Procedure Reference Lists (prior authorization and coverage lookup)
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Guidance for searching HAP Procedure Reference Lists to determine coverage, prior authorization, and billing requirements for procedure and drug codes; intended for providers and staff who submit authorizations or bill HAP.
No material clinical or coverage changes in this revision.
Coverage and Authorization Guidance
Authorization and submission criteria
Coverage and authorization actions based on Procedure Reference Lists indicators
See CCN/MSI/SPC annotations for delegated vendors.
Failure to obtain authorization may result in denial.
Medicare Advantage members should submit via Care Affiliate request profiles; CCN/MSI indicate eviCore handling.
This guide does not list any standalone exclusions. Specific exclusions or carve-outs are maintained on the HAP Procedure Reference Lists or in the Benefit Administration Manual (BAM); users should consult those sources for procedure- or code-specific exclusion language.
The Procedure Reference Lists help operationalize authorization and billing but do not themselves define medical necessity. For diagnosis- or indication-specific coverage determinations (including limitations, restrictions, or step therapy), refer to the BAM for the applicable medical necessity and clinical criteria.
Coding and Billing Requirements
| No codes listed |
Provider Submission and Authorization Actions
Refer to BAM for specific criteria — Specific coverage criteria or limitations/restrictions apply
Refer to BAM for specific coverage criteria, limitations, or restrictions that may apply to services listed. Where the Procedure Reference Lists or code annotations indicate specific coverage requirements (including step therapy, diagnosis-specific criteria, or other medical necessity conditions), follow the BAM policy language for applicable criteria and documentation requirements. For services annotated with 'CCN' or 'MSI', submit prior authorization requests to eviCore (formerly CareCore National / MedSolutions) per the instructions in BAM. For services annotated 'SPC' (Specialty Medication): for commercial members contact Pharmacy Advantage at 800-456-2112 or FAX 888-400-0109; for Medicare Advantage members submit the request via Care Affiliate using the appropriate medication Request Profile. When a code is not found on the Procedure Reference Lists, a prior authorization is required — proceeding without authorization risks claim denial. All outpatient drug-related HCPCS and CPT codes must be billed with an 11-digit NDC (5-4-2 format), quantity and unit of measure as required for CMS-1500, UB-04, EDI transactions and Medicare crossover claims. For CCN-participating networks, obtain authorization from eviCore; for non-CCN networks, authorization is required from HAP. For services designated as carved out (ExGEN) or requiring CBHM authorization, follow the routing instructions in BAM and contact HAP Referral Management Team (RMT) or CBHM as specified.
- Refer to BAM for specific coverage criteria, limitations, and step therapy requirements.
- Submit prior authorization to eviCore for codes annotated 'CCN' or 'MSI'.
- SPC (Specialty Medication): Commercial — Pharmacy Advantage 800-456-2112 (FAX 888-400-0109); Medicare Advantage — submit via Care Affiliate with drug Request Profile.
- If a code is not found on Procedure Reference Lists, prior authorization is required and services billed without authorization may be denied.
- All outpatient drug HCPCS/CPT billing must include a valid 11-digit NDC (5-4-2), quantity, and unit of measure.
- For CCN-participating networks obtain eviCore authorization; for non-CCN networks obtain authorization from HAP.
- For ExGEN (carved-out) services or CBHM-designated services follow BAM routing and contact RMT or CBHM as directed.
Help Guide Purpose
Use HAP’s Procedure Reference Lists to determine whether a code requires prior authorization: if the column Prior Auth Required is marked ‘Yes’, submit an authorization before performing the service; if marked ‘No’, proceed with the service without prior authorization. If a code is not found on the lists, a prior authorization is required and proceeding without one may risk denial. Codes annotated CCN or MSI must be submitted to eviCore, and codes annotated SPC (specialty medications) direct commercial-member authorization to Pharmacy Advantage as noted in the key and BAM.
List Annotations and Definitions
Infusion and Place-of-Service Notes
Infusion center request profile and place-of-service selection
When requesting authorization for infusion-site medications, select the appropriate Request Profile configured as 'Drug - XXXXX-xxxx' and ensure you also select the correct place of service; commercial specialty medications use Pharmacy Advantage for authorization.
- Request profiles are named 'Drug - XXXXX-xxxx' where 'XXXXX' is the medication category and 'xxxx' indicates place of service.
- For commercial SPC medications, contact Pharmacy Advantage (800-456-2112 or FAX 888-400-0109) for authorization.
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