Referral/Prior Authorization Grid. Contents. allcare cco

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1 allcare cco Referral/Prior Authorization Grid Contents 2-3 Alcohol and Drug 4-6 Mental Health 4 Adult Outpatient 4 Adult 5 Child Outpatient 5-6 Child 6 Peer Delivered Services 7 Physical Health 7-8 Provider Services 9 Diagnostic Services 9-12 Surgical Procedures & Services (ASC and Hospital) 13 Vision Services 13 Non-emergent Transportation Hospital Services 15 Pharmacy Services 15 Hospice Services 15 Skilled Nursing Facility Services 16 Home Health Services 16 Hearing Services 16 Dietary Counseling/Medical Education Services 16 Chemical Dependency Services 17 Dental Services Equipment and Supplies

2 AllCare CCO Alcohol and Drug Referral/Prior Authorization Grid Effective 01/01/2017 For alcohol and drug services contact the contracted provider: Curry County: Curry Community Health (541) Jackson County: Addictions Recovery Center (541) ; OnTrack, Inc. (541) Josephine County: OnTrack, Inc. (541) Modifiers are to be used on all codes: UA Adolescent Residential A&D HB Adult Residential A&D HF Substance Abuse/Outpatient Modifier Codes/Comments Prior Auth Required Outpatient - Adult and Adolescent Services provided in the community by a contracted Member may self-refer No Alcohol and Drug Provider Buprenorphine / Suboxone J0571-J0575, J0592 Probuphine (implant) J3490 Naltrexone J2315 Detoxification ASAM level IV-D Medically managed HF H0008-H0009 Yes detoxification ASAM level III.7-D Medically monitored HF H0010-H0011 Yes detoxification ASAM level III.2-D Clinically managed HF H0012-H0013 Yes detoxification ASAM level III-D Ambulatory detoxification HF H0014 Yes monitoring Residential - Adult ASAM level III.1 Clinically-Managed HB H0018-H0019 Yes Low Intensity treatment ASAM level III.3 Clinically-Managed HB H0018-H0019 Yes Medium Intensity treatment ASAM level III.5 Clinically-Managed HB H0018-H0019 Yes High Intensity treatment ASAM level III.7 Medically-Monitored HB H0018-H0019 Yes Intensive Inpatient Services Residential - Adolescent ASAM level III.1 Clinically-Managed UA H0018-H0019 Yes Low Intensity treatment ASAM level III.3 Clinically-Managed Medium Intensity treatment UA H0018-H0019 Yes 2 AllCare CCO (541) Toll free (888) Effective January 1, 2017

3 AllCare CCO Alcohol and Drug Referral/Prior Authorization Grid Effective 01/01/2017 For alcohol and drug services contact the contracted provider: Modifiers are to be used on all codes: Curry County: Curry Community Health (541) UA Adolescent Residential A&D Jackson County: Addictions Recovery Center (541) ; OnTrack, Inc. (541) HB Adult Residential A&D Josephine County: OnTrack, Inc. (541) HF Substance Abuse/Outpatient ASAM level III.5 Clinically-Managed High Intensity treatment ASAM level III.7 Medically-Monitored Intensive Inpatient Services Modifier Codes/Comments Prior Auth Required UA H0018-H0019 Yes UA H0018-H0019 Yes 3 AllCare CCO (541) Toll free (888) Effective January 1, 2017

