Molina Healthcare Medicaid Prior Authorization Guide

Molina Healthcare Medicaid Prior Authorization Guide

This guide applies to Molina Medicaid members only

What is the Prior Authorization Guide? The Medicaid Prior Authorization Guide is a listing of codes that allows contracted providers to determine if a prior authorization is required for a health care service and the supporting documentation requirements to demonstrate the medical necessity for a service. The Medicaid Prior Authorization Guide may be subject to change at any time. Please see current effective date of this guide. Prior Authorization is not a guarantee of payment for services. Payment is made in accordance with a determination of the member's eligibility on the date of service, benefit limitations/exclusions and other applicable standards during the claim review, including the terms of any applicable provider agreement.

All Inpatient services require prior authorization All non-par provider requests require authorization regardless of service. Emergency services do not require prior authorization Office visits to contracted/participating (PAR) providers and referrals to network specialists do not require prior authorization Services noted as non-covered will be reviewed for medical necessity for children ages 21 and under, if requested (WAC 182-501-0050)

Prior authorization requests for unlisted or non-specific codes should include the code and a full description of the procedure or service. Please note: If the member's PCP belongs to a dedicated medical group/Independent Practice Association (IPA), listed in section 14 of the Provider Manual, the Provider should contact the medical group/IPA for authorization guidance.

Instructions: To search: Use CTRL + F for PCs or Command + F for Macs and type in the code.

Refer to the current Molina Medicaid Provider Manual for additional information.

1 MHW PART #1250-1910 MHW-10/8/2019

MHW PART #1251-1910 MHW-10/8/2019

Molina Healthcare Medicaid Prior Authorization Guide

For dates of service (DOS) 7/1/19 forward; Posted 10/16/2019

***All Inpatient services require prior authorization*** ***All Medicaid services subject to the limitations in the HCA provider billing guides and fee schedules ***

Code Code Description

0001F 0001U 0002M 0002U 0003M 0003U 0004M

HRT FAILURE ASSESSED RBC DNA HEA 35 AG 11 BLD GRP WHL BLD CMN ALLEL LIVER DIS 10 ASSAYS SERUM ALGORITHM W ASH ONC CLRCT QUAN 3 UR METABOLITES ALG ADNMTS PLP LIVER DIS 10 ASSAYS SERUM ALGORITHM W NASH ONC OVARIAN ASSAY 5 PROTEINS SERUM ALG SCOR SCOLIOSIS 53 SNPS SALIVA PROGNOSTIC RISK SCORE

0005F 0005U

OSTEOARTHRITIS COMPOSITE ONCO PRST8 GENE XPRS PRFL 3 GENE UR ALG RSK SCOR

0006M ONCOLOGY HEP MRNA 161 GENES RISK CLASSIFIER

0006U RX MONITORING 120 PLUS DRUGS AND SUBSTANCES 0007M ONCOLOGY GASTRO 51 GENES NOMOGRAM DISEASE INDEX

0007U 0008U 0009M 0009U 00100 00102 00103 00104 0010U 0011M 0011U 00120 00124 00126

RX TEST PRESUMPTIVE URINE W DEF CONFIRMATION HPYLORI DETECTION AND ANTIBIOTIC RESISTANCE DNA FETAL ANEUPLOIDY 21 18 SEQ ANALY TRISOM RISK ONC BRST CA ERBB2 COPY NUMBER FISH AMP NONAMP ANESTHESIA SALIVARY GLANDS WITH BIOPSY ANESTHESIA CLEFT LIP INVOLVING PLASTIC REPAIR ANESTHESIA EYELID RECONSTRUCTIVE PROCEDURE ANESTHESIA ELECTROCONVULSIVE THERAPY NFCT DS STRN TYP WHL GENOME SEQUENCING PR ISOL ONC PRST8 CA MRNA 12 GENES BLD PLSM AND UR ALG RX MNTR DRUGS PRESENT LC-MS MS ORAL FLUID PR DOS ANESTHESIA EXTERNAL MIDDLE AND INNER EAR W BX NOS ANES EXTERNAL MIDDLE AND INNER EAR W BX OTOSCOPY ANES XTRNL MID AND INNER EAR W BX TYMPANOTOMY

Outpatient Facility

Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov

Not Cov Yes

Not Cov

Not Cov Not Cov

Not Cov Not Cov Not Cov Not Cov

No No No No Not Cov Not Cov Not Cov No No No

Outpatient Professional

(POS 22)

Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov

Yes

Not Cov Yes

Yes

Not Cov Yes

Not Cov Not Cov Not Cov Not Cov

No No No No Not Cov Not Cov Not Cov No No No

ASC (POS 24)

Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov

Not Cov Not Cov

Not Cov

Not Cov Not Cov

Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov

Office Setting (POS 11/20/81)

IMC / BHSO (Mental Health covered svcs)

Supporting Documentation (most current)

Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov

Yes

Not Cov Yes

Yes

Not Cov Yes

Not Cov Not Cov Not Cov Not Cov

No No No No Not Cov Not Cov Not Cov No No No

History and Physical (H&P) Progress Notes

History and Physical (H&P) Progress Notes

History and Physical (H&P) Progress Notes

History and Physical (H&P) Progress Notes

Guide may be subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization. Claim

payment is subject to eligibility and benefits at the time of service. Claim processing edits will apply.

2

Molina Healthcare Medicaid Prior Authorization Guide

For dates of service (DOS) 7/1/19 forward; Posted 10/16/2019

***All Inpatient services require prior authorization*** ***All Medicaid services subject to the limitations in the HCA provider billing guides and fee schedules ***

Code Code Description

0012F 0012M 0012U 0013M 0013U 00140 00142 00144 00145 00147 00148 0014F 0014U 0015F 00160 00162 00164 0016U 00170 00172 00174 00176 0017U 0018U 00190 00192 0019U 00210 00211 00212 00214 00215 00216 00218

COMMUNITY-ACQUIRED BACTERIAL PNEUMONIA ASSMT ONC MRNA 5 GENES UR ALG RISK UROTHELIAL CANCER GERMLN DO GENE REARGMT DETCJ DNA WHOLE BLOOD ONC MRNA 5 GENES UR ALG RISK RECR UROTHELIAL CA ONC SLD ORGN NEO GENE REARGMT DNA FRSH FRZN TISS ANESTHESIA EYE NOT OTHERWISE SPECIFIED ANESTHESIA EYE LENS SURGERY ANESTHESIA EYE CORNEAL TRANSPLANT ANESTHESIA EYE VITREORETINAL SURGERY ANESTHESIA EYE IRIDECTOMY ANESTHESIA EYE OPHTHALMOSCOPY COMP PREOP ASSESS CATARACT SURG W IOL PLACEMNT HEM HMTLMF NEO GENE REARGMT DNA WHL BLD MARROW MELANOMA FOLLOW UP COMPLETED ANESTHESIA NOSE AND ACCESSORY SINUSES NOS ANES NOSE AND ACCESSORY SINUSES RADICAL SURGERY ANES NOSE AND ACCESSORY SINUSES BIOPSY SOFT TISSUE ONC HMTLMF NEO RNA BCR ABL1 BLD BNE MARROW ANESTHESIA INTRAORAL WITH BIOPSY NOS ANES INTRAORAL W BIOPSY REPAIR CLEFT PALATE ANES INTRAORAL W BX EXC RETROPHARYNGEAL TUMOR ANESTHESIA INTRAORAL W BIOPSY RADICAL SURGERY ONC HMTLMF NEO JAK2 MUTATION DNA BLD BNE MARROW ONC THYR 10 MICRORNA SEQ PLUS - RSLT MOD HI RSK MAL ANESTHESIA FACIAL BONES OR SKULL NOS ANES FACIAL BONES SKULL RAD SURG W PROGNATHISM ONC RNA WHL TRANSCIPTOME SEQ TISS PREDCT ALG ANESTHESIA INTRACRANIAL PROCEDURE NOS ANES INTRACRANIAL CRANIOTOMY CRANIECTOMY HMTMA ANESTHESIA INTRACRANIAL PROCEDURE SUBDURAL TAPS ANES INTRACRANIAL BURR HOLES W VENTRICULOGRAPHY ANES INTRACRANIAL ELEVATION DEPRSD SKULL FX XDRL ANESTHESIA INTRACRANIAL VASCULAR PROCEDURE ANES INTRACRANIAL PROCEDURE IN SITTING POSITION

Outpatient Facility

Not Cov Not Cov Not Cov Not Cov Not Cov

No No No No No No Not Cov Not Cov Not Cov No No No Not Cov No No No No Not Cov Not Cov No No Not Cov No No No No No No No

Outpatient Professional

(POS 22)

Not Cov Not Cov Not Cov Not Cov Not Cov

No No No No No No Not Cov Not Cov Not Cov No No No Not Cov No No No No Not Cov Not Cov No No Not Cov No No No No No No No

ASC (POS 24)

Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov

Office Setting (POS 11/20/81)

IMC / BHSO (Mental Health covered svcs)

Supporting Documentation (most current)

Not Cov Not Cov Not Cov Not Cov Not Cov

No No No No No No Not Cov Not Cov Not Cov No No No Not Cov No No No No Not Cov Not Cov No No Not Cov No No No No No No No

Guide may be subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization. Claim

payment is subject to eligibility and benefits at the time of service. Claim processing edits will apply.

