Medicare Advantage 2014 Precertification Requirements (Effective for Jan 1, 2014 to June 30, 2014) The precertification requirements filed with the Centers for Medicare & Medicaid Services remain in effect for calendar year 2014. The following Medicare Advantage plans require precertification i for in network providers. Call the telephone number listed on the back of the member s identification card for precertification, verification of member eligibility, benefits and account information. This document replaces Precertification lists effective prior to January 1, 2014. Changes included the addition and non-renewal of some plans as well as new and removed procedures requiring precertification as listed below. Medicare Advantage Plans requiring in-network provider precertification. Medicare Advantage Senior Advantage OH, KY HMO Plans requiring precertification (in network) BlueValue GA Medicare Advantage PPO Plans requiring precertification (in-network) MediBlue **Medicare Preferred **Medicare Access **MediBlue CT, NY, WI,, ME, NH, MO OH, IN, KY, VA, MO, WI, GA, CA, ME, NH, CT OH, IN, KY NY ** = Indicates there is a national service area for select Employer Group Retiree Medicare Advantage plans. Precertification is the determination that selected medical services meet medical necessity criteria under the member's benefits contract. For the member to receive maximum benefits, the health plan must authorize or precertify these covered services prior to being rendered. Precertification includes a review of both the service and the setting. Care will be covered according to the member's benefits for the services and/or number of days precertified unless our concurrent review determines that additional services and/or days do not qualify for coverage. Certain services may require the member to use a provider designated by the health plan s Utilization Management staff. A copy of the approval will be provided to you, the physician and the hospital or facility. For benefits to be paid the member must be eligible for benefits and the service must be a covered benefit under the contract at the time the services are rendered. Precertification Responsibility For HMO type health plans: It is the participating physician s or provider s responsibility to contact the health plan s Utilization Management Department to obtain precertification. The request must come from the provider or facility rendering the service, not the referring physician. If precertification is not obtained, the claim may be penalized or denied by the Plan and the member must be held harmless. The Precertification number is listed on the back of the member s health plan ID card. For PPO type health plans: It is the network provider s responsibility to contact the health plan s Utilization Management Department to obtain precertification. Claims from out of network providers will typically pend for a medical necessity review prior to payment if 19001WPPENMUB Page 1 of 8 Y0071_14_18239_I 10/01/2013
associated with a service in this document. The Precertification number is listed on the back of the member s health plan ID card. Inpatient Admissions Also see Behavioral Health and Transplants sections for precertification requirements. The health plan must be notified of emergency admissions or transfers within 1 business day of admission. Precertification required for non-emergent inpatient transfers between acute facilities. Precertification is required for: o Elective Inpatient Admissions o Rehabilitation Facility admissions o Long Term Acute Care (LTAC) o Skilled Nursing Facility admissions Precertification is NOT required, however notice is requested for all members initiating dialysis treatment. Outpatient Services: Select Outpatient Surgery and Outpatient Procedures (see appendix for specific procedures) Sleep Studies and Sleep Study related equipment and supplies. UPPP surgery (Uvulopalatopharyngoplasty - removal of excessive soft tissue in the back of the throat to relieve obstruction.) Bariatric/ Gastric Obesity Surgery All potentially Cosmetic surgeries Non-emergent ground air and water transportation Home Infusion Therapy Home Health Care Physical Therapy Chiropractic Care Page 2 of 8
