AUTHORIZATION REQUIREMENTS

Transcription

1 AUTHORIZATION REQUIREMENTS For dates of service on or after January 1, 2019 The following list contains services, items and medications that require authorization prior to being provided or administered for Cigna-HealthSpring plan participating care providers. Authorization requirements outlined in this document apply to all Cigna-HealthSpring markets except Arizona and Leon in Florida. Any code marked with an * are designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only. Authorization requirements for Part B medications are listed separately at the end of this document. Authorization is not required for emergency or urgent care. All out of network physicians, facilities and other health care providers must request authorization for all procedures and services, excluding emergent or urgent care. Services must be provided according to Medicare coverage guidelines established by CMS. According to the guidelines, all medical care, services, supplies and equipment must be medically necessary. You may review Medicare coverage guidelines at All final decisions concerning coverage and payment are based upon plan customer eligibility, the customer s benefits, the care provider s contract and applicable State law at the time of service delivery. Authorization and/or referral number(s) is/are not a guarantee of payment. Please always verify benefits. Authorization request can be submitted by phone, fax or via Cigna-HealthSpring s web-based HealthSpring Connect (HSC). Please see the HSC section of the Provider Manual for an overview of capabilities and instructions for obtaining access. Cigna-HealthSpring referral policy Cigna-HealthSpring values the relationship between the patient, the Primary Care Physician and other providers involved in the patient s medical care. Cigna-HealthSpring s network of specialty physicians are contracted to work closely with our referring PCPs to coordinate and improve the quality of care provided to Cigna-HealthSpring customers. In 2019, a referral may or may not be required for a patient to see a specialist. Please refer to the 2019 Provider Manual below to determine if a referral is required for your patient. Cigna-HealthSpring authorization requirements When required, it is the participating provider s responsibility to obtain authorization prior to services being rendered. Facilities are encouraged to verify that a prior authorization has been approved before providing a service or item, unless the service is urgent or emergent care. Payment may be denied for services rendered without authorization. Refer to the online directory at provider-manual/2019-provider-manual. Or contact Provider Customer Service, toll-free to locate an in-network health care professional or facility. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. INT_19_72040_C Approved

2 Admissions All inpatient admissions including: Inpatient Medical and Behavioral Health Inpatient Rehabilitation LTAC Inpatient Observation Skilled Nursing Facility Ambulance A0430 A0431 A0435 A0999 Cardiology Echo EKG C C C8929 Stress T Other T T T * T T T 0463T Diagnostic Services T Durable Medical Equipment (DME) **All non-preferred DME items require authorization in addition to the codes listed in this document T T T T T T T 0422T T 0434T T 0435T T 0436T T 0506T T 0507T T 0508T E0156 E0760 K0005 K0837 E0184 E0766 K0009 K0841 E0188 E0770 K0011 K0848 E0194 E0784 K0554 K0849 E0303 E0986 K0800 K0850 E0466 E1002 K0801 K0851 E0483 E1006 K0802 K0852 E0627 E1007 K0806 K0856 E0628 E1008 K0807 K0858 E0629 E1010 K0808 K0861 E0635 E1220 K0812 K0862 E0651 E1230 K0813 K0898 E0652 E1399 K0814 L2005

3 DME continued E0657 E1810 K0816 L5781 E0667 E2300 K0820 L5782 E0670 E2301 K0821 L5848 E0676 E2363 K0822 L5856 E0692 E2387 K0823 L5858 E0694 E2510 K0824 L6638 E0730 E2512 K E0745 E2599 K E0747 E2603 K E0748 E2620 K0835 Home Health G0151 G0156 S9122 S9341 G0152 G0248 S9123 S9342 G0153 G0249 S9128 S9343 G0154 G0299 S9338 T1030 G0155 G0300 Invasive Diagnostic Services * T *0076T * T 0355T T *0075T C9741 *48400 Laboratory Including Genetic Testing U 0050U 0106T U 0053U 0107T U 0054U 0108T U 0055U 0109T U 0056U 0110T U 0057U 0111T U 0058U 0423T 0012M 0045U 0059U G M 0047U 0060U S U 0048U 0061U S U 0049U Mental Health OB / GYN *59120 *59140 *59830 *59856 *59121 *59325 *59850 *59857 *59130 *59350 *59851 *99478 *59135 *59514 *59852 *99479 *59136 *59620 *59855 *99480 Orthotics and Prosthetics L0457 L5321 L5981 L8040 L0650 L5701 L5987 L8041 L1832 L5814 L5999 L8042 L1833 L5828 L6611 L8045 L1844 L5840 L6624 L8400 L1846 L5845 L6880 L8499 L2397 L5850 L6935 L8605 L3000 L5925 L6955 L8614 L3908 L5930 L7007 L8619

