Medicaid Prior Auth (PA) Code Matrix Effective July 1, 2018
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1 Behavioral Health, Mental Health, Alcohol & Chemical Dependency Services; Autism Spectrum Disorder Medicaid: Inpatient, Residential Treatment, Partial Hospitalization, Electroconvulsive Therapy (ECT), Applied Behavior Analysis (ABA) for tx of Autism Spectrum Disorder (ASD) * 90837* 90849* H0011 H0018 H0046 H2015 H2019^ S9482 T1027^ T2013^ S T 0368T * 90838* 90853* H0012* H0019 H2012^ H2016 H2020 T1023^ T1028^ T2040^ 0359T 0363T 0369T * 90846* H0015 H0031^ H2013 H2017^ H2030 T1025^ T1025^ S T 0364T 0370T * 90847* H0010 H0017 H0032^ H2014^ H2018 H2037 T1026^ T1027^ S5150^ 0361T 0365T * Authorization required after 24 visits annually (Year considered 7/1-6/30) ^ PA required only when submitted with Autism Dx. [ICD10: F84.0, F84.2, F84.3, F84.4, F84.5, F84.8 or F84.9] Cosmetic, Plastic & Reconstructive Procedures [In Any Setting] 11900* * 19324* 19330* 19350* * * 19325* 19340* 19355* * * 19328* 19342* 19396* * PA required, EXCEPT with breast CA Dx. [ICD10 codes: C50 - C and D05 - D05.92] Durable Medical Equipment (DME) A7025 E0265 E0372 E0629 E0673 E0783 E1007 E1226 E2202 E2323 E2362 E2381 E2402 E2631 K0108 K0823 K0843 K0864 S A8004 E0266 E0373 E0630 E0675 E0784 E1008 E1227 E2203 E2324 E2363 E2382 E2500 E8000 K0554 K0824 K0848 K0868 S A8003 E0277 E0433 E0635 E0691 E0785 E1010 E1229 E2204 E2325 E2364 E2383 E2502 E8001 K0606 K0825 K0849 K0869 S A9900 E0292 E0434 E0636 E0692 E0786 E1011 E1230 E2218 E2326 E2365 E2384 E2504 E8002 K0733 K0826 K0850 K0870 S1037 A9901 E0293 E0435 E0638 E0693 E0849 E1012 E1232 E2227 E2327 E2366 E2385 E2506 K0002^ K0800 K0827 K0851 K0871 S1040 A9276 E0294 E0444 E0640 E0694 E0855 E1014 E1233 E2228 E2328 E2367 E2386 E2508 K0003 K0801 K0828 K0852 K0877 T5001 A9277 E0295 E0462 E0641 E0731 E0947 E1020 E1234 E2291 E2329 E2368 E2387 E2510 K0004 K0802 K0829 K0853 K0878 T5999 A9278 E0296 E0465 E0650 E0740 E0948 E1029 E1235 E2292 E2330 E2369 E2388 E2511 K0005 K0806 K0830 K0854 K0879 V2530 C2624 E0297 E0466 E0651 E0744 E0983 E1030 E1236 E2293 E2331 E2370 E2389 E2512 K0006 K0807 K0831 K0855 K0880 V2531 E0193 E0300 E0470 E0652 E0747 E0984 E1035 E1237 E2294 E2340 E2371 E2390 E2599 K0007 K0808 K0835 K0856 K0884 E0194 E0301 E0471 E0656 E0748 E0986 E1036 E1238 E2295 E2341 E2372 E2391 E2609 K0008 K0813 K0836 K0857 K0885 E0217 E0302 E0472 E0657 E0749 E0988 E1037 E1296 E2310 E2342 E2373 E2392 E2617 K0009 K0814 K0837 K0858 K0886 MHSC 2018 Q3 Medicaid PA Code Matrix (Final) Page 1 of 10
2 E0248 E0303 E0481 E0667 E0760 E1002 E1050 E1298 E2311 E2343 E2374 E2393 E2626 K0010 K0815 K0838 K0859 K0890 E0255 E0304 E0483 E0670 E0762 E1003 E1060 E1310 E2312 E2351 E2375 E2394 E2627 K0011 K0816 K0839 K0860 K0891 E0256 E0328 E0601 E0668 E0764 E1004 E1070 E1399 E2313 E2359 E2376 E2395 E2628 K0012 K0820 K0840 K0861 K0900 E0260 E0329 E0625 E0671 E0766 E1005 E1161 E1700 E2321 E2360 E2377 E2396 E2629 K0013 K0821 K0841 K0862 L8619 E0261 E0371 E0627 E0672 E0782 E1006 E1225 E2201 E2322 E2361 E2378 E2397 E2630 K0014 K0822 K0842 K0863 Note to MHI: Red codes added to SC PA requirements ^PA required if claim >$500 Experimental/Investigational 0042T 0101T 0165T 0200T 0214T 0231T 0265T 0290T 0329T 0349T 0361T 0373T 0404T 0416T 0428T 0436T 0476T 0488T 0500T T 0102T 0174T 0201T 0215T 0234T 0266T 0295T 0330T 0350T 0362T 0374T 0405T 0417T 0429T 0437T 0477T 0489T 0501T T 0106T 0175T 0202T 0220T 0235T 0267T 0296T 0331T 0351T 0363T 0394T 0406T 0418T 0430T 0440T 0478T 0490T 0502T T 0107T 0254T 0205T 0221T 0236T 