DME/ Prosthetics Precertification is required for: Prosthetics, Orthotics Power Wheelchairs, Accessories, and POV Non-Standard Wheelchairs Non-Standards Beds Patient Transfer Systems Speech Generating Devices and accessories Sleep Study related equipment and supplies. Continuous Glucose Monitoring Systems Radiology Services Precertification is required for: PET Nuclear Cardiac CT Scan (includes CTA) MRI MRA MRS Echocardiograms Behavioral Health Services Mental Health/ Substance Abuse Services: Specially trained professionals will handle referrals and coordinate care for mental health and substance abuse. This includes: referrals to mental health and substance abuse treatment providers, general information about mental health and substance abuse benefits and treatment, emergency and urgent care information and assistance Plan must be notified of emergency admissions within 1 business day of admission. Precertification is required for: o Inpatient admissions o Rehabilitation Facility admissions (Rehabilitation requires precertification but benefit availability is limited. Please be sure to check benefits the member s benefits.) o Day Hospital admissions o Intensive Outpatient therapy Page 3 of 8
Transplants: Human Organ and Bone Marrow/ Stem Cell Transplants Precertification is required for Medicare Covered Transplant admits. All Inpatient admits for the following: Heart transplant Liver transplant Lung or double lung transplant Simultaneous Pancreas/ Kidney Pancreas transplant Kidney transplant Small bowel transplant Multi-visceral transplant Stem cell/ Bone Marrow transplant (with or without myeloablative therapy) All Outpatient services for the following: Stem Cell/ Bone Marrow transplant (with or without myeloablative therapy) Donor Leukocyte Infusion Specialty Pharmacy Part D drugs - please refer to separate Precertification list. Part B drugs Please see the Appendix. The codes related to the services above that require prior authorization are listed in the appendix. Precertification requirements document is posted to the Medicare Advantage Provider Portals. i Precertification For the purpose of this document, precertification (aka - prior authorization) indicates a requirement to precertify prior to rendering a service which includes authorization of additional days on concurrent review. Out of network providers may optionally choose to call the health plan to obtain precertification (or a predetermination) regarding whether a service meets benefit and medical necessity criteria. Page 4 of 8
APPENDIX The following codes which required Pre-Certification in 2013, continue to require Pre- Certification in 2014. 0014T 12057 29825 70481 72148 75557 93350 C8920 J1568 K0835 11400 13100 29826 70482 72149 75559 93351 E0193 J1569 K0836 11401 13101 29827 70486 72156 75561 93352 E0194 J1572 K0837 11402 13102 29828 70487 72157 75563 95808 E0265 J2503 K0838 11403 13120 29870 70488 72158 75565 95810 E0266 J2505 K0839 11404 13121 29871 70490 72191 75571 95811 E0277 J2778 K0840 11406 13122 29873 70491 72192 75572 A0430 E0296 J2820 K0841 11420 13131 29874 70492 72193 75573 A0431 E0297 J7321 K0842 11421 13132 29875 70496 72194 75574 A0435 E0300 J7322 K0843 11422 13133 29876 70498 72195 75635 A0436 E0329 J7323 K0848 11423 13150 29877 70540 72196 76376 A4604 E0371 J7324 K0849 11424 13151 29879 70542 72197 76377 A7027 E0372 K0005 K0850 11426 13152 29880 70543 72198 77078 A7028 E0373 K0010 K0851 11440 13153 29881 70544 73200 78451 A7029 E0462 K0011 K0852 11441 14000 29882 70545 73201 78452 A7030 E0470 K0012 K0853 11442 14001 29883 70546 73202 78453 A7031 E0471 K0013 K0854 11443 14020 29884 70547 73206 78454 A7032 E0561 K0014 K0855 11444 14021 29885 70548 73218 78466 A7033 E0562 K0800 K0856 11446 14040 29886 70549 73219 78468 A7034 E0601 K0801 K0857 11920 14041 29887 70551 73220 78469 A7035 E1002 K0802 K0858 11921 14060 29888 70552 73225 78472 A7036 E1003 K0806 K0859 11922 14061 43632 70553 73700 78473 A7037 E1004 K0807 K0860 12031 14300 43770 71275 73701 78481 A7038 E1005 K0808 K0861 12032 15820 43771 71550 73702 78483 A7039 E1006 K0812 K0862 12034 