Colorado Rocky Mountain Health Plans Prior Auth

Coverage statements and exclusions

Covered when product applicability permits; listing is for reference only.

The procedure and/or diagnosis codes listed are provided for reference only and do not by themselves imply that the service is covered or non-covered; benefit coverage is determined by the member-specific benefit plan and applicable laws.

Inclusion of a code does not imply a right to reimbursement or guarantee of claim payment; other policies and guidelines may apply.

Refer to the Advance Notification and Clinical Submission Requirements for state- or product-specific prior authorization rules.

Out-of-scope service categories: Cardiology; Genetic and molecular testing (including BRCA); Injectable medications (including hemophilia and chemotherapy agents); Oncology medications; Radiology; Transplants.

Code applicability mapping (partial)

Codes listed with product applicability flags (X or N/A) — an X indicates the crosswalk applies for that product.

Examples of listed codes and product applicability (presence of X means applicable to that product): 12032 (Commercial=X; Individual Exchange=X; Medicare Advantage=N/A; Community Plan=X).

Additional examples: 12034, 12035 show Commercial=X; Individual Exchange=X; Medicare Advantage=N/A; Community Plan=X; 12037 shows Commercial=N/A; Individual Exchange=N/A; Medicare Advantage=N/A; Community Plan=X.

Some procedure groups show Medicare Advantage applicability as X for specific codes (e.g., 15820 shows Medicare Advantage = X).

Breast/procedure end-of-list examples: codes such as 19370–19396 show Commercial and Individual Exchange applicability with Medicare Advantage often N/A for many of those codes (per-code variation present).

Applicable codes (partial list)

Partial excerpt of applicable codes and groupings; clinical coverage criteria are not stated in these excerpts.

Examples from the excerpt include breast surgery codes (19350, 19361, 19364, 19367–19369) with product applicability flags per code (Commercial/Individual/Medicare/Community).

Head/neck and injection-related codes (20200–20245 series) are listed with claim-submitted-for groupings and per-product applicability indicators.

Per-code product applicability varies by code; see crosswalk rows for exact X vs N/A markings.

Code-to-product applicability mappings (partial)

Selected CPT/HCPCS crosswalk lines showing mapping entries and product applicability (X = applicable; N/A = not applicable).

21215 → Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = X; Community Plan = X.

21230 → Claim submitted for 21209, 21235; Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = X; Community Plan = X.

21235 → Claim submitted for 15769; Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = X; Community Plan = X.

21280 → Claim submitted for 21282, 67950; Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X (Medicare Advantage listed as N/A).

21365 → Product applicability: Commercial = N/A; Individual Exchange = N/A; Medicare Advantage = N/A; Community Plan = X.

Code applicability listing (partial excerpt)

Additional crosswalk entries and product applicability—Commercial and Community Plan frequently marked X; Medicare Advantage often marked N/A for many codes in this segment.

Example entries in this segment include upper extremity and related procedure codes where Community Plan applicability is commonly X and Medicare Advantage may be N/A per code.

26215 → Claim submitted for 26200, 26205, 26210; Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X.

28020 and related codes → product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X (per the 280xx series crosswalk lines).

Code applicability (partial)

Code-to-code mappings with per-product applicability markers; clinical coverage criteria are not included here.

28020 → Claim submitted for 28050; Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X.

29804–29807 series → claim-submitted-for groupings listed with product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X for many entries in this segment.

29863 → Claim submitted for 27054, 29860–29862; Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X.

Applicability mappings

Code group mappings with explicit per-product applicability flags.

29877 group → Claim submitted for 29850, 29870, 29871, 29873, 29874, 29875, 29880, 29881, 29884; Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X.

29894 → Claim submitted for 29895, 29897; Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = X; Community Plan = X.

Applicable codes crosswalk

Primary CPT entries with claim-submitted companion codes and product applicability noted per entry.

Each primary CPT entry includes companion CPT/HCPCS codes to be used for claim submission and marks product applicability (Commercial, Individual Exchange, Medicare Advantage, Community Plan) as X or N/A — see per-code lines for exact flags (examples include multiple cardiac/device and cardiovascular procedure codes).

