q/S codes for supplemental services.

Procedure and Q‑codes require PA (extensive lists)

Extensive lists of Q‑codes and other CPT/HCPCS procedure codes require prior authorization as listed (effective 12/31/2025); providers must secure PA for the Q‑code ranges and other procedure code groups enumerated.

• Large ranges of Q‑codes (e.g., Q4139–Q4397 series) are included.
• Inclusion of a code in these lists indicates PA is required before reimbursement is approved.

Integumentary (debridement/excision/graft) codes require PA

Integumentary procedures including debridement, excision of skin lesion, and skin graft procedure codes require prior authorization effective 12/31/2025; obtain PA for the specific CPT/HCPCS codes listed (e.g., debridement codes and graft/excision codes such as 14000, 14040, 15100, 15271–15278, 15570, etc.).

• Debridement examples and related codes are listed in chunk 37–38.
• Skin graft and excision examples include 14000, 14040, 15100, 15271–15278 and additional codes shown.

Laboratory & pathology (genetic/molecular) codes require PA

Extensive genetic, molecular, laboratory and pathology testing codes require prior authorization effective 12/31/2025; providers must obtain PA for the listed CPT codes (for example 81105–81195 and 81200–81479 ranges and numerous specific molecular panels).

• Genetic/molecular testing examples: 81105–81195 and 81200–81210 ranges shown.
• Molecular pathology examples: 81400–81479 series and additional numeric codes listed.

PLA / proprietary lab (U‑codes) require PA

Proprietary laboratory analyses (PLA) and many PLA U‑codes require prior authorization effective 12/31/2025; obtain PA for the listed U‑codes and associated PLA procedure codes included under Medication & Pharmacy/PLA services.

• Examples include PLA/U‑codes such as 0002U, 0003U, 0005U and many others listed (see chunks 43–46).
• PLA codes are listed under Medication & Pharmacy/PLA services and require PA.

Medication and J‑code prior authorization list

Numerous HCPCS A‑/C‑/J‑codes for medications, injections and infusions require prior authorization effective 12/31/2025; providers must obtain PA for the specific J‑codes and related HCPCS codes enumerated in the policy.

• Includes multiple J‑codes (examples in chunks 46–48) and selected A/C codes (e.g., A9274, A9277, A9513, etc.).
• Medication/injectable examples and extensive J‑code listings are provided in the document.

Neurosurgery procedure codes require PA

Neurosurgery procedure codes for CNS incision/excision and device insertion (including spinal stimulators and catheter insertions) require prior authorization effective 12/31/2025; obtain PA for the listed T‑codes and procedure codes (e.g., 0662T, 0663T, 0735T, 0776T, 0947T, 0956T, 61736–61737, and numerous insertion/device codes).

• Incision/excision examples: 0662T, 0663T, 0735T, 0776T, 0947T, 0956T, 61736, 61737.
• Insertion/device examples: 0587T–0590T, 0674T–0680T, 0720T, 0766T–0767T and listed spinal stimulator/catheter codes.

Ophthalmology & vision care codes require PA

Ophthalmology and general vision care procedure codes require prior authorization effective 12/31/2025; obtain PA for the enumerated diagnostic, glaucoma, lens/cataract, and other eye procedure codes (e.g., 0198T, 0207T, 0330T, 92002–92020 series, 66989, 66991, and glaucoma/eyeball codes listed).

• General eye exam/diagnostic examples: 0198T, 0207T, 0330T, 92002, 92004, 92012–92020, etc.
• Lens/cataract and glaucoma examples include 66989, 66991 and 0100T, 0253T, 0308T, 0329T, 0402T, 0621T, etc.

Orthopedic & spine surgery codes require PA

Orthopedic and spine surgery procedure codes (general orthopedics, trauma/fracture treatment, major joint reconstruction/arthroscopy, and spine surgery) require prior authorization effective 12/31/2025; providers must obtain PA for the comprehensive lists of CPT/T codes provided (see chunks 55–57 for full lists).

• General orthopedics/trauma examples: 0054T–0055T, 0101T–0102T, 0200T–0232T, and extensive 20000–27570 series listed.
• Major joint and spine examples include 23405–23474 series, 27130–27138 series, 29805–29999 series, and numerous spine fusion/laminectomy codes (see chunks 55–57).

Ophthalmology & Vision Care — specific PA required codes

Specific Ophthalmology & Vision Care procedure codes listed (e.g., 0100T, 0253T, 0308T, 0329T, 0402T, 0621T, 0660T, 06989, 67715, and lens/cataract codes 66989, 66991) require prior authorization effective 12/31/2025.

• Glaucoma & eyeball procedure examples include 0100T, 0253T, 0308T, 0329T, 0402T, 0621T, 0622T, 0660T, 0661T, 0671T, 0730T, 0936T, and 67715.
• Lens and cataract examples include 66989 and 66991.

Orthopedic & Spine Surgery — PA required for listed codes

The extensive Orthopedic & Spine Surgery procedure code lists (General Orthopedics, Major Joint Reconstruction & Arthroscopy, Spine Surgery) require prior authorization effective 12/31/2025; obtain PA for the numerous CPT and T codes enumerated in the policy.

• Major joint reconstruction and arthroscopy examples: 23405–23474, 27130–27138, 29805–29899, and associated codes listed in chunk 56.
• Spine surgery examples: fusion/laminectomy codes such as 22533, 22548, 22800–22870 series and additional spine CPTs in chunk 57.

Chiropractic service codes require PA

Chiropractic services procedure codes (98925–98929, 98940–98943) require prior authorization effective 12/31/2025; obtain PA for those chiropractic CPT codes before rendering services.

• Chiropractic manipulation and related codes listed: 98925, 98926, 98927, 98928, 98929, 98940–98943.

Therapy modality and cross‑service procedure codes require PA

Numerous therapy modality codes (ultrasound, traction, stimulation) and related CPT/HCPCS codes mapped to specialty procedures require prior authorization effective 12/31/2025; providers must secure PA for the listed modality codes (e.g., 97010–97039 series, 97750, 97755, 97760–97763, 97799, G0283) and the mapped specialty procedure codes shown.

• Modality examples: 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032–97039.
• Therapy examples include 97750, 97755, 97760, 97761, 97763, 97799, and G0283; many specialty procedure mappings are provided (see chunks 58–61).

Specialty procedure codes mapped to therapy modality codes require PA

Specific specialty procedure codes mapped to therapy modality codes (plastic/reconstructive, respiratory, hearing/speech, telehealth, injections, transportation, urological) require prior authorization effective 12/31/2025; providers must obtain PA for the enumerated specialty CPT/T codes that map to the modality codes.

• Examples include plastic/reconstructive codes (11950–11954, 15780–15793, 15824–15842 etc.), respiratory and PFT mappings, speech/hearing codes (0208T–0212T, 92507–92508, 92526, 92606, 92612–92617), telehealth mappings (0175T, 0650T, S9110), injection codes (20552, 20553), transportation (A0430, A0435), and numerous urological procedure codes listed.