Plan variability & quarterly updates

Code lists are maintained and updated quarterly. Immunizations, injectable drugs, and specialty medications are not managed in these coding lists; those items are handled through Pharmacy. Coverage and preauthorization requirements vary by plan type and employer group — verify member benefits before billing.

• Code lists updated quarterly — verify member plan benefits before billing
• Lists exclude immunizations, injectable drugs, specialty meds — consult Pharmacy link
• Coverage differs by plan type (Small Employer Individual vs Large Employer)

Preauthorization: provider actions

Providers must obtain prior authorization when a code is marked Preauthorization Required for the member’s specific plan. For rental DME items, operational policy requires preauthorization if criteria are not met after the third rental month.

• Obtain prior authorization for codes marked Preauthorization Required = X for the member’s plan
• 'Preauth after 3rd rental month when criteria not met' — applies to DME rentals (operational rule)

Not Covered = denial risk

Codes flagged Not Covered for a given plan type are a denial risk. Do not bill these codes as covered for affected plans; claims submitted for Not Covered codes will deny unless an approved exception exists.

• Do not bill codes marked Not Covered (X) for the specified plan type; claims will deny
• Examples: representative Not Covered codes from the policy (sample CPT/HCPCS): 11950, 11951, 11952, 11954, 15775, 15776, 15780, 15781, selected U/Q codes