Partial code mapping set (part 10)

Selected code mappings with companion codes and product applicability indicators.

33771 → Claim submitted for 33257, 33259, 33770, 33774, 33775, 33776, 33777, 33924; Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X.

33778 → Claim submitted for 33257, 33259, 33770, 33771, 33774, 33775, 33776, 33777, 33924; Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X.

33786 → Claim submitted for 33257, 33259, 33600, 33602, 33675, 33676, 33677, 33681, 33684, 33688, 33924; Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X.

Code-specific product applicability crosswalks

Code-specific product applicability crosswalk examples showing how certain CPTs map to crosswalk lists and how product applicability varies.

37296 → Claim submitted for multiple companion vascular codes (37254, 37258, 37263, etc.); Product applicability: Commercial = X; Individual Exchange = N/A; Medicare Advantage = X; Community Plan = N/A.

43200–43255 series → Many entries reference the 'Gastroenterology Endoscopy Advance Notification CPT Code List and Crosswalk' for Commercial product crosswalks; per-code product applicability varies (Commercial may reference the centralized GI crosswalk; Individual/Medicare/Community applicability varies per code).

40510 → Claim-submitted-for list and product applicability indicate Community Plan = X while Commercial/Individual/Medicare may be N/A for that entry.

Code mappings

Specific claim-submitted crosswalk examples and per-product applicability notes.

43245 → Claim submitted for 43249; Product applicability: Commercial = N/A; Individual Exchange = N/A; Medicare Advantage = N/A; Community Plan = X.

43247 → Product applicability: Commercial = Refer to Gastroenterology Endoscopy Advance Notification CPT Code List and Crosswalk; Individual Exchange = 43239; Medicare Advantage = N/A; Community Plan = 43239.

43248 → Commercial product uses the Gastroenterology Endoscopy Advance Notification CPT Code List and Crosswalk; Individual Exchange = 43249; Medicare Advantage = N/A; Community Plan = 43249.

Example mapping node

Example per-code mapping node with companion codes and product applicability flags.

52325/52341 example → 52341 maps to 52224, 52234, 52276, 52281, 52283; Product applicability for 52341: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X.

Product applicability crosswalk rows (examples)

Representative code-to-product applicability rows (examples) showing X vs N/A per product line.

54406 → Product applicability: Commercial = N/A; Individual Exchange = N/A; Medicare Advantage = N/A; Community Plan = X.

54500 → Claim submitted for 54505; Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = N/A.

58260 → Part of mapping groups (e.g., 58294 crosswalk); Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = X; Community Plan = X (per examples in the 582xx/585xx group).

Partial code mapping set (examples)

Partial mapping examples showing primary codes, mapped codes, and product applicability flags.

58541 → Claim submitted for 58543; Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = X; Community Plan = X.

58542 → Claim submitted for 58260, 58541, 58570; Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = X; Community Plan = X.

58294 → Claim submitted for multiple companion CPTs including 57110, 58150, 58180, 58260, 58541–58544, etc.; Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = X; Community Plan = X.

CPT / HCPCS crosswalks and code lists

Sample CPT crosswalk entries (more listed throughout document)CPT

10121	Crosswalk entries indicate claim submitted for 10120; product applicability: Commercial=X, Individual Exchange=X, Medicare Advantage=N/A, Community Plan=X
10180	Crosswalk entries indicate claim submitted for 10060, 10140; product applicability: Commercial=X, Individual Exchange=X, Medicare Advantage=N/A, Community Plan=X
11010	Crosswalk entries indicate claim submitted for 11042, 11045; product applicability: Commercial=X, Individual Exchange=X, Medicare Advantage=N/A, Community Plan=X

Additional CPT crosswalk examplesCPT

11960	Claim submitted for 11970, 11971; product applicability: Commercial=X, Individual Exchange=X, Medicare Advantage=X, Community Plan=X
11970	Claim submitted for 11971; product applicability: Commercial=X, Individual Exchange=X, Medicare Advantage=N/A, Community Plan=X

12000–12037 group (partial)CPT

12001	suture of skin, simple (example grouping shown)
12002	suture of skin, simple (example grouping shown)