3

Molina Healthcare Medicaid Prior Authorization Guide

For dates of service (DOS) 7/1/19 forward; Posted 10/16/2019

***All Inpatient services require prior authorization*** ***All Medicaid services subject to the limitations in the HCA provider billing guides and fee schedules ***

Code Code Description

0021U 00220 00222 0022U 0023U 0024U 0025U 0026U 0027U 0029U 00300 0030U 0031U 00320 00322 00326 0032U 0033U 0034U 00350 00352 0035U 0036U 0037U 0038U 0039U 00400 00402 00404 00406 0040U 00410 0041U 0042T

ONC PRST8 DETCJ 8 AUTOANTIBODIES ALG RSK SCOR ANES INTRACRANIAL CEREBROSPINAL FLUID SHUNTING ANES INTRACRANIAL ELECTROCOAGULATION ICRA NERVE TRGT GEN SEQ ALYS NONSM LNG NEO DNA AND RNA 23 GENES ONC AML DNA GNTYP INT TANDEM DUP DETCJ NONDETCJ GLYCA NUC MR SPECTROSCOPY QUANTITATIVE TENOFOVIR LIQ CHROM TANDEM MASS SPECT UR QUAN ONC THYR DNA AND MRNA 112 GENES FNA NDUL ALG ALYS JAK2 GENE ANALYSIS TRGT SEQ ALYS EXONS 12-15 RX METAB ADVRS RX RXN AND RSPSE TRGT SEQ ALYS ANES INTEG MUSC AND NRV HEAD NECK AND POSTERIOR TRUNK RX METAB WARFARIN RX RESPONSE TRGT SEQ ALYS CYP1A2 GENE ANALYSIS COMMON VARIANTS ANES ESOPH THYRD LARYNX TRACH AND LYMPH NECK 1YR ANES ESOPH THYRD LARX TRACH AND LYMPH NCK BX THYRD ANESTHESIA LARYNX AND TRACHEA CHILDREN UNDER 1 YEAR COMT GENE ANALYSIS C.472G OVER A VARIANT HTR2A HTR2C GENE ANALYSIS COMMON VARIANTS TPMT NUDT15 GENE ANALYSIS COMMON VARIANTS ANESTHESIA MAJOR VESSELS NECK NOS ANESTHESIA MAJOR VESSELS NECK SIMPLE LIGATION NEURO CSF DETCJ PRION PRTN QUAKG CONF CONV QUAL EXOME TUMOR TISSUE AND NORMAL SPECIMEN SEQ ALYS TRGT GEN SEQ ALYS SLD ORGN NEO DNA 324 GENES VITAMIN D SERUM MICROSAMPLE QUANTITATIVE DNA ANTIBODY DOUBLE STRANDED HIGH AVIDITY ANES INTEG EXTREMITIES ANT TRUNK AND PERINEUM NOS ANESTHESIA RECONSTRUCTION BREAST ANESTHESIA RADICAL MODIFIED RADICAL BREAST ANES RADICAL MODIFIED RADICAL BREAST W NODES BCR ABL1 GENE TLCJ ALYS MAJOR BP QUANTITATIVE ANES INTEG SYS ELEC CONVERSION ARRHYTHMIAS B BURGDORFERI ANTB 5 PRTN GRP IMMUNOBLOT IGM CEREBRAL PERFUSION ANALYS CT W BLOOD FLOW AND VOLUME

Outpatient Facility

Not Cov No No

Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov

No Not Cov Not Cov

No No No Not Cov Not Cov Not Cov No No Not Cov Not Cov Not Cov Not Cov Not Cov No No No No Not Cov No Not Cov Not Cov

Outpatient Professional

(POS 22)

Not Cov No No

Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov

No Not Cov Not Cov

No No No Not Cov Not Cov Not Cov No No Not Cov Not Cov Not Cov Not Cov Not Cov No No No No Not Cov No Not Cov Not Cov

ASC (POS 24)

Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov

Office Setting (POS 11/20/81)

IMC / BHSO (Mental Health covered svcs)

Supporting Documentation (most current)

Not Cov No No

Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov

No Not Cov Not Cov

No No No Not Cov Not Cov Not Cov No No Not Cov Not Cov Not Cov Not Cov Not Cov No No No No Not Cov No Not Cov Not Cov

Guide may be subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization. Claim

payment is subject to eligibility and benefits at the time of service. Claim processing edits will apply.