0268T 0297T 0332T 0352T 0364T 0395T 0407T 0419T 0431T 0441T 0479T 0491T 0503T T 0108T 0184T 0206T 0222T 0237T 0269T 0298T 0333T 0353T 0365T 0396T 0408T 0420T 0432T 0445T 0480T 0492T 0504T T 0109T 0188T 0207T 0228T 0238T 0270T 0308T 0335T 0354T 0366T 0397T 0409T 0421T 0433T 0469T 0481T 0493T T 0110T 0189T 0208T 0229T 0249T 0271T 0312T 0337T 0355T 0367T 0398T 0410T 0422T 0434T 0470T 0482T 0494T Q T 0111T 0190T 0209T 0216T 0253T 0272T 0313T 0338T 0356T 0368T 0399T 0411T 0423T 0435T 0471T 0483T 0495T Q T 0126T 0191T 0210T 0217T 0254T 0273T 0314T 0339T 0357T 0369T 0400T 0412T 0424T 0439T 0472T 0484T 0496T Q T 0159T 0195T 0211T 0218T 0255T 0274T 0315T 0342T 0358T 0370T 0401T 0413T 0425T 0442T 0473T 0485T 0497T Q T 0163T 0196T 0212T 0219T 0263T 0275T 0316T 0347T 0359T 0371T 0402T 0414T 0426T 0443T 0474T 0486T 0498T Q T 0164T 0198T 0213T 0230T 0264T 0278T 0317T 0348T 0360T 0372T 0403T 0415T 0427T 0444T 0475T 0487T 0499T Genetic Counseling & Testing Green highlighted CPT codes can be auto approved if PA is requested with a pregnancy diagnosis* 0004M 0012U G9143 S U 0013U S3722 S M 0014U S3800 S M 0016U S M 0017U ^ S U ^81521 * S3842 MHSC 2018 Q3 Medicaid PA Code Matrix (Final) Page 2 of 10
3 0009U S U ^S U * G0464 S3861 *Code 84999: Including Oncotype Dx Habilitative Therapy Note: Please refer to the "Speech Therapy" section later in this document ^ PA required, EXCEPT with breast CA Dx. [ICD10 codes: C50 - C and D05 - D05. *PA required, EXCEPT when billed with a Prostate CA Dx Home Health Care Services For 2018: starting 1/1/2018 Home Health Services require prior authorization after the initial evaluation/visit. (See green shaded note below for home based PT/OT and Speech Therapy. for home based PT/OT and Speech Therapy. NOTE: Prior Authorization may be required for medications associated with HOME INFUSION therapy G0155 G0162 G0299 G0493 G0496 G9680 G9683 S9122 S9127 S5150 S9379 T1000 T1005 T G0156 G0163 G0300 G0494 G0515 G9681 G9684 S9123 S5130 S5151 S9470 T1002 T1021 T G0162 G0164 G0490 G0495 G9679 G9682 S9124 S5135 S9129 S9977 T1003 T1022 T1031 NOTE: Green shaded codes - although the therapy codes noted below are performed in the home setting, prior authorization requirements follow the appropriate therapy service (e.g. see Physical or Occupational Therapy secti G0151 G0157 G0160 S9128 G0152 G0158 G0161 S9129 G0153 G0159 S9131 Hospice Requires NOTIFICATION only Q5001 Q5003 Q5005 Q5007 Q5009 Q5002 Q5004 Q5006 Q5008 Q5010 MHSC 2018 Q3 Medicaid PA Code Matrix (Final) Page 3 of 10
4 Hyperbaric Therapy G Q4176 Q4177 Q4178 Q4179 Q4180 Q4181 Q4182 Incontinent Supplies Do NOT Require Prior Authorization up to Allowable Amounts Imaging Advanced & Specialty C8900 C8909 C8931 S C8901 C8910 C C8902 C8911 C C8903 C8912 C C8904 C8913 C C8905 C8914 C C8906 C8918 G C8907 C8919 G C8908 C8920 S Incontinence Supplies No Prior authorization required up to allowable limits For members 4 years of age and older. Physician must certify, in writing, the member has an inability to control bowel or bladder function Physician Certification of Incontinence Form must be completed by the Primary Care Physician for a 3, 6, 9 or 12 month timeframe (as chosen by the physician). Incontinence Physicial Certification Forms MUST be kept on file by the incontinence supply provider and are subject to validation and auditing In-Patient Admissions MHSC 2018 Q3 Medicaid PA Code Matrix (Final) Page 4 of 10