15800–17100 group (partial)CPT

15820	laser procedure / destruction code group (as listed)
17000	chemical cauterization or destruction codes (as listed)

19000–20220 group (partial)CPT | HCPCS

19396	breast prosthesis code L8035 referenced
20200	injections, neck/head region codes (as listed)

Breast surgery/related codes (partial)CPT

19350	Applicable; product flags indicated in chunk
19361	Included in claim-submitted groupings
19364	Product applicability flags present

Craniofacial/cranial codes (partial)CPT

21198	Listed with related claim-submitted codes and product applicability
21206	Listed with product applicability across products

Facial/craniofacial procedure codes (excerpt)CPT

21208	CPT/HCPCS crosswalk entry (related submitted codes listed)
21209	CPT/HCPCS crosswalk entry (related submitted codes listed)
21210	CPT/HCPCS crosswalk entry (related submitted codes listed)
21215	CPT/HCPCS crosswalk entry (product applicability indicated)
21230	CPT/HCPCS crosswalk entry (product applicability indicated)
21235	CPT/HCPCS crosswalk entry (related submitted code 15769 listed)

Spine procedure codes (excerpt)CPT

22554	Spine surgery related code (crosswalk entries)
22612	Spine surgery related code (crosswalk entries)
22802	Spinal instrumentation code (crosswalk entries)

Shoulder/upper extremity codes (sample from list)CPT

23412	Referenced as claim submitted CPT/HCPCS code mapping and product applicability
23415	Referenced as claim submitted CPT/HCPCS code mapping and product applicability
23440	Referenced as claim submitted CPT/HCPCS code mapping and product applicability

Upper extremity/shoulder codes (additional examples)CPT

24360	Listed with product applicability flags
25441	Listed with product applicability flags

Example code crosswalk entries (partial)CPT

26200	Referenced as claim-submitted CPT/HCPCS mapping
26215	Referenced; product applicability flags present

Hip/pelvis procedure crosswalks (example)CPT

27120	Claim submitted for 27122, 29915; product applicability flags
27132	Claim submitted for multiple codes; product applicability flags

Partial code crosswalks from document segmentCPT | HCPCS

28020	Claim submitted for the following CPT/HCPCS code(s) = 28050
29806	Claim submitted for the following CPT/HCPCS code(s) = 23450, 23455, 29805, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29828, S2300
29837	Claim submitted for the following CPT/HCPCS code(s) = 29830, 29834, 29835

29893 mappingCPT

29893

Claim submitted for CPT/HCPCS code(s) = 28008

304xx mappingsCPT

30400	Claim submitted for CPT/HCPCS code(s) = 30430, 30460
30410	Claim submitted for CPT/HCPCS code(s) = 30400, 30430, 30435, 30460

3129x mappingsCPT

31295	Claim submitted for CPT/HCPCS code(s) = 31297
31296	Claim submitted for CPT/HCPCS code(s) = 31295, 31297

Cardiac/device and cardiovascular procedure codes (partial list)CPT

33202	Procedure code with product applicability entries and crosswalks
33250	Procedure code with related submitted codes 33254
33251	Procedure code with related submitted codes 33250, 33254, 33261

Cardiac/thoracic procedure codes (partial list)CPT

33476	Procedure with related codes 33257, 33259, 33924
33500	Procedure with many related codes including 33257, 33259, 33501-33504, 33702, 33720, 33724
33600	Procedure with related codes 33257, 33259, 33602, 33924

Cardiac vascular/graft codes (partial list)CPT

33690	Procedure with related codes 33257, 33258, 33768
33702	Procedure with related codes 33257, 33259, 33501-33504
33710	Procedure with extensive related codes (see chunks)

3377x series mappingsCPT

33771	Listed with companion codes 33257, 33259, 33770, 33774-33777, 33924
33774	Listed with companion codes 33257, 33259, 33924
33775	Listed with companion codes 33257, 33259, 33774, 33924

3651x groupCPT

36511	Mapped to 36512/36513/36514/36516; Commercial = N/A, Individual Exchange = X
36514	Mapped to 36516; multiple product applicability including Medicare Advantage = X