4

Molina Healthcare Medicaid Prior Authorization Guide

For dates of service (DOS) 7/1/19 forward; Posted 10/16/2019

***All Inpatient services require prior authorization*** ***All Medicaid services subject to the limitations in the HCA provider billing guides and fee schedules ***

Code Code Description

0042U 0043U 0044U 00450 00454 0045U 0046U 00470 00472 00474 0047U

B BURGDORFERI ANTB 12 PRTN GRP IMMUNOBLOT IGG TBRF B GRP ANTB DETCJ 4 RECOMB PRTN IMUNOBLT IGM TBRF B GRP ANTB DETCJ 4 RECOMB PRTN IMUNOBLT IGG ANESTHESIA CLAVICLE AND SCAPULA NOS ANESTHESIA CLAVICLE AND SCAPULA BIOPSY CLAVICLE ONC BRST DUX CARC IS MRNA 12 GENES ALG RSK SCOR FLT3 GENE INT TANDEM DUPL VARIANTS QUANTITATIVE ANESTHESIA PARTIAL RIB RESECTION NOS ANESTHESIA PARTIAL RIB RESECTION THORACOPLASTY ANESTHESIA PARTIAL RIB RESECTION RADICAL ONC PRST8 MRNA GEN XPRS PRFL 17 GEN ALG RSK SCOR

0048U 0049U 00500 0050U 0051U 00520 00522 00524 00528 00529 0052U 00530 00532 00534 00537 00539 0053U 00540 00541 00542 00546

ONC SLD ORG NEO DNA 468 CANCER ASSOCIATED GENES NPM1 GENE ANALYSIS QUANTITATIVE ANESTHESIA ESOPHAGUS TRGT GEN SEQ ALYS AML 194 GENE INTERROG SEQ VRNT RX MNTR DRUGS PRESENT LC-MS MS UR 31 DRUG PANEL ANESTHESIA CLOSED CHEST W BRONCHOSCOPY NOS ANESTHESIA CLOSED CHEST NEEDLE BIOPSY PLEURA ANESTHESIA CLOSED CHEST PNEUMOCENTESIS ANES MEDIASTINOSCOPY AND THORACSCOPY W O 1 LUNG VNTJ ANES MEDIASTINOSCOPY AND THORACOSCOPY W 1 LUNG VNT LPOPRTN BLD W 5 MAJ CLASS AUTO PRFL UCENTRFUGTN ANES PERMANENT TRANSVENOUS PACEMAKER INSERTION ANESTHESIA ACCESS CENTRAL VENOUS CIRCULATION ANES TRANSVENOUS INSJ REPLACEMENT PACING CVDFB ANES CARDIAC ELECTROPHYSIOL STDY W RF ABLATION ANESTHESIA TRACHEOBRONCHIAL RECONSTRUCTION ONC PRST8 CA FISH ALYS 4 GENES NDL BX SPEC ALG ANES THORACOTOMY AND THORACOSCOPY NOS ANES THORACOTOMY AND THORACOSCOPY W 1 LUNG VNTJ ANES THORACOTOMY AND THORACOSCOPY DECORTICATION ANES THORACOTOMY AND THORACOSCOPY PULMONARY RESC

Outpatient Facility

Not Cov Not Cov Not Cov

No No Not Cov Not Cov No No No Yes

Not Cov Not Cov

No Not Cov Not Cov

No No No No No Not Cov No No No No No Not Cov No No No No

Outpatient Professional

(POS 22)

Not Cov Not Cov Not Cov

No No Not Cov Not Cov No No No Yes

Not Cov Not Cov

No Not Cov Not Cov

No No No No No Not Cov No No No No No Not Cov No No No No

ASC (POS 24)

Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov

Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov Not Cov

Office Setting (POS 11/20/81)

IMC / BHSO (Mental Health covered svcs)

Supporting Documentation (most current)

Not Cov Not Cov Not Cov

No No Not Cov Not Cov No No No Yes

Not Cov Not Cov

No Not Cov Not Cov

No No No No No Not Cov No No No No No Not Cov No No No No

History and Physical (H&P) Progress Notes

Guide may be subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization. Claim

payment is subject to eligibility and benefits at the time of service. Claim processing edits will apply.

5

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