PA Lookup

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

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12465 Results

R&B/SELF

Service Code
0167 (Revenue) R&B/SELF
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

R&B/OTHER

Service Code
0169 (Revenue) R&B/OTHER
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

Anesthesia for intraoral procedures, including biopsy; not otherwise specified

Service Code
00170 (CPT) Anesthesia for intraoral procedures, including biopsy; not otherwise specified
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

NURSERY

Service Code
0170 (Revenue) NURSERY
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

NURSERY/LEVEL I

Service Code
0171 (Revenue) NURSERY/LEVEL I
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

Anesthesia for intraoral procedures, including biopsy; repair of cleft palate

Service Code
00172 (CPT) Anesthesia for intraoral procedures, including biopsy; repair of cleft palate
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

NURSERY/LEVEL II

Service Code
0172 (Revenue) NURSERY/LEVEL II
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

Anesthesia for intraoral procedures, including biopsy; excision of retropharyngeal tumor

Service Code
00174 (CPT) Anesthesia for intraoral procedures, including biopsy; excision of retropharyngeal tumor
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for intraoral procedures, including biopsy; radical surgery

Service Code
00176 (CPT) Anesthesia for intraoral procedures, including biopsy; radical surgery
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0180- Leave of Absence- Non- Covered Code

Service Code
0180 (Revenue) 0180- Leave of Absence- Non- Covered Code
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

Therapeutic Leave for Residential Treatment Services and Psychiatric Residential Treatment Facilities

Service Code
0183 (Revenue) LOA/THERAP
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Intellectual/ Developmental Disability, Mental Health, Substance Use

Each member who is occupying a tx facility bed for which the Medicaid is paying reimbursement is entitled to take up to 45 (non-consecutive) days of therapeutic leave in any calendar year from any such bed without the facility in which the bed is located suffering any loss of reimbursement during the period of leave. Therapeutic leave shall be defined as the absence of a member from the residential facility overnight, with the expectation of return, to participate in a medically acceptable therapeutic or rehabilitative facility as agreed upon by the treatment team and documented on the tx/ habilitation plan.

Authorization Guidelines

Maintained in the Record (not all inclusive):

  • 1. Complete PCP: Required, to include this service. PCP should detailing the member’s progress with the service.
  • 2. Service Order: Required.

Unit Value

One unit = 1 day

Limits

Facilities must reserve a therapeutically absent member’s bed and are prohibited from deriving any Medicaid revenue for that member other than the reimbursement for that bed during the period of absence. Therapeutic leave cannot be billed when Medicaid is paying for any other 24-hour service.

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

N/A - No authorization is required

Resources

Therapeutic Leave from an ICF/IID

Service Code
0183 (Revenue) LOA/THERAP
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Intellectual/ Developmental Disability

Leave from an Intermediate Care Facility for Individuals with Intellectual Disabilities for therapeutic purposes only. Each Medicaid-eligible member in an ICF/IID is entitled to take up to 60 calendar days of therapeutic leave in any calendar year. The leave must be for therapeutic purposes only and must be ordered by the member’s attending physician.

Unit Value

One day = 1 unit.

Limits

  • 1. ICF/IIDs are not reimbursed for therapeutic-leave days which exceed the limit.
  • 2. ICF/IIDs will reserve a therapeutically absent member’s bed and are prohibited from deriving any MCD revenue for that member other than the reimbursement for the bed during the period of absence.
  • 3. ICF/IID group homes can take residents on vacation within the rules and requirements of the MCD program. The time away from the group home is not considered therapeutic leave.

Length of Stay

Maximum of 60 days per calendar year

How to Submit

N/A - No authorization is required

Resources

Anesthesia for procedures on facial bones or skull; not otherwise specified

Service Code
00190 (CPT) Anesthesia for procedures on facial bones or skull; not otherwise specified
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for procedures on facial bones or skull; radical surgery (including prognathism)

Service Code
00192 (CPT) Anesthesia for procedures on facial bones or skull; radical surgery (including prognathism)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0200 General

Service Code
0200 (Revenue) 0200 General
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

0201 Surgical

Service Code
0201 (Revenue) 0201 Surgical
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

0202 Medical

Service Code
0202 (Revenue) 0202 Medical
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

0203 Pediatric

Service Code
0203 (Revenue) 0203 Pediatric
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

0204 Psychiatric

Service Code
0204 (Revenue) 0204 Psychiatric
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

0206 Intermediate intensive care unit (ICU)

Service Code
0206 (Revenue) 0206 Intermediate intensive care unit (ICU)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required