3722x-3723x vascular codesCPT

37221	Claim companions include 37220; product applicability includes Medicare Advantage = X
37225	Companions 37224/37226; product applicability includes Medicare Advantage = X

Representative CPT/HCPCS crosswalk entriesCPT

37296	Listed with claim-submitted-for crosswalks; product applicability: Commercial = X; Medicare Advantage = X; Individual Exchange = N/A; Community Plan = N/A
37298	Listed with claim-submitted-for crosswalks; product applicability: Commercial = X; Medicare Advantage = X; Individual Exchange = N/A; Community Plan = N/A
43200	Refer to Product Applicability columns for crosswalk codes; Commercial applicability references Gastroenterology Endoscopy Advance Notification CPT Code List and Crosswalk
43237	Has many related crosswalk codes; Community Plan = X
40510	Claim-submitted-for list includes multiple skin procedure codes; Community Plan = X; Commercial/Individual/Medicare = N/A

Selected CPT crosswalk examplesCPT

43259	Crosswalks to multiple upper endoscopy and related CPTs (e.g., 43191-43270)
43644	Crosswalks to 43846
43770	Crosswalks to 43772, 43774

Additional crosswalk mappingsCPT | HCPCS

44705	Claim submitted for G0455
45172	Claim submitted for 45190
45395	Crosswalks to 45110-45123 series

Sample crosswalk mappingCPT

45395

Crosswalk to CPTs 45110, 45111, 45112, 45113, 45114, 45116, 45123

Urology / related crosswalksmixed

50590	Crosswalk to HCPCS S0400
51702	Crosswalk to 51701

Crosswalk group examplesCPT

58260	Claim submitted for following CPT/HCPCS codes = 58541, 58570
58541	Claim submitted for following CPT/HCPCS codes = 58543
58542	Claim submitted for following CPT/HCPCS codes = 58260, 58541, 58570

Urology procedure crosswalksCPT

54660	Claim submitted for following CPT/HCPCS code(s) = 54520
54690	Claim submitted for following CPT/HCPCS code(s) = 54520, 54530

Example mapping entriesCPT | HCPCS

58294

Mapped to multiple CPT/HCPCS codes including 57110, 58150, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58541-58544, 58550, 58552, 58570-58573

Spine procedure crosswalk exampleCPT | HCPCS

63087

Mapped to 63001, 63005, 63012, 63016, 63017, 63030, 63042, 63046, 63047, 63077, 63090, 63101, 63102, 0274T

Medicare Advantage applicability frequency

SummaryMultiple codes in the crosswalk are marked 'N/A' for Medicare Advantage in this section (examples in chunks 36–37).

ImplicationAn 'N/A' in the Product Applicability column means the crosswalk does not apply to Medicare Advantage members for that code; providers must obtain a new authorization per product rules.

Example codes (from source)19364, 19367, 19368, 19369, 19370, 19371, 19396 — many show Medicare Advantage = N/A in chunks 36–37.

Medicare Advantage applicability — many codes marked N/A

SummaryMany listed CPT/HCPCS codes in the document are marked 'N/A' for Medicare Advantage, indicating the crosswalk does not apply for those codes.

Example entriesExamples include multiple cardiac and vascular procedure codes where Medicare Advantage is N/A (see chunk 144) and additional codes across the list (chunk 169).

Provider actionWhen Medicare Advantage is 'N/A', obtain authorization through the Provider Portal chat for Medicare Advantage members if the right-column service is not listed.

Medicare Advantage applicability specific note — some codes applicable

SummarySome codes are applicable to Medicare Advantage (marked 'X'); examples include 33982, 33983 and 33976 which are marked applicable in the crosswalk (chunk 169 and 169/162 contexts).

Examples from source33982, 33983 (both show Medicare Advantage = X in chunk 169); 33976 is shown as applicable for all products in the brief (inv-72).

NoteApplicability varies by code — confirm the Product Applicability column for each CPT/HCPCS code before using an existing prior authorization.