4 Orthotics & and Prosthetics continued L3960 L5968 L7009 L8641 L5050 L5973 L7259 L8690 L5220 L5980 L7499 L8691 Pain Management T T T T T Part B Drugs and Biologics J0606 Q2040 Q4118 Q4152 J1439 Q2050 Q4121 Q4159 J7312 Q4102 Q4124 J7325 J7330 Q4106 Q4128 J7326 J7336 Q4110 J3385 J7327 Q0138 J1458 J3490 J7328 C9030 J1459 J3590 J7682 C9032 J1460 J7175 J9017 C9399 J1556 J7179 J9035 J0129 J1557 J7180 J9047 J0135 J1559 J7181 J9055 J0178 J1560 J7182 J9214 J0180 J1561 J7183 J9226 J0202 J1566 J7185 J9228 J0220 J1568 J7186 J9271 J0221 J1569 J7187 J9299 J0256 J1572 J7188 J9301 J0257 J1575 J7189 J9303 J0490 J1595 J7190 J9305 J0585 J1599 J7192 J9306 J0586 J1602 J7193 J9308 J0587 J1743 J7194 J9310 J0588 J1745 J7195 J9354 J0597 J1786 J7197 J9355 J0598 J1931 J7198 J9400 J0717 J2278 J7199 J9999 J0725 J2323 J7200 Q2040 J0775 J2354 J7201 Q2041 J0800 J2357 J7202 Q2043 J0881 J2425 J7205 Q2050 J0882 J2503 J7210 J0885 J2504 Q4131 J0886 J2505 Q4132 Q0139 Q4117 Q4133

5 Part B Drugs and Biologics continued J0887 J2507 J J0888 J2778 J J0897 J2796 J J1290 J3060 J J1300 J3240 J J1438 J3262 J J1442 J J1447 J T G G G T * T *99191 Q *99192 Q9995 *99184 J Radiology Cat scan (CT) T 71260

6 Magnetic Resonance Imaging (MRI) C S Nuclear Medicine T T A A9513 A9543 C9408 Positron Emission Tomography (PET) Radiation Therapy T T G G G G G G G G G G G G G G G G G6016

7 Radiation Therapy continued G C9726 C C9726 C A9543 Therapeutic Radiology * * * *75958 Other T G T 0353T G T 0354T G T C9733 G T G0210 S8035 Ultrasound Rehab and Therapy * * G G G Services and Supplies A6196 C1722 C2616 Q4119 A6197 C1759 C2624 Q4135 A6212 C1764 K0553 Q4166 A6222 C1767 K0606 Q4167 A7031 C1778 L6881 Q4168 A7032 C1783 L6882 Q4169 A7033 C1785 L8679 Q4170 A7036 C1813 Q0479 Q4171 A7046 C1874 Q0481 Q4172 A7507 C1875 Q0495 Q4173 A7520 C1882 Q0508 Q4174 B4150 C1889 Q4100 Q4175 C1721 Surgery Anesthesia 0102T Cardio / Thoracic *33365 *33910 * *33366 *33915 * *33367 *33916 * *33368 *33917 * *33369 *33920 *35560 *31725 *33390 *33922 *35563 *31760 *33391 *33924 *35565 *31766 *33404 *33925 *35566 *31770 *33405 *33926 *35570 *31775 *33406 *33930 *35571 *31780 *33410 *33933 *35583

