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Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12465 Results

Anesthesia for; perineal prostatectomy

Service Code
00908 (CPT) Anesthesia for; perineal prostatectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0909 Reserved for national use

Service Code
0909 (Revenue) 0909 Reserved for national use
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for transurethral procedures (including urethrocystoscopy); not otherwise specified

Service Code
00910 (CPT) Anesthesia for transurethral procedures (including urethrocystoscopy); not otherwise specified
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Psychiatric Residential Treatment Facilities (PRTF)

Service Code
0911 (Revenue) BH/REHAB
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Mental Health, Substance Use

Service provides non-acute inpatient facility care for Medicaid beneficiaries under 21 years of age who have a mental illness or a substance use disorder and need 24-hour supervision and specialized interventions.

Authorization Guidelines

  • 1. TAR: Prior authorization is required
  • 2. CON: Required, completed within the last 15 days
  • 3. CCA or DA: Required. Re-assessment is required when new behavioral concerns are identified, there are changed/ unmet service or tx needs, and/or as part of the annual review of the service plan. Assessment must include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
  • 4. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
  • 5. Evidence of Family Engagement: Required
  • 6. Discharge/Transition Plan: Required, to include a step-down plan
  • 7. Out-of-State Paperwork: Required, if applicable.
  • 8. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Guidelines

  • 1. TAR: prior authorization required
  • 2. Complete PCP: recently reviewed detailing the member’s progress with the service.
  • 3. Updated ASAM Score: Required, if applicable
  • 4. Family Engagement Plan: Required OR Visiting Resources, if there has been no family engagement
  • 5. Child/Adolescent Discharge/ Transition Plan: Required
  • 6. Submission of applicable records that support the member has met the medical necessity criteria.

Unit Value

One unit = 1 day

Limits

  • 1. MCD will not cover PRTF services that are ordered by the court when medical necessity criteria are not met.
  • 2. MCD will cover not cover PRTF services when the primary issues are social or economic, such as placement issues.
  • 3. Federal regulations require the completion of a Certification of Need [CON] form prior to admission to a PRTF facility. The last dated signature on the CON determines the effective date of the CON and authorization for payment and must be maintained in the record.

Age Group Details

Children & Adolescents (Service is available to youth under the age of 21. Continued tx can be provided until the member’s 22nd birthday when medically necessary.)

Level of Care

While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

Resources

Anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of bladder tumor(s)

Service Code
00912 (CPT) Anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of bladder tumor(s)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0913 Partial hospitalization-Intensive

Service Code
0913 (Revenue) 0913 Partial hospitalization-Intensive
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of prostate

Service Code
00914 (CPT) Anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of prostate
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0915 Group Therapy

Service Code
0915 (Revenue) 0915 Group Therapy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for transurethral procedures (including urethrocystoscopy); post-transurethral resection bleeding

Service Code
00916 (CPT) Anesthesia for transurethral procedures (including urethrocystoscopy); post-transurethral resection bleeding
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0917 Biofeedback

Service Code
0917 (Revenue) 0917 Biofeedback
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for transurethral procedures (including urethrocystoscopy); with fragmentation, manipulation and/or removal of ureteral calculus

Service Code
00918 (CPT) Anesthesia for transurethral procedures (including urethrocystoscopy); with fragmentation, manipulation and/or removal of ureteral calculus
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0919 Other

Service Code
0919 (Revenue) 0919 Other
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Visual Evoked Potential (VEP)

Service Code
0920 (Revenue) NOT ON DESCRIPTION SHEET
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Visual Evoked Potential (VEP) test is a diagnostic tool for the neurological assessment of the visual system. VEP measures the time it takes for nerves to respond to stimulation. The size of the response is also measured. During the VEP test, the eyes are stimulated by looking at a test pattern. Each type of response is recorded from brain waves by using electrodes taped to the head. The VEP test is the most commonly used evoked potential test in the diagnosis of multiple sclerosis (MS). Interpretation is provided by neurologists, physiatrists, ophthalmologists or optometrists specially trained or skilled in VEP testing. The VEP test involves a flashing stroboscope or viewing a black and white checkered pattern on a television (TV) monitor in a darkened room. The black and white squares alternate on a regular cycle which generates electrical potentials along the optic nerve and into the brain producing wave patterns that are recorded. These are detected with electroencephalographical (EEG) sensors placed at specific sites on the back of the head (the occipital scalp). Each eye is tested independently while an eye patch is worn on the other eye. VEPs are very sensitive at measuring slowed responses to visual events and can often detect dysfunction which is undetectable through clinical evaluation and the person is unaware of any visual defects. Because of their ability to detect silent lesions and historic demyelinating episodes, they are very useful diagnostic tools. A definite diagnosis of multiple sclerosis requires at least two distinct demyelinating episodes, in two different central nervous system sites which are separated by at least one month (the Schumacher criteria). VEPs can often provide evidence of such episodes when other tests, even MRI, cannot.

Unit Value

1 unit per test

Limits

VEP is considered experimental and investigational if the Clinical Coverage Policy eligibility criteria are not met (section 2.0 and 3.0)

Exclusions

Medicaid does not cover VEP as a routine screening tool to meet the requirements of vision screening during an Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) exam. However, if during an EPSDT exam the physician documents a medical need for additional vision services, (i.e. an abnormality is suspected) the physician is expected to make the appropriate referral for a more formal vision assessment. Physicians providing children’s vision assessments shall follow the American Academy of Pediatrics policy for “Eye Examination in Infants, Children, and Young Adults by Pediatricians.”

Place of Service

Inpatient, Outpatient, Office and Independent Diagnostic Testing Facilities (IDTF)

Additional Service Specifics

Use modifier 26 when billing the professional component. Use modifier TC when billing the technical component.

How to Submit

N/A - No authorization is required

Resources

Anesthesia for procedures on male genitalia (including open urethral procedures); vasectomy, unilateral or bilateral

Service Code
00921 (CPT) Anesthesia for procedures on male genitalia (including open urethral procedures); vasectomy, unilateral or bilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for procedures on male genitalia (including open urethral procedures); seminal vesicles

Service Code
00922 (CPT) Anesthesia for procedures on male genitalia (including open urethral procedures); seminal vesicles
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0923 Pap smear

Service Code
0923 (Revenue) 0923 Pap smear
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for procedures on male genitalia (including open urethral procedures); undescended testis, unilateral or bilateral

Service Code
00924 (CPT) Anesthesia for procedures on male genitalia (including open urethral procedures); undescended testis, unilateral or bilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0925 Pregnancy test

Service Code
0925 (Revenue) 0925 Pregnancy test
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for procedures on male genitalia (including open urethral procedures); radical orchiectomy, inguinal

Service Code
00926 (CPT) Anesthesia for procedures on male genitalia (including open urethral procedures); radical orchiectomy, inguinal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for procedures on male genitalia (including open urethral procedures); radical orchiectomy, abdominal

Service Code
00928 (CPT) Anesthesia for procedures on male genitalia (including open urethral procedures); radical orchiectomy, abdominal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required