4 AllCare CCO Mental Health Referral/Prior Authorization Grid Effective 01/01/2017 For mental health services contact the community mental health program in your county: Curry Community Health: (541) or toll-free 1 (877) Jackson County Mental Health: (541) or toll-free 1 (888) Options for Southern Oregon (Josephine County and Douglas County): (541) Adult Outpatient Services provided in the community and coordinated by Community Health Program. Adult Acute Inpatient Hospital Psychiatric Care (admission to a hospital behavioral health unit or on psychiatric hold in a hospital hold unit) Sub-Acute Psychiatric Care (admission to a non-hospital hold unit, crisis resolution center, crisis respite) Residential Treatment (Adult Foster Care, Residential Treatment Home, Residential Treatment Facility, Secured Residential Treatment Facility) Codes/Comments Member may self-refer, contact Community Mental Health Program H2013 Paid by Fee-For-Service OHP Prior Auth Required No Electroconvulsive Therapy (ECT) Health Program and AllCare Medical Director. Transcranial Magnetic Stimulation Applied Behavior Analysis (age 19 and older) Long-Term Psychiatric Care (State Hospitalization and Post Acute Intermediate Psychiatric Care) Services must be rendered by a Certified Provider in Oregon. Paid by Fee-For-Service OHP. Referrals are only coordinated from Acute Inpatient Hospital Psychiatric Care prior to admit into Oregon State Hospital. Referrals are coordinated by the Community Mental Health Agency, the Hospital, and the CCO. Determination and payments are done by the State Addictions and Mental Health Division. Yes. AMH makes determination. Supported Employment H2023 Assertive Community Treatment (ACT) H AllCare CCO (541) Toll free (888) Effective January 1, 2017

5 AllCare CCO Mental Health Referral/Prior Authorization Grid Effective 01/01/2017 For mental health services contact the community mental health program in your county: Curry Community Health: (541) or toll-free 1 (877) Jackson County Mental Health: (541) or toll-free 1 (888) Options for Southern Oregon (Josephine County and Douglas County): (541) Child Outpatient Services provided in the community and coordinated by Community Health Program. Child Wraparound Acute Codes/Comments Member may self-refer, contact Community Mental Health Program 90882, H0038, H2014, T1023, G1076, G1077 This is a specialized service that is currently offered to children with Child Welfare involvement. If you have questions regarding referral or eligibility, contact the Community Mental Prior Auth Required No Sub-Acute H2013 Respite H0045, S5151, T1005, H0002 Intensive Community-based Treatment Service (ICTS) Behavioral Rehabilitative Services (BRS) Psychiatric Residential Treatment Services (PRTS) (plus interactive code add-on 90785), 90862, H0004, T0123, 90882, G0176, G , (plus interactive add-on code 90785), H0036, H0038, S9484, H2011, 90847, H2010, 90792, H2021, H2022, (plus interactive code add-on 90785), 90833, 90834, 90836, Placement at BRS Facility paid by Department of Human Services (DHS) or Oregon Youth Authority (OYA), outpatient MH services paid 90849, 96101, H2032, H0034, T1016, H0031, H2014, T1013, 90846, H0032, (plus interactive code add-on 90785), 90862, H0004, T0123, 90882, G0176, G0177, 90887, plus interactive add-on code 90785, H0036 H AllCare CCO (541) Toll free (888) Effective January 1, 2017

6 AllCare CCO Mental Health Referral/Prior Authorization Grid Effective 01/01/2017 For mental health services contact the community mental health program in your county: Curry Community Health: (541) or toll-free 1 (877) Jackson County Mental Health: (541) or toll-free 1 (888) Options for Southern Oregon (Josephine County and Douglas County): (541) Codes/Comments Prior Auth Required Day Treatment H0037, H2012 Secured Children s Inpatient Program (SAIP) Secured Adolescent Inpatient Program (SAIP) Applied Behavior Analysis (age 0 through age 18) Peer Delivered Services Peer Support Specialist, Peer Wellness Specialist (Youth, Adult, and Family Member) Referrals are only coordinated from Acute Inpatient Hospital Psychiatric Care prior to admit into Oregon State Hospital. Referrals are coordinated by the Community Mental Health Agency, the Hospital, and the CCO. Determination and payments are done by the State Addictions and Mental Health Division. H0018-H0019 H0018-H0019 H0038 Yes. AMH makes determination. Yes. AMH makes determination. No. 6 AllCare CCO (541) Toll free (888) Effective January 1, 2017

7 Provider Services (in office setting- place of service 11) Referrals to Specialist (with exception of routine OB care and contraceptive management) (for vision see Vision Services) Pediatric Assessment Neuropyschology testing Preventive and Wellness Services Screening Colonoscopy (under age 50) Bone mass measurement (if over the benefit limit - once every 2 years) Prostate cancer screening (under age 50) Anesthesia Services Pain management , , , , , , Spinal Cord Stimulator , Injections and Treatments Acupuncture Allergy Injections Botox Injections J0585-J AllCare CCO (541) Toll free (888) Effective January 1, 2017