8 Cardio / Thoracic continued *31781 *33411 *33935 *35585 *31786 *33412 *33940 *35587 *31800 *33413 *33944 *35600 *31805 *33414 *33945 * *33415 *33946 *35606 *32035 *33416 *33947 *35612 *32036 *33417 *33948 *35616 *32096 *33418 *33949 *35621 * *33951 *35623 *32098 *33420 *33952 *35626 *32100 *33422 *33953 *35631 *32110 *33425 *33954 *35632 *32120 *33426 *33955 *35633 *32124 *33427 *33956 *35634 *32140 *33430 *33957 *35636 *32141 *33460 *33958 *35637 *32150 *33463 *33959 *35638 *32151 *33464 *33962 *35642 *32160 *33465 *33963 *35645 *32200 *33468 *33964 *35646 *32215 *33470 *33965 *35647 *32220 *33471 *33966 *35650 *32225 *33474 *33967 *35654 *32310 *33475 *33968 *35656 *32320 *33476 *33969 *35661 *32440 *33477 *33970 *35663 *32442 *33478 *33971 *35665 *32445 *33496 *33973 *35666 *32480 *33500 *33974 *35671 *32482 *33501 *33975 *35681 *32484 *33502 *33976 *35682 *32486 *33503 *33977 *35683 *32488 *33504 *33978 *35691 *32491 *33505 *33979 *35693 *32501 *33506 *33980 *35694 *32505 *33510 *33981 *35695 *32506 *33511 *33982 *35700 *32507 *33512 *33983 *35701 *32540 *33513 *33984 * *33514 *33985 *35741 *32650 *33516 *33986 *35800 *32651 *33517 *33987 *35820 *32652 *33518 *33988 *35840 *32653 *33519 *33989 *35870 *32654 *33521 *

9 Cardio / Thoracic continued *32655 *33522 * *32656 *33523 *33992 *35901 *32658 *33530 *33993 *35905 *32659 * *35907 *32661 *33534 * *32662 *33535 * *32663 *33536 * *32664 *33542 *34401 *36823 *32665 *33545 *34451 *37140 *32666 *33548 *34502 *37145 *32667 * *37160 *32668 * *37180 *32669 *33602 *34808 *37181 *32670 *33606 *34812 *37182 *32671 *33608 * *32672 *33610 * *32673 * *37215 *32674 * *37217 *32800 *33615 *34830 *37218 *32810 *33617 * *32815 *33619 * *32820 *33620 * *32850 *33621 * *32851 *33622 * *32852 *33641 * *32853 *33645 * *32854 *33647 * *32900 *33660 * *32905 *33665 * *32906 *33670 * *32940 *33675 * *32997 * *33677 * *33681 * *33015 *33684 * *33020 *33688 * *33025 *33690 *35021 *37616 *33030 *33692 *35022 *37617 *33031 *33694 *35081 *37618 *33050 *33697 *35082 *37660 *33120 *33702 * *33130 *33710 * *33140 *33720 * *33141 *33722 * *33202 *33724 *

10 Cardio / Thoracic continued *33203 *33726 * *33730 * *33732 *35122 * *33735 * *33736 * *33737 * *33750 * *33755 * *33762 *35152 * *33764 * *33766 *35189 * *33767 *35211 * *33768 * *33770 * T *33771 *35241 *0235T *33774 * T *33236 *33775 * T *33237 *33776 * T *33238 *33777 *35276 *0254T *33778 *35281 *0266T *33243 *33779 * T *33780 * T *33250 *33781 *35303 *0345T *33251 *33782 * T *33254 *33783 * T *33255 *33786 * T *33256 *33788 * T *33257 *33800 * T *33258 *33802 * T *33259 *33803 * T *33261 *33813 * T *33814 * T *33820 * T *33822 *35371 *0451T *33265 *33824 *35372 *0452T *33266 *33840 * T *33845 * T *33851 *35506 *0455T *33852 *35508 *0456T *33300 *33853 * T *33305 *33860 * T *33310 *33863 *35515 *0459T *33315 *33864 * T *33320 *33870 *35518 *0461T *33321 *33875 *35521

11 Cardio / Thoracic continued *33322 *33877 *35523 *33330 *33880 *35526 *33335 *33881 *35531 *33340 *33883 *35533 *33361 *33884 *35535 *33362 *33886 *35536 *33363 *33889 *35537 *33364 *33891 *35538 Dermatology / Plastic T T C C5272 * C5273 * C5275 * C Ear Nose Throat * * * *31360 * *31365 * *31367 * * * * *31380 * * *31390 * *31225 * * *69554 * T T * General Surgery *11004 *43116 *44156 *47480 *11005 *43117 *44160 *47550 *11006 * *11008 *43121 * *16036 *43122 * *43123 *44202 *47570 *19271 *43124 *44203 *47600 * *44204 * *43135 *44205 *47610