How providers should use or modify existing prior authorizations

Prior Authorization

Prior Authorization Modification & Use

Using or modifying an existing prior authorization: If you have an approved prior authorization for a CPT/HCPCS code listed in the left column of the crosswalk and you perform a service listed in the right column, check the Product Applicability column for your member's product. If the product column shows an X for that product, the original prior authorization can be used. If it shows N/A, the crosswalk does not apply for that product. If the performed service is not listed in the right column: for Community Plan or Medicare Advantage members, contact us via chat 24/7 in the UnitedHealthcare Provider Portal to obtain a new authorization; for Commercial members, modify the original prior authorization request before submitting the claim. You may make CPT/HCPCS code changes to an existing approved prior authorization if the change is medically necessary. We will allow changes made within 5 business days after you provide the service, before you submit the claim. Connect with us through chat 24/7 in the UnitedHealthcare Provider Portal.

Check the Product Applicability column for an X or N/A before using a prior authorization.
Community Plan or Medicare Advantage members: obtain a new authorization via chat in the Provider Portal if the service is not listed in the right-column crosswalk.
Commercial members: modify the original prior authorization request before claim submission when the performed service is not in the right-column crosswalk.
You may change CPT/HCPCS codes on an approved prior authorization if medically necessary; changes must be made within 5 business days after the service and before claim submission.
Chat support available 24/7 in the UnitedHealthcare Provider Portal.

Note

Applicable Codes — sample crosswalk

Applicable codes and product applicability (sample): The crosswalk lists CPT/HCPCS codes with the claim-submitted companion codes and indicates product applicability per product line. Use these mappings to determine whether an existing authorization covers the service for the member's product.

Example mapping: 12032 -> claim submitted for 12001,12002,12031. Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X.
Example mapping: 19370 -> claim submitted for 19328,19330. Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X.
Example mapping: 21244 -> claim submitted for 21210,21215,21245,21246. Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = X; Community Plan = X.

Billing Rule

Musculoskeletal / Procedures

Musculoskeletal / procedure codes — provider impact: Many musculoskeletal and injection-related CPT codes appear in the crosswalk with explicit claim-submitted companions and product applicability. Confirm companion codes and product flags to know whether an existing authorization applies or must be modified.

Injection and procedure examples: 20600 -> claim submitted for 20552,96372. Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X.
Shoulder/elbow: 23472 -> claim submitted for 23470. Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = X; Community Plan = X.
Hand/wrist/forearm: 26215 -> claim submitted for 26200,26205,26210. Product applicability: Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X.
When codes map to N/A for Medicare Advantage (or other products), obtain a new authorization for members on those products per modification rules.

Documentation Required

GI Endoscopy — Advance Notification Crosswalks

Advance notification / crosswalk reference for GI endoscopy codes: Several upper and lower GI endoscopy CPT codes reference the Gastroenterology Endoscopy Advance Notification CPT Code List and Crosswalk in the Product Applicability column. For these codes, consult the referenced advance-notification list to determine the correct claim-submitted mapping and authorization requirements.

Codes referencing the advance-notification list include, but are not limited to: 43200, 43201, 43202, 43204, 43205, 43211, 43212, 43213, 43215, 43248–43251, 43259, 43266, 43270. Product Applicability for Commercial often points to the Gastroenterology Endoscopy Advance Notification CPT Code List and Crosswalk.
For codes tied to the advance-notification list, do not rely solely on left/right column crosswalks in this document—use the Gastroenterology Endoscopy Advance Notification CPT Code List and Crosswalk to confirm companion codes and product rules before billing.
If the commercial Product Applicability points to the advance-notification resource, follow its instructions to determine whether the existing prior authorization covers the performed service or if a new/modified authorization is needed.

Note

Reading Product Applicability Flags

Code applicability flags (how to read X / N/A): The Product Applicability column uses X to indicate the crosswalk applies for that product and N/A to indicate the crosswalk does not apply. Use these flags to decide whether to use, modify, or request a new authorization.

X = Crosswalk applies for the member's product; an existing authorization for the left-column code can be used for the right-column service when clinically appropriate.
N/A = Crosswalk does not apply for the member's product; do not use the existing authorization for the crosswalked service — obtain a new authorization according to product rules.
If a code group shows Commercial = X but Medicare Advantage = N/A, Commercial members may use/modify the existing authorization while Medicare Advantage members need a new authorization via chat in the Provider Portal.
Always verify the claim-submitted companion codes listed for each left-column code to ensure accurate billing and authorization alignment.