5 Acute Hospital, Skilled Nursing Facilities (SNF), Rehabilitation, Long Term Acute Care (LTAC) Facility, Psychiatric Residential Treatment Facility (PRTF) All elective inpatient; SNF, Rehab and LTAC admissions require prior authorization with the exception of hospice. Hospice does NOT require prior authorization but rather simply notification of services. All urgent/emergent inpatient admissions require that authorization be obtained and Molina notified of the admission within 1 business day. Long Term Services & Support S5100 S5101 S5102 S5105 S5125 S5126 S9122 T1019 T1020 T1021 Neuropsychological & Psychological Tests (in any setting) Non-PAR Offices/Providers/Facilities PA required for Office Visits, Surgical Procedures, Labs, Diagnostic Studies & In-patient stays, except for: Emergency Department Services Professional fees associated with an Emergency Department visit and approved Ambulatory Surgery Center (ASC) or in-patient stay Local Health Department (LHD) services Other services based on State requirements Occupational Therapy SC - Age 18 and younger require prior authorization after the initial evaluation plus six (6) visits for outpatient and home settings SC - Age 19 and over do NOT require prior authorization for occupational therapy G0281 G0152 S G0283 G G0329 G G0160 Unlike the OT codes noted above, the following home based OT code requires prior authorization AFTER the INITIAL Evaluation/visit. G0160 MHSC 2018 Q3 Medicaid PA Code Matrix (Final) Page 5 of 10
6 ** In SC is not reimbursable to Occupational Therapy providers. Prior Auth requests with an occupational therapist as the servicing provider will be denied. Office Visits & Office Based Surgical Procedures for Participating (PAR) Providers Participating Physician/Provider office-based procedures do NOT require Prior Authorization Non-Participating Offices/Providers/Facilities see section above entitled Non-PAR Offices/Providers/Facilities for authorization requirements Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures C C C C C C S MHSC 2018 Q3 Medicaid PA Code Matrix (Final) Page 6 of 10
7 Pain Management Procedures Except trigger point injections G Physical Therapy Ages 18 and younger require authorization after the initial evaluation plus six (6) visits for outpatient and home settings. Ages 19 and over do NOT require prior authorization for physical therapy services G G0151 G G0157 G S9131 Unlike the PT codes noted above, the following home based PT codes required prior authorization AFTER the INITIAL Evaluation/visit. G0159 MHSC 2018 Q3 Medicaid PA Code Matrix (Final) Page 7 of 10
8 ** In SC is not reimbursable to Physical Therapy providers. Prior Auth requests with an physical therapist as the servicing provider will be denied. Pregnancy and Delivery Notification Only Prosthetics & Orthotics L0480 L0452 L0627 L0632 L0640 L0651 L1005 L1685 L1730 L1844 L1904 L1945 L1980 L2010 L2036 L2060 L2108 L2800 L7259 L9900 L0482 L0622 L0629 L0634 L0648 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L7700 S1040 L0484 L0624 L0630 L0636 L0649 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8614 L0486 L0626 L0631 L0637 L0650 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 L8692 Radiation Therapy & Radio Surgery G0339 G0340 G6015 G6016 G6017 Q9950 Sleep Studies Note: Home Sleep Studies do NOT require prior authorization Specialty Pharmacy Drugs J0135 J0588 J0882 J1555 J1650 J2020 J2562 J3095 J7182 J7207 J7340 J9027 J9145 J9214 J9293 J9360 Q0138 S J0178 J0592 J0885 J1556 J1652 J2170 J2597 J3110 J7183 J7209 J7504 J9032 J9150 J9215 J9295 J9370 Q0139 S J0180 J0594 J0888 J1557 J1675 J2182 J2724 J3145 J7185 J7210 J7511 J9033 J9155 J9216 J9299 J9371 Q2040 S J0202 J0596 J0894 J1559 J1725 J2212 J2778 J3240 J7186 J7211 J7527 J9034 J9160 J9217 J9301 J9390 Q2043 S0128 A9542 J0205 J0597 J0895 J1560 J1726 J2248 J2783 J3262 J7187 J7296 J7639 J9035* J9171 J9218 J9302 J9395 Q2050 S0132 MHSC 2018 Q3 Medicaid PA Code Matrix (Final) Page 8 of 10