15821 43773 71551 73706 78494 A7044 E1007 K0813 K0863 12035 15822 43775 71552 73718 78496 A7045 E1008 K0814 K0864 12036 15823 43886 71555 73719 93303 A7046 E1230 K0815 K0868 12037 17106 43888 72125 73720 93304 A9274 E1239 K0816 K0869 12041 17107 67901 72126 73725 93306 C1789 G0289 K0820 K0870 12042 17108 67902 72127 74150 93307 C8900 J0585 K0821 K0871 12044 17380 67903 72128 74160 93308 C8901 J0587 K0822 K0877 12045 29805 67904 72129 74170 93312 C8902 J0881 K0823 K0878 12046 29806 67906 72130 74175 93313 C8909 J0882 K0824 K0879 12047 29807 67908 72131 74181 93314 C8910 J0885 K0825 K0880 12051 29819 67909 72132 74182 93315 C8911 J0886 K0826 K0884 12052 29820 70336 72133 74183 93316 C8912 J1440 K0827 K0885 12053 29821 70450 72141 74185 93317 C8913 J1441 K0828 K0886 12054 29822 70460 72142 74261 93320 C8914 J1459 K0829 K0890 12055 29823 70470 72146 74262 93321 C8918 J1561 K0830 K0891 12056 29824 70480 72147 74263 93325 C8919 J1566 K0831 K0898 Page 5 of 8
(Continuation of codes which required Pre-Certification in 2013, and will continue to require Pre-Certification in 2014.) K0899 L5930 L7274 21143 43774 96920 L8685 L0454 L5968 L8600 21145 43842 96921 L8686 L0456 L5979 Q4081 21146 43843 96922 L8687 L0458 L5980 S2066 21147 43845 A7025 L8688 L0460 L5981 S2067 21150 43846 C8903 Q0515 L0462 L5987 S2068 21151 43847 C8904 S0196 L0464 L5988 S2083 21154 43848 C8905 S2112 L0466 L5990 S2342 21155 43887 C8906 S3818 L1005 L6025 S9123 21159 67900 C8907 S3819 L1831 L6611 S9124 21160 70554 C8908 S3820 L1832 L6677 74174 21188 70555 E0481 S3822 L1834 L6881 74176 21193 71250 E0483 S3823 L1836 L6882 74177 21194 71260 E0485 S3828 L1840 L6920 74178 21195 71270 E0486 S3829 L1843 L6925 95800 21196 72159 E0784 S3830 L1844 L6930 95801 21198 73221 G0219 S3831 L1845 L6935 11950 21199 73222 G0235 S3833 L1846 L6940 11951 21206 73223 G0252 S3834 L1847 L6945 11952 21208 73721 G0398 S3840 L1850 L6950 11954 21209 73722 G0399 S8042 L1860 L6955 15775 21210 73723 G0400 L5250 L6960 15776 21245 76390 J0129 L5270 L6965 15780 21246 77058 J0135 L5280 L6970 15781 21247 77059 J1325 L5301 L6975 15782 29866 77079 J1438 L5311 L7007 15783 29867 77084 J1745 L5321 L7008 15786 29868 78459 J2278 L5331 L7009 15787 30120 78491 J2357 L5341 L7040 15788 30400 78492 J2940 L5610 L7045 15789 30410 78608 J2941 L5611 L7170 15792 30420 78609 J3285 L5613 L7180 15793 30430 78811 J9035 L5614 L7181 15830 30435 78812 J9055 L5616 L7185 15847 30450 78813 J9303 L5617 L7186 15877 36468 78814 J9355 L5814 L7190 19318 36469 78815 L8614 L5828 L7191 21125 42145 78816 L8619 L5830 L7260 21127 43644 90378 L8680 L5840 L7261 21141 43645 95806 L8682 L5845 L7272 21142 43772 95807 L8683 Page 6 of 8
The following codes will require Pre-Certification beginning January 1, 2014. 21060 54401 63030 93452 22206 54405 63035 93453 26045 54410 63040 93454 29848 54411 63042 93455 58180 54416 63043 93456 77371 54417 63044 93457 77373 58200 63045 93458 0275T 58260 63046 93459 19316 58262 63047 93460 19325 58263 63048 93461 22207 58290 63050 93641 22208 58291 63051 93642 22220 58292 63055 C1721 22226 58294 63056 C1771 22533 58541 63057 C2614 22558 58542 63064 E0986 22612 58543 63066 E1009 22614 58544 63075 E1220 22630 58548 63076 E2227 22633 58550 63077 E2300 22634 58553 63078 E2328 27447 58570 63081 E2609 30520 58572 63082 E2616 30620 58661 63085 E2617 31237 58720 63086 G0173 37700 58940 63087 G0251 37718 62267 63088 G0339 37722 63001 63090 G0340 37735 63003 63091 L1907 37760 63005 63185 L2005 37761 63012 63190 L2530 37780 63015 63191 Q0479 37785 63016 65757 Q0489 53445 63017 77372 S2350 54400 63020 93451 S2351 Page 7 of 8
The following Specialty Pharmacy Codes required Pre-Certification in 2013 and will continue to require Pre-Certification in 2014. J2505 J1745 J7325 J0135 J9035 J0897 J7322 J2278 J3940 J0881 J0129 J1325 J1566 J0882 J7321 J3285 J1572 J0885 J7323 J9303 J1569 J0886 J7324 J1561 J9055 J2357 J1568 J1440 J2940 J1459 J1441 J2941 J9355 J0585 J1438 The following Specialty Pharmacy Codes will require Pre-Certification beginning January 1, 2014. J9310 J9263 J9305 J9041 J2323 J9033 J9171 J3487 J9228 J3488 J7686 J2352 J2354 J2353 J9025 J3590 J9395 J0894 J0941 J0640 J7192 Page 8 of 8