8 Bursa Injections No (must be covered diagnosis)(not covered for spine diagnosis that fall on Lines 351 or 407) Carpal Tunnel Surgery Chiropractic Coaptite 51715, L8606 Circumcision (less than 28 days of age) 54150, no Dental procedure under general anesthesia *dental procedure must be covered Neurostimulators Osteopathic Manipulation Photodynamic/Photochemotherapy/Laser treatment/actinotherapy , 96900, , Sinus Endoscopy Tympanostomy Varicose vein treatment , (see Vision Services for eye procedures) Ziconotide J AllCare CCO (541) Toll free (888) Effective January 1, 2017

9 Diagnostic Services (Do not require an auth for services necessary and reasonable to diagnose the presenting condition and/or preventative services, except as listed) Genetic testing (beyond amniocentesis and routine , 81519, , pre-natal screening) MRI 70336, , , , , , , , , , , Myelography , Pet Scan , Sleep Studies , Video EEG (Inpatient) , Capsule Endoscopy Surgical Procedures & Services (ASC and Hospital - place of service 22 or 24) (Services should be provided in the allowed place of service setting as identified by CMS and/or DMAP) General anesthesia and facility charges related *must be a covered dental service to dental services* Elective surgery General surgery excluding services below (see Vision Services for eye procedures) 9 AllCare CCO (541) Toll free (888) Effective January 1, 2017

10 General Surgery Angiogram no Port A Cath placement and removal , no Biopsy , , 11755, , , , no , , , , , , 30100, , , , 37200, , 40490, 40808, , 42100, , , 43605, 45100, , 47100, , 49180, , 53200, , , 54800, , , , , 60100, 62267, 62269, 64795, 65410, 67346, 67810, 68100, 68510, 68525, Placement of breast localization device no ERCP no G Tube placement, change & removal , no Incision and Drainage 10030, , , , 10140, 10160, 10180, no 19001, 19020, 20005, , 21510, 22010, 22015, , , , , 27030, , , 27610, , 30000, 30020, , , 42000, 42700, 42720, 42725, 44900, , 45020, 46040, 46045, 46050, 46060, 49020, 49040, , , 52700, 53040, 53060, , 54015, 54700, 56405, 56420, , 60000, 67700, 68020, 68400, 68420, Lumbar Puncture no 10 AllCare CCO (541) Toll free (888) Effective January 1, 2017

11 Paracentesis/Thoracentesis , no Vascular embolization or occlusion , no Vasectomy , (Must have DMAP form appropriately completed by member within DMAP time limits) Cardiac Surgery Heart Catheterization , no Pacemaker/Generator change/defibrillator , , no Operative ablation , 33261, 93609, 93613, , , no Implantation / Removal Cardiac event recorder 33282, no no Cardioversion no Cardiac Stent Placement/CABG , 33530, , , no Urology Ureteral Stent no (internal removal with/without replacement) TURP/Laser Coagulation no Lithotripsy , no Cystoscopy , , no 11 AllCare CCO (541) Toll free (888) Effective January 1, 2017

12 ENT PE tube removal no GYN Cerclage of cervix , no D & C , no Ectopic pregnancy no Cesarean Section (scheduled or emergent) , (see Hospital Services for admission no requirements) Vaginal delivery , (see Hospital Services for admission no requirements) Curettage / Episiotomy 59160, 59200, no Hysterorrhaphy no Hysteroscopy (diagnostic or biopsy) 58555, no Removal of adnexa no Tubal Ligation 58565, , (Must have DMAP form appropriately no completed by member within DMAP time limits) Dermatology Destruction malignant skin lesion , no 12 AllCare CCO (541) Toll free (888) Effective January 1, 2017

13 Vision Services Routine visual exam (beyond OHP benefit limitation) Medical - consult/office visit (annual diabetic exam does not require referral) Eyeglasses/Fittings/Polycarb lenses (beyond OHP benefit limitation) *Must use Sweep Optical Vision Procedures Blepharoplasty Strabismus surgery Ptosis repair Reconstruction , Eye procedures (applies to in-office, ambulatory surgery center and outpatient hospital) Non-emergent Transportation , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 67938, , , , , 68520, Routine non-emergent transportation Benefit is administered through ReadyRide: (541) Refer to ReadyRide policy no 13 AllCare CCO (541) Toll free (888) Effective January 1, 2017

