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Ambetter Prior Authorization Change Summary

Fecha: 21/06/23

Ambetter from Sunshine Health requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Ambetter products offered by Sunshine Health.

Ambetter from Sunshine Health is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice.

Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.

For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on our website at https://ambetter.sunshinehealth.com/provider-resources/manuals-and-forms/pre-auth.html

Effective August 1, 2023, the following are changes to prior authorization requirements:

Behavioral Health

PA Rule

Services

Procedure Codes

PA Required

BH short-term residential

H0018

No PA Required

Alcohol and/or drug services

H0004, H0005, H0007, H0014

No PA Required

Crisis intervention services

H2011

No PA Required

Substance abuse/detoxification and mental health services

S9475, S9484

Breast reconstruction

PA Rule

Services

Procedure Codes

PA Required except with breast cancer diagnosis

 

Breast reconstruction, prosthesis

19316, 19318, 19325, 19328,

19340, 19342, 19350, 19370,

19371, 19499, L8031

Cardiovascular

PA Rule

Services

Procedure Codes

PA Required

Revascularization

37220, 37221

PA Required

Unlisted procedure

37799

PA Required

Implantable wireless pulmonary artery wireless pressure sensor

C2624

No PA Required

Other cardiac procedures

93797, 93798

No PA Required

Intense cardiac rehab

G0422, G0423

No PA Required

Cardiac rehab program

S9472

Diagnostic and Therapeutic Radiology services

PA Rule

Services

Procedure Codes

PA Required

Indium in-111 ibritumomab, dx

A9542

PA Required

Ablation Liver Tumor

47382

DME & Supplies

PA Rule

Services

Procedure Codes

PA Required

Repair/maintenance for home

hemodialysis equipment

  A4870, A4890

PA Required

Osteogenesis stimulator

E0749

PA Required

 

Wheelchairs and accessories

E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613, E2614, E2615, E2616, E2617,

E2620, E2621, E2622, E2624

PA Required

Personal care item

S5199

No PA Required

Wheelchair and accessories

E2611

No PA Required

Respiratory equipment

E0550, E0565, E1390

No PA Required

Infusion pumps and supplies

K0455, B9002

Gastroenterology

PA Rule

Services

Procedure Codes

PA Required

Gastrointestinal transit and pressure measurement

91112

Home care

PA Rule

Services

Procedure Codes

PA Required

Home Care Management Services

G0087

PA Required

Home therapy

G2168

No PA Required

Home dialysis (ESRD)

90966

No PA Required

Home visit for prenatal monitoring and assessment

99500

No PA Required

In-home visit post-discharge and care plan oversight

G2001, G2002 G2004, G2005,

G2006, G2007, G2008, G2009, G2013, G2014, G2015

No PA Required

BCPI home visit

G9187

No PA Required

 

Remote in-home visits

G9978, G9979, G9980, G9981, G9982, G9983, G9984, G9985,

G9986, G9987

No PA Required

Management of patient home care

S0270, S0271, S0272, S0273,

S0274

No PA Required

Medical home program

S0280, S0281

No PA Required

Home visit, wound care

S9097, S9098

No PA Required

Home therapy hemodialysis and peritoneal dialysis

S9335, S9339

Infusion services

PA Rule

Services

Procedure Codes

No PA Required

Home infusion therapy

S5035, S5036, S5108, S5109, S5110, S5111, S5115, S5116, S9347

Laboratory

PA Rule

Services

Procedure Codes

PA Required

Genetic testing

0089U

No PA Required

 

Blood and blood products

P9010, P9011, P9016, P9021, P9022, P9051, P9054, P9056, P9057, P9058

No PA Required

Routine venipuncture

S9529

No PA Required

Multianalyte assays with algorithmic analyses

81508

Nutrition

PA Rule

Services

Procedure Codes

PA Required

Medical food nutritionally complete (oral)

S9433

Obstetric care

PA Rule

Services

Procedure Codes

No PA Required

Vaginal delivery

59400, 59409

Oncology

PA Rule

Services

Procedure Codes

PA Required

Radiation therapy services

77372, 77373, G0339, G0340

Orthopedic

PA Rule

Services

Procedure Codes

PA Required

Procedures lower extremities

28285, 28299

PA Required

Endoscopy wrist

29848

Other medical items or services

PA Rule

Services

Procedure Codes

PA Required unless performed on the same day as surgery

Injection, anesthetic agent or steroid

62320, 62321, 62322, 62323,

62325, 62327, 64400, 64405,

64415, 64417, 64418, 64420,

64421, 64430, 64445, 64447,

64448, 64450, 64451, 64454,

64479, 64480, 64483, 64484,

64505, 64510, 64517, 64520

PA Required

Injection procedure for sacroiliac joint

G0260

No PA Required

Transversus abdominis plane (TAP) block

64486, 64488

No PA Required

Nerve block

64632

Preventive

PA Rule

Services

Procedure Codes

PA Required

Direct skilled RN services

G0299

No PA Required

Physician or other qualified health care professional supervision

G0068, G0069, G0070, G0179,

G0182

No PA Required

Services performed in the hospice setting

G9473, G9474, G9475, G9476, G9477, G9478, G9479

Skin substitute

PA Rule

Services

Procedure Codes

PA RequiredSkin substitute products

Q4114, Q4130, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226

Sleep Medicine

PA Rule

Services

Procedure Codes

No PA Required

Sleep medicine testing

95800, 95806