Prior authorization required for transplant evaluation and event

Prior authorization is required for the transplant evaluation and for the transplant event; submit requests for Medical Director review as indicated.

• Prior authorization must be obtained before the transplant evaluation and before the transplant event is performed.
• Clinical trial participation related to transplant also requires prior authorization and submission of trial documentation.

Prior authorization required for inpatient elective admissions

Prior authorization is required for all inpatient elective admissions to an acute care facility and must be obtained prior to patient admission.

• This requirement applies to elective inpatient admissions to acute care settings; verify member-specific exceptions by contacting customer service if needed.
• Failure to obtain required prior authorization may result in claim denial or benefit nonpayment.

Therapeutic drug monitoring — prior auth not required but claim review and limits apply

Prior authorization is not required for routine therapeutic drug monitoring/urine drug testing, but limits apply and claims will be reviewed for medical necessity; limits of 12 presumptive and 12 definitive tests are noted.

• Relevant example codes: CPT 80305–80307 and HCPCS G0480/G0481 are referenced for urine drug testing.
• Claims may be reviewed at submission for medical necessity; lack of medical necessity may lead to denial.

Prior authorization required for transplant care and clinical trials

Prior authorization is required for transplant evaluation/transplant events and for participation in clinical trials; clinical trial prior authorization must include the trial number, chart notes, protocol, and signed consent for Medical Director review.

• Submit trial number, chart notes, study protocol and signed informed consent when requesting authorization for clinical trial participation.
• Transplant evaluation and transplant event requests must be submitted for review and prior authorization before proceeding.

Clinical trial participation requires prior authorization and documentation

Prior authorization is required for participation in a clinical trial; include the trial number, chart notes, protocol and signed consent when submitting for review by the Medical Director.

• Documentation listed (trial number, chart notes, protocol, signed consent) must be attached to the request for prior authorization.
• Clinical trial requests will be reviewed by the Medical Director as part of the authorization process.

Prior authorization for Coordinated Specialty Programs may be required

Some Coordinated Specialty Programs require prior authorization per program rules and member handbook language; verify requirements for the specific program before enrolling the member.

• Programs referenced include ACT (H0039/H0040), IIBHT (H0023), IOSS (H0037), EASA (H2016/H0240/H0241) and others.
• Confirm program-specific prior authorization requirements and follow Moda’s prior authorization process.

Medical Nutrition Therapy — prior authorization not required; claim review applies

Prior authorization is NOT required for Medical Nutrition Therapy (CPT 97802–97804), but these services will be reviewed at claim submission for medical necessity and appropriate coding; visit limits and review guidance apply.

• Codes: 97802, 97803, 97804 — prior authorization not required but claims are subject to medical necessity review.
• Limits referenced: 12 presumptive and 12 definitive (applies to related service visit limits guidance).

Drug testing/therapeutic drug monitoring — claim review and not-covered codes

Prior authorization is NOT required for drug testing (CPT 80305–80307; HCPCS G0480/G0481), but claims for these tests will be reviewed for medical necessity at submission and certain related codes are listed as Not Covered.

• Examples: 80305, 80306, 80307, G0480, G0481 — claims reviewed for medical necessity; limits of 12 presumptive and 12 definitive apply.
• Not-covered testing codes (e.g., G0482, G0483, 0082U, 0227U, 0517U–0520U) may be denied if billed.

Prior authorization required for listed behavioral health services

Prior authorization is required for the listed mental health and substance use disorder services; verify member benefits and obtain prior authorization per the member handbook before providing or billing these services.

• Referenced program codes include H0010–H0019 series, H0023, H0035, H0037, H0039, H0040, S0201, S0315, S0317, S9480, ABA (97151–97158, 0362T, 0373T), and TMS (90867–90869).
• Use the Medical/Surgical Services Prior Authorization List and Moda Health Medical Necessity Criteria (MHMNC) or MCG Guidelines (28th Edition) for review guidance.

Behavioral health services — obtain prior authorization per member handbook

Prior authorization is reviewed per member handbook language for the listed mental health and substance use disorder services; failure to obtain required prior authorization may result in denial.

• Providers should verify benefit availability and prior authorization requirements for members (Texas-specific notes may apply).
• Use ASHLink for eligibility/claims and follow Moda’s prior authorization submission instructions.

Codes listed require prior authorization — verify via ASHLink

Prior authorization is referenced for multiple behavioral health codes; providers must verify and obtain necessary authorizations (use ASHLink for Texas members to check eligibility and submit claims).

• Codes requiring prior authorization are listed on the Medical/Surgical Services Prior Authorization List and reviewed using Moda criteria.
• For Texas members, www.ashlink.com may be used to verify eligibility, submit claims and access ASH materials.

Prior authorization required for listed behavioral health/related services

Prior authorization is indicated for multiple behavioral health and related services (ABA, TMS, nutritional therapy, pain programs); follow Moda’s prior authorization process and the Medical/Surgical Services Prior Authorization List before billing.

• Examples include ABA (97151–97158, 0362T, 0373T), TMS (90867–90869), nutritional therapy (97802–97804) and pain management programs (S0315/S0317).
• Review determinations reference Moda Health Medical Necessity Criteria (MHMNC) or MCG Guidelines (28th Edition).

Codes on the Prior Authorization List require authorization and medical necessity review

The CPT/HCPCS/H codes shown on Moda’s Medical/Surgical Services Prior Authorization List require prior authorization and are reviewed against Moda Health Medical Necessity Criteria (MHMNC) or MCG Guidelines (28th Edition).