Key terms and legend

Applicable Codes — reference-only disclaimer

DefinitionApplicable Codes — procedure and/or diagnosis codes in the table are provided for reference only; listing does not imply coverage or payment and other policies may apply.

GuidanceBenefit coverage is determined by the member-specific benefit plan document and applicable laws; inclusion does not guarantee reimbursement.

ReferenceRefer to Advance Notification and Clinical Submission Requirements for state- or product-specific prior authorization requirements.

X / N/A legend

LegendX = original prior authorization can be used for that product; N/A = crosswalk does not apply to that product.

ImplicationIf Product Applicability shows N/A for the member's product, the prior authorization crosswalk does not apply and a new authorization may be required.

ActionWhen in doubt, check the Product Applicability column and follow product-specific provider instructions (e.g., chat in Provider Portal).

Product applicability — definition of flags

DefinitionProduct applicability flags indicate whether the listed CPT/HCPCS code is applicable to each product line (Commercial, Individual Exchange, Medicare Advantage, Community Plan).

PurposeFlags determine whether an existing prior authorization may be used for a different or additional code depending on member product.

ExampleChunk 18 shows Commercial = X, Individual Exchange = X, Medicare Advantage = N/A, Community Plan = X for codes 12032–12035.

Product applicability — flags shape and meaning

DisplayProduct applicability flags are provided per code line and list applicability for: Commercial; Individual Exchange; Medicare Advantage; Community Plan.

InterpretationAn 'X' marks the code as applicable for that product; 'N/A' marks it not applicable for that product.

ExampleChunk 36 shows codes 19350/19364 with Medicare Advantage = N/A while Community Plan = X.

Claim-submitted groupings — definition

Definition'Claim submitted for the following CPT/HCPCS code(s)' groups related codes that may be submitted together or serve as the crosswalk targets for claim submission.

UseProviders should list the claim-submitted code(s) on claims when billing the primary code or its mapped equivalents per the crosswalk.

ExampleChunk 36–37 show entries where codes like 19364 map to 19361, 19367, 19368, 19369 as claim-submitted companions.

Product applicability — short note about applicability entries

Short noteProduct applicability entries mark whether a given CPT/HCPCS code is applicable for a product (Commercial; Individual Exchange; Medicare Advantage; Community Plan) using X or N/A.

Practical impactThese entries determine if an existing prior authorization can be reused for another code for that product.

ExampleChunk 54 shows 21215 and 21230 with Medicare Advantage = X and Community Plan = X.

Product applicability — flag explanation

Flag meaningAn applicability flag marks whether the code mapping applies to the product line; 'X' = applicable, 'N/A' = not applicable.

ColumnsFlags are shown for four product lines: Commercial; Individual Exchange; Medicare Advantage; Community Plan.

Provider actionCheck the flag when determining whether to modify an existing authorization or obtain a new one for the member's product.

Product applicability flags (X / N/A)

LegendProduct applicability flags (X / N/A) indicate which product(s) the listed CPT/HCPCS code applies to for claims submission (Commercial, Individual Exchange, Medicare Advantage, Community Plan).

InterpretationUse the flags to decide if an approved prior authorization for a left-column code can be used for the right-column code for the member's product.

ExampleChunk 72 shows 23412 with Commercial/Individual/Medicare = N/A and Community Plan = X.

Applicable Codes / Product applicability — usage

PurposeApplicable Codes / Product applicability indicates which CPT/HCPCS codes should be used on claims and which product lines the listed codes apply to.

Crosswalk usageThe table lists primary codes, their claim-submitted companions, and product applicability to guide claim submission and authorization reuse.

ExampleChunks 180–199 include entries that reference the Gastroenterology Endoscopy Advance Notification crosswalk for certain Commercial mappings.

Product applicability — flag definition

Flag definitionProduct applicability flag indicates whether the listed code mapping applies to each product line; 'X' = applicable, 'N/A' = not applicable.