12 General Surgery continued *44206 * *43279 *44207 *47620 * *44208 *47700 * *44210 * *44211 * *44212 * *44213 * *44227 * * * *43305 *44300 * *43310 *44310 * *43312 *44314 * *43313 *44316 * *43314 *44320 * *43320 *44322 *47785 *19361 *43325 *44345 *47800 *19364 *43330 *44346 * *43331 *44602 *47802 *19367 *43340 *44603 *47900 *19368 *43341 *44604 *48000 *19369 *43351 *44605 * *43352 *44615 * *43360 *44620 * *43361 *44625 * *43400 *44626 * *43401 *44640 * *43405 *44650 * *43410 *44660 * *43415 *44661 * *43425 *44680 * *43460 *44700 * * * *44800 * *43500 *44820 * *43501 *44850 * *43502 *44899 * *43520 *44900 * * * *43610 *44960 * * *48554 *38100 *43620 *45110 *48556 *38101 *43621 * *38102 *43622 *45112 *49000 *38115 *43631 *45113 * *43632 *45114 *49010

13 General Surgery continued *43633 *45116 * *43634 *45119 *49040 *38380 *43635 *45120 *49060 *38381 *43640 *45121 *49062 *38382 *43641 *45123 *49215 * *45126 *49220 * *45130 * *43771 * * * *45395 *49412 * *45397 *49425 *38747 *43775 *45400 *49428 *38765 *43800 *45402 *49605 *38770 *43810 *45540 *49606 *38780 *43820 *45550 * *43825 *45562 *49611 *39000 *43832 * *39010 *43840 * *39200 *43843 * *39220 *43846 * *43847 * *39499 * *39501 *43850 * *39503 * *39540 *43860 *46710 *49900 *39541 *43865 *46712 *49904 *39545 *43880 *46715 *49905 * *46716 *49906 * * * *46735 * *44005 * *41130 *44010 * *41135 *44015 * *41140 *44020 * *41145 *44021 * *41150 *44025 * *41153 * *41155 *44055 *47010 * *44110 *47015 * *44111 * *44120 * *44121 *47122 * *44125 * *44126 *47130 * *44127 *47133 * *44128 *47135 *60540

14 General Surgery continued * *60545 *42426 *44132 *47300 * *44133 *47350 * *44135 *47360 *60650 *42845 *44136 * *42894 *44139 *47362 * * *61635 *42953 * *42961 *44143 * T *42971 *44144 * T *43045 * T *43100 * T *43101 *44147 * T *43107 *44150 * T *43108 *44151 * T *43112 *44155 *47460 S8030 *43113 Gynecology * *58611 *56630 *57308 * *56631 *57311 * * * * *58293 *58700 *56634 * *58720 *56637 *57540 *58400 *58740 *56640 *57545 *58410 *58750 * *58520 *58752 *57111 *58140 *58540 *58760 *57112 * * * * * *58940 *57270 * *58943 *57280 * * * * * * * *58267 *58605 *58960 *57305 Neurosurgery *61571 *62143 * *61575 *62145 * *61576 *62146 * *61580 *62147 *63273 *61105 *61581 *62148 *63275 *61107 *61582 *62161 *63276 *61108 *61583 *62162 *63277

15 Neurosurgery continued *61120 *61584 *62163 *63278 *61140 *61585 *62164 *63280 *61150 *61586 *62165 *63281 *61151 *61590 *62180 *63282 *61154 *61591 *62190 *63283 *61156 *61592 *62192 *63285 *61210 *61595 *62200 *63286 *61250 *61596 *62201 *63287 *61253 *61597 *62220 *63290 *61304 *61598 *62223 *63295 *61305 *61600 *62256 *63300 *61312 *61601 *62258 *63301 *61313 * *63302 *61314 * *63303 *61315 * *63304 *61320 * *63305 *61321 * *63306 *61322 * *63307 *61323 * *63308 *61332 * *61333 * *61340 * *61343 * *61345 * *63700 *61450 * *63702 *61458 * *63704 *61460 * *63706 *61480 * *63707 *61500 * *63709 *61501 * *63710 *61510 *61697 *63050 *63740 *61512 *61698 * *61514 * *61516 *61702 * *61518 *61703 * *61519 *61705 * *61520 *61708 * *61521 *61710 * *61522 *61711 * *61524 *61735 * *61526 *61750 * *61530 *61751 * *61531 *61760 *63091 *64755 * *63101 *64760 * *63102 *64809