14 Air transport A0430-A0431 (all claims for air transport, emergent and non-emergent are subject for review) Ambulance transport A0426, A0428 Hospital Services Emergent Department Emergent department visit no Scheduled visits in the emergent department unless service otherwise specified in PA grid Inpatient admission Emergent hospital admission Requires notification within 48 hours no Inpatient hospital admission (scheduled) also requires notification within 48 hours of admission Inpatient Rehabilitative Care also requires notification within 48 hours of admission Specialty hospital (such as Long Term Acute also requires notification within 48 hours of admission Care) Outpatient Hospital Services Outpatient Surgical Services - (No separate authorization required for facility if surgical procedure is prior authorized when applicable) Scheduled visits in an outpatient facility unless service otherwise specified in PA grid Infusion services 14 AllCare CCO (541) Toll free (888) Effective January 1, 2017

15 Outpatient Therapy/Rehabilitation Services Biofeedback/Neurofeedback Cardiac or Pulmonary Rehab , G0237-G0239, G0422-G0424 Ostomy/Wound Care Hyperbaric oxygen wound therapy 99183, G0277 Radiation Therapy Wheelchair evaluation no Therapy/Rehabilitation visits , , , 97036, , (evaluation does not require a PA) Pharmacy Services Medications (including OTC medications) See formulary for requirements Hospice Services Hospice care (must be Medicare/Medicaid certified hospice) Palliative care Skilled Nursing Facility Services Inpatient skilled nursing care Supplies/Equipment if not included in per diem see Equipment and Supplies section for requirements 15 AllCare CCO (541) Toll free (888) Effective January 1, 2017

16 Home Health Services All home health services Home Infusion therapy Supplies/Equipment if not included in per diem Hearing Services Hearing Aids see Equipment and Supplies section for requirements V5030-V5060, V5100, V5120-V5150, V5170-V5190, V5210-V5230, V5242-V5263 Repairs V5014, Total repair cost over DMAP and/or contract allowable of $350 Dietary Counseling/Medical Education Services Medical nutrition therapy (must use registered dietitian) (after 5 visits per calendar year) Diabetes self-management training G0108-G0109 (after 10 visits per calendar year) Chemical Dependency Services Inpatient medical detox notification required within 48 hours of admission 16 AllCare CCO (541) Toll free (888) Effective January 1, 2017

17 Dental Services Verify member's eligiblity and assigned dental Provider in the AllCare Health Provider Portal or by calling AllCare Health. Please contact the Dental Provider to access dental benefits and referrals. Equipment and Supplies Durable Medical Equipment (DME) / Repairs Purchase (includes rent to purchase) or repair (total cost) over DMAP and/ or contract allowable of $350 (excluding services below) All Miscellaneous and/or Not Otherwise Specified all requests must be submitted with an invoice and will be subject to review codes for benefit and coverage limitation DME - Rent to purchase items Apnea Monitor E0618-E0619 *first 3 months do not require a PA - 4th month and thereafter CPAP/BIPAP/Humidifier E0560-E0562, E0565, E0601, E0470-E0472 (must use Lincare or Pacific Pulmonary Services) Oxygen and O2 equipment E0424-E0440, E1390-E1392 (must use Lincare or Pacific Pulmonary Services) (for pediatrics use Northwest Medical) Tens Unit E0720, E0730-E0731 Wound Therapy Pump A6550, A7000, E2402 DME - Purchase Only Compression Stockings (2 pairs per yr) A6530-A6544, A6549 no Enteral Formula B4149-B AllCare CCO (541) Toll free (888) Effective January 1, 2017

18 Incontinent Supplies T4521-T4544, A4335 (quantity limits apply) (3-5 years old) (Preferred vendor is Byram Healthcare) Insulin Pump/Continuous Glucose Monitor E0784, A9277-A9278 (Preferred vendor is Byram Healthcare) 18 AllCare CCO (541) Toll free (888) Effective January 1, 2017