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Ambetter Prior Authorization

Fecha: 05/04/23

Ambetter from Sunflower Health Plan requires prior authorization (PA) as a condition of payment for many services. This notice contains information regarding such prior authorization requirements and is applicable to all Ambetter products offered by Sunflower Health Plan.

Ambetter from Sunflower Health Plan is committed to delivering cost-effective quality care to our members.  This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice.  Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in-network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES, EXCEPT WHERE INDICATED.       

For complete CPT/HCPCS code listing, please see the Online Prior Authorization Tool on our website.        

Effective June 1, 2023, the following are changes to prior authorization requirements:

Audiology                               

PA Rule

Services

Procedure Codes

No PA Required

Hearing aid, assistive hearing devices, supplies

V5267

Behavioral Health

PA Rule

Services

Procedure Codes

No PA Required

Behavioral health counseling

S9484

No PA Required

Developmental and behavioral screening

96110, 96112

No PA Required

Alcohol and/or drug services

H0004, H0005, H0007, H0014, S9475

No PA Required

Crisis intervention services

H2011

Breast reconstruction

PA Rule

Services

Procedure Codes

PA Required except with breast cancer diagnosis

Breast reconstruction, prosthesis

19316, 19318, 19325, 19328, 19340, 19342, 19350, 19370, 19371, 19499, L8031

Cardiovascular

PA Rule

Services

Procedure Codes

PA Required

Insertion/removal of Cardiac Rhythm Monitor

33285

PA Required

Revascularization

37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231

PA Required

Unlisted procedure

37799

PA Required

Wireless pressure sensor

C2624

PA Required

External counterpulsation

G0166

No PA Required

Catheter

C2623

No PA Required

Cardiac rehab program

G0422, G0423, S9472

Diagnostic and Therapeutic Radiology services

PA Rule

Services

Procedure Codes

No PA Required

Indium In-111 ibritumomab tiuxetan

A9542

No PA Required

Ablation Liver Tumor

47382

No PA Required

Radiation therapy

77372, 77373, G0339, G0340

No PA Required

Radiolabeled item

C9898

DME & Supplies

PA Rule

Services

Procedure Codes

PA Required

Osteogenesis stimulator

E0749

PA Required

Supplies for home delivery of infant

S8415 

PA Required

Personal care items

S5199

No PA Required

Infusion pumps and supplies

B9002, E0781, K0455

No PA Required

Respiratory equipment

E0550, E0565

No PA Required

Wheelchair and accessories

E2611, K0001

Ears, Nose, and Throat

PA Rule

Services

Procedure Codes

No PA Required

Otorhinolaryngologic Services

92611

No PA Required

Dysphagia screening

V5364

Home Care

PA Rule

Services

Procedure Codes

PA Required

Home health skilled nursing visit

0551

PA Required

Repair/maintenance for home hemodialysis equipment

A4870, A4890

PA Required

Home Care Management Services

G0087

PA Required

Home therapy

G2168, G2169

PA Required

Unskilled respite care

S5150, S5151

PA Required

Home modifications, meals, laundry

S5175

PA Required

In-home telemonitoring

S9110

PA Required

Nursing assessment/evaluation

T1001 

No PA Required

End Stage Renal Disease services

90966, S9335, S9339

No PA Required

Prenatal home visit

99500

No PA Required

Home visits post-discharge and care plan oversight

G2001, G2003, G2004, G2005, G2006, G2007, G2008, G2009, G2013, G2014, G2015

No PA Required

Coordinated care – home monitoring

G9006

No PA Required

Remote in-home visits

G9978, G9979, G9980, G9981, G9982, G9983, G9984, G9985, G9986, G9987

No PA Required

Services, supplies and accessories used in the home

Q2052

No PA Required

Management of patient home care

S0271, S0273, S0274

No PA Required

Medical home program

S0280, S0281

No PA Required

BPCI home visit

G9187

No PA Required

Home care training

S5108, S5109, S5110, S5111, S5115, S5116

No PA Required

Home visit – wound care and phototherapy services

S9097, S9098

No PA Required

Home infusion therapy

S5035, S5036, S9347

Hospice

PA Rule

Services

Procedure Codes

No PA Required

Physician supervision

G0182

No PA Required

Counseling Services

G9473, G9474, G9475, G9476, G9477, G9478, G9479, S0255

Laboratory

PA Rule

Services

Procedure Codes

PA Required

Genetic analysis/studies, surgical pathology procedures

81235, 81263, 81265, 81267, 81268, 81270, 81275, 81310, 81315, 88237, 0089U

Nutrition

PA Rule

Services

Procedure Codes

PA Required

Medical food nutritionally complete (oral)

S9433

Orthopedic

PA Rule

Services

Procedure Codes

PA Required

Procedures lower extremities

28285, 28299

PA Required

Endoscopy wrist

29848

Orthotics and Prosthetics

PA Rule

Services

Procedure Codes

PA Required

Lower extremity orthotics

L1851, L1852

No PA Required

Lower extremity orthotics

L2112

Pain management

PA Rule

Services

Procedure Codes

PA Required unless

Injection, anesthetic agent or steroid

62320, 62321, 62322, 62323, 62325, 62327, 64400, 64405, 64415, 64417, 64418, 64420, 64421, 64430, 64445, 64447, 64448, 64450, 64451, 64454, 64479, 64480, 64483, 64484, 64505, 64510, 64517, 64520, 64530

No PA Required

Transversus abdominis plane (TAP) block

64486, 64488

No PA Required

Nerve block

64632

Professional services

PA Rule

Services

Procedure Codes

No PA Required

Inpatient telehealth

G0459

No PA Required

Drug infusion services

G0068, G0069, G0070

Skin substitute

PA Rule

Services

Procedure Codes

PA Required

Skin substitute products and injectables

Q4114, Q4130, Q4137, Q4139, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226

Surgical

PA Rule

Services

Procedure Codes

No PA Required

Complex repair of eyelids, nose and ears

13153

Transplant

PA Rule

Services

Procedure Codes

PA Required

Small intestine and liver allografts

S2053