• Providers must follow the Medical/Surgical Services Prior Authorization List when submitting authorization requests.
• Failure to obtain prior authorization for listed codes may lead to denial or delay.

Prior authorization required for specific behavioral health program codes

Prior authorization is required for the listed behavioral health and substance use disorder program codes (examples include IIBHT H0023, IOSS H0037, and inpatient/residential codes H0010–H0019); obtain authorization per the Prior Authorization List before providing services.

• Examples: H0023 (IIBHT), H0037 (IOSS), H0010–H0019 (inpatient/residential variants), H0035/S0201 (partial hospitalization), S9480 (ASAM intensive outpatient).
• Authorization requests will be reviewed per member handbook and Moda criteria.

Prior authorization required for DME and select procedure codes

Prior authorization is listed for various DME and selected surgical/procedure codes (for example airway clearance devices A7025/A7026 and E0480–E0484); obtain prior authorization per the Medical/Surgical Services Prior Authorization List.

• DME examples: A7025, A7026, E0480–E0484, K1027 — prior authorization required.
• Selected procedural and implant codes (many CPT/HCPCS/T-codes) are listed and require prior authorization per Moda’s process.

Breast reconstruction following mastectomy — submit for eviCore review

Breast reconstruction following mastectomy for breast cancer is always covered; requests are reviewed by eviCore and should be submitted for authorization/review.

• Breast reconstruction CPT codes cited include 19328 and 19330; eviCore handles review and authorization.
• Other breast-related procedures and testing (BRCA and gene expression assays) are reviewed per MHMNC/MCG guidance.

Clinical trial documentation required for prior authorization

For participation in a clinical trial, submit the trial number, chart notes, protocol and signed consent to Moda for review by the Medical Director as part of the prior authorization process.

• Required attachments: trial number, chart notes, study protocol, and signed informed consent.
• Clinical trial participation will not be authorized without submission of the required documentation.

Transplant prior authorization — submit required documentation

For transplant-related prior authorization requests, submit documentation required for the transplant evaluation and transplant event for Medical Director review.

• Include clinical records and any evaluation documentation necessary to demonstrate medical necessity for the transplant evaluation and event.
• Prior authorization for both the evaluation and the transplant event is required before services proceed.

Medical Nutrition Therapy — claim-level medical necessity review

Medical Nutrition Therapy (CPT 97802–97804) does not require prior authorization, but claims will be reviewed for medical necessity and appropriate coding; follow member handbook language for benefit availability.

• Codes: 97802, 97803, 97804 — prior authorization not required, but claims are subject to review.
• Providers should verify benefit availability per the member handbook before delivering services.

Notify Moda within two days for emergency inpatient mental health admissions

Contact Moda Health within two days of any emergency inpatient mental health admission; failure to notify within this timeframe risks non‑compliance with plan instructions.

• Notification timeframe: contact Moda within two days (48 hours) of the emergency admission.
• This applies to inpatient mental health emergency admissions and is part of admission/coverage workflow.

Use ASHLink for eligibility, claims and prior authorization checks

Use www.ashlink.com to verify member eligibility and benefits, submit claims, and access ASH materials (especially for members with plans sold or residing in Texas).

• ASHLink functions: eligibility verification, claim submission, and access to current ASH materials.
• For Texas members, ASHLink is specifically noted as the portal to verify prior authorization and claim instructions.

Follow member handbook and MHMNC/MCG guidance for claims and prior authorization

Claims and prior authorization submissions for listed behavioral health services must follow member handbook instructions and Moda’s prior authorization process; review determinations reference Moda Health Medical Necessity Criteria (MHMNC) or MCG Guidelines (28th Edition).

• When MHMNC or MCG criteria apply, reference those guidelines in authorization requests.
• Services on the Medical/Surgical Services Prior Authorization List require prior authorization and review against Moda criteria.

Reference MHMNC or MCG criteria in authorization requests

Medical necessity and prior authorization determinations are reviewed using Moda Health Medical Necessity Criteria (MHMNC) or MCG Guidelines (28th Edition); authorization requests must reference the applicable criteria.

• When applicable, cite MHMNC or MCG (28th Edition) in authorization documentation.
• Failure to meet referenced criteria may result in denial of prior authorization or claim payment.

eviCore review — submit supporting documentation for reconstructive requests

Review requests such as breast reconstruction are performed by eviCore; include documentation that supports medical necessity (vs cosmetic) when submitting for review.

• eviCore reviews breast reconstruction requests (e.g., CPT 19328, 19330) and determines coverage.
• Provide documentation demonstrating medical necessity when the indication is not post‑mastectomy reconstruction for cancer.

Not-covered codes — these codes may be denied if billed

Claims for certain codes listed as Not Covered (for example G0482, G0483, 0082U, 0227U, 0517U–0519U, 0520U) are identified as Not Covered and may be denied if billed.

• If billed with Not Covered codes (G0482, G0483, 0082U, 0227U, 0517U–0520U), claims may be denied.
• Verify appropriate codes (use covered codes such as 80305–80307, G0480/G0481 for urine testing) before submission.

Confirm prior authorization requirement via the Medical/Surgical Services Prior Authorization List

Use the Medical/Surgical Services Prior Authorization List to identify services requiring prior authorization; services on that list require review per Moda Health Medical Necessity Criteria (MHMNC) or MCG Guidelines and may be denied if authorization is not obtained.

• Providers should consult the Prior Authorization List to confirm which CPT/HCPCS codes need prior authorization.
• Lack of required prior authorization for list items may lead to claim denial.