9 A9543 J0207 J0598 J0897 J1561 J1729 J2315 J2786 J3285 J7188 J7308 J7682 J9039 J9176 J9219 J9303 J9400 Q3027 S0145 C9014 J0220 J0606 J1230 J1562 J1740 J2323 J2788 J3315 J7189 J7309 J7686 J9040 J9178 J9225 J9305 J9600 Q3028 S0148 C9015 J0221 J0637 J1290 J1566 J1743 J2326 J2790 J3355 J7190 J7310 J7999 J9041 J9179 J9226 J9306 J9999 Q4074 S0157 C9016 J0256 J0638 J1300 J1568 J1744 J2350 J2791 J3357 J7191 J7311 J8499 J9042 J9181 J9228 J9307 Q5101 C9024 J0257 J0640 J1322 J1569 J1745 J2353 J2792 J3358 J7192 J7312 J8520 J9043 J9185 J9230 J9308 Q5102 C9028 J0287 J0641 J1324 J1570 J1750 J2354 J2793 J3380 J7193 J7313 J8521 J9045 J9190 J9245 J9310 C9029 J0289 J0695 J1325 J1571 J1756 J2357 J2796 J3385 J7194 J7316 J8655 J9047 J9200 J9261 J9315 C9132 J0364 J0714 J1428 J1572 J1786 J2425 J2820 J3396 J7195 J7320 J8670 J9050 J9201 J9262 J9325 C9257 J0480 J0717 J1438 J1573 J1826 J2430 J2840 J3489 J7196 J7321 J8700 J9055 J9202 J9263 J9328 C9293 J0485 J0725 J1439 J1575 J1830 J2440 J2860 J3490 J7197 J7323 J9000 J9060 J9203 J9264 J9330 C9399 J0490 J0740 J1442 J1595 J1833 J2469 J2916 J3590 J7198 J7324 J9015 J9065 J9205 J9265 J9340 C9488 J0565 J0775 J1447 J1599 J1930 J2502 J2940 J7175 J7199 J7325 J9017 J9070 J9206 J9266 J9351 C9492 J0570 J0800 J1453 J1602 J1931 J2503 J2941 J7178 J7200 J7326 J9019 J9098 J9207 J9267 J9352 C9493 J0585 J0850 J1458 J1627 J2504 J3030 J7179 J7201 J7327 J9022 J9100 J9208 J9268 J9354 C9494 J0586 J0875 J1459 J1640 J1950 J2505 J3060 J7180 J7202 J7328 J9023 J9120 J9209 J9280 J9355 J0129 J0587 J0881 J1460 J1645 J1955 J2507 J3090 J7181 J7205 J7330 J9025 J9130 J9211 J9285 J9357 *J9035: No PA required when used with ocular Dx's. (See "Dx Codes" tab for diagnosis codes ICD9 & ICD10 Codes allowed) Q2040 Mandatory review by Medical Director Speech Therapy Ages 18 and younger require authorization after the initial evaluation for outpatient and home settings. Ages 19 and over do NOT require prior authorization for speech therapy services S9152 S9128 G0153 G0161 Unlike the OT codes noted above, the following home based OT code requires prior authorization AFTER the INITIAL Evaluation/visit. G0161 ** In SC is not reimbursable to Speech Therapy providers. Prior Auth requests with an speech therapist as the servicing provider will be denied. \ Transplant Services (Including Solid Organ and Bone Marrow) Corneal Transplants do not require PA. MHSC 2018 Q3 Medicaid PA Code Matrix (Final) Page 9 of 10
10 S2053 S2061 S S2054 S2065 S S2055 S2140 S S2060 S2142 Transportation Services Prior Authorization is required for NON-EMEGENT Ambulance (air or ground). Emergent transport does NOT require Prior Authorization but is subject to retrospective claim review for medical necessity. A0426 A0428 A0430 A0431 A0999 S9960 S9961 Unlisted/Miscellaneous Codes ALL Unlisted and Miscellaneous Codes (not simply limited to the ones noted below) require prior authorization. Medical necessity documentation and rationale must be submitted with the request C1889 L3999 Q0509 V A4649 J7599 L5999 S0590 V A4913 K0898 L7499 T A9999 K0899 L8039 T B9999 L0999 L8499 V E0769 L1499 L8699 V E0770 L2999 Q0507 V E2599 L3649 Q0508 V2799 MHSC 2018 Q3 Medicaid PA Code Matrix (Final) Page 10 of 10
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