16 Neurosurgery continued * *63103 *64818 * *63170 *64866 *61537 *61850 *63172 *64868 *61538 *61860 * *61539 *61863 * *61540 *61864 * *61541 *61867 *63185 *0202T *61543 *61868 * T *61544 *61870 * T * * T * * T * * T * * T *61552 *62005 * T *61556 *62010 * T *61557 *62100 * T *61558 *62115 * T *61559 *62117 * T *61563 *62120 * T *61564 *62121 * T *61566 *62140 * T *61567 *62141 * T *61570 *62142 * T Ophthalmology *

17 Ophthalmology continued T T T T T T T T T T T T S Orthopedics * *27557 * *27558 * *25900 *27580 * *25905 *27590 * *25915 *27591 *20808 *22532 *25920 *27592 *20816 *22533 *25924 *27596 *20824 *22534 *25927 *27598 *20827 * * *27645

18 Orthopedics continued * * *22558 * *20955 *22586 * *20956 *22590 * *20957 *22595 * *20962 * *20969 * * * *22630 *26992 * *22632 * *22633 * *22634 *27030 * *22800 *27036 * *22802 *27054 *27724 *21045 *22804 *27070 * *22808 * *22810 *27075 * *22812 * *22818 * *21141 *22819 * *21142 *22830 * *21143 *22841 * *21145 *22843 * *21146 *22844 * *21147 *22846 * *21151 *22847 * *21154 *22848 *27132 *27880 *21155 *22849 *27134 *27881 *21159 *22850 *27137 *27882 *21160 *22852 *27138 *27886 *21179 *22855 *27140 *27888 * * *21182 *22857 * * * *21184 *22861 * *21188 *22862 * *21194 *22864 * *22865 * * * * * *23200 * *23210 * *23220 * *23335 *

19 Orthopedics continued * * * * *21255 *23472 * * * *23474 * * * * * * * * * * * * * *21366 *23900 * *23920 *27268 * * * * * * * * * * * * * * * * * * * * * * * * * * * *21750 *24900 * *21825 *24920 * *24930 * *22010 *24931 * *22015 *24940 * *27465 *0095T * *27466 *0098T

20 Orthopedics continued * *27468 *0163T * *27470 *0164T * *27472 *0165T * *27486 *0195T * *27487 *0196T * * T * * T * *27506 *0219T * *27507 *0220T * T * * T * * T * * T * *27519 *0375T * T * *27535 *G0412 * *27536 *G0414 * *27540 *G0415 * *27556 Other *43845 * *43881 * *43882 * T *44137 * T *32503 *44157 * T *32504 *44158 * T *32855 *44715 * T *32856 *44720 *49205 C9600 *33507 * C * C *47141 *57296 *G * *G0342 *43644 *47143 *58548 *G0343 *43645 *47144 *58957 S *47145 *58958 S2900 Respiratory Urology *48552 *50545 *51550 * *50546 * *50010 *50547 * *50040 *50548 *51570 *54390 * * *50060 *50600 * *50065 *50605 * *50070 *50610 * *50075 *50620 * *50100 *50630 *

21 Urology continued *50120 *50650 * *50125 *50660 *51800 *54430 *50130 *50700 *51820 *54438 *50135 *50715 * *50205 *50722 * *50220 *50725 * * * *50230 *50728 *51920 *55605 *50234 *50740 *51925 *55650 *50236 *50750 *51940 *55801 *50240 *50760 *51960 *55810 *50280 *50770 *51980 *55812 *50290 * *55815 *50300 * *55821 *50320 * *55831 *50323 * *55840 *50325 * *55842 *50327 * *55845 *50328 * *55862 *50329 * *55865 *50340 * *50360 *50830 * *50365 * *50370 * *50380 * *50400 * *50405 *50920 * *50500 * *58953 *50520 * *58954 * T * T * T *51525 *54125 C *51530 *54130 C9740 Vision / Eyewear V2200 V V2203 V V2207 V V2300 V V2531 V V2623 V V2624 V V2020 V2625 V V2100 V2626 V V2103 V2627