Example mappingChunk 162 shows 33771 with Commercial = X; Individual Exchange = X; Medicare Advantage = N/A; Community Plan = X.

ActionConfirm flags for each companion code when applying an existing prior authorization across mapped codes.

Gastroenterology crosswalk — referenced list

DefinitionThe Gastroenterology Endoscopy Advance Notification CPT Code List and Crosswalk is a referenced, separate list used for certain Commercial product mappings in the crosswalk table.

How referencedSeveral CPT entries (e.g., 43200–43217 series) indicate to 'Refer to the Product Applicability columns' which point to the Gastroenterology Endoscopy Advance Notification crosswalk.

Provider noteFor Commercial products, follow the Gastroenterology Endoscopy Advance Notification list when the Product Applicability column references it.

Product applicability — tag definition

Tag definitionProduct applicability tags denote which product lines (Commercial, Individual Exchange, Medicare Advantage, Community Plan) the listed code applies to.

UsageTags are applied per code row to indicate crosswalk applicability when submitting claims or reusing authorizations.

ExampleChunk 234 shows 54406 with Commercial/Individual/Medicare = N/A and Community Plan = X.

Gastroenterology Endoscopy Advance Notification — reference description

DescriptionThe Gastroenterology Endoscopy Advance Notification CPT Code List and Crosswalk is used as a centralized crosswalk for certain Commercial product mappings referenced in this table.

Where usedEntries for upper endoscopy and colonoscopy CPTs (chunks 199–204) direct Commercial product users to this crosswalk for claim-submission mapping.

Provider actionFollow the referenced Gastroenterology crosswalk where the Product Applicability column points to it for Commercial claims.

Applicability flag (X/N/A) — legend reiterated

Legend reiterationApplicability flag legend: 'X' indicates the crosswalk/code is applicable for that product; 'N/A' indicates not applicable.

Operational noteProviders must check the flag for the member's product before reusing an existing authorization or submitting a claim under a mapped code.

ExampleChunk 216 shows many Commercial entries that reference the Gastroenterology crosswalk while Medicare Advantage and Individual Exchange are often N/A.

Product applicability — note

NoteProduct applicability flags indicate whether a code entry applies to a product: Commercial, Individual Exchange, Medicare Advantage, Community Plan (marked X or N/A).

ImplicationUse the flags to determine whether an existing prior authorization can be applied or whether a new/modification is required per product rules.

ExampleChunk 244 lists gynecologic/OB crosswalks showing mixed applicability across product lines; confirm flags per code.

Claim-submission mapping — definition

Definition'Claim submitted for the following CPT/HCPCS code(s)' indicates related codes that should be used or referenced on claims when billing the listed primary code (claim-submission mapping).

PurposeThese mappings guide which CPT/HCPCS codes to report on claims and which prior authorization may be cross-applied for each product.

ExampleChunk 126 shows 29877 maps to a group including 29850, 29870, 29871, 29873, 29874, 29875, 29880, 29881, 29884.

Product applicability — final definition entry

Final definitionProduct applicability flags indicate whether the listed code mapping applies to each product line (Commercial, Individual Exchange, Medicare Advantage, Community Plan). 'X' denotes applicable; 'N/A' denotes not applicable.

Practical useConsult these flags when deciding to reuse or modify an existing prior authorization for a different code for a member's product.

ExampleChunk 162 shows 33771 with Medicare Advantage = N/A while Commercial/Individual Exchange/Community Plan = X.

Claim-submitted mapping — final definition

Definition'Claim submitted for the following CPT/HCPCS code(s)' label identifies the target codes that may be submitted on claims as the mapped equivalents for the primary code; used for crosswalk/authorization purposes.

GuidanceProviders should reference these claim-submitted mappings when changing CPT/HCPCS codes on an existing authorization or submitting claims.

ExampleChunk 108 shows 28020 maps to 28050; chunk 126 shows 29877 maps to multiple 298xx companion codes.

OpenPayer

Prior authorization crosswalk table

Coverage rules and code applicability

CPT / HCPCS crosswalks and code lists

How providers should use or modify existing prior authorizations

Key terms and legend