Effective 2016

Some procedures and services require prior authorization to determine medical necessity and/or medical appropriateness prior to receiving services. The 2016 Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes listed below are not an all-inclusive list of codes requiring prior authorization and/or may have coverage limitations. This Prior Authorization list is a Care Management listing of what is typically reviewed for medical necessity for Care Management. If a code requires prior authorization, please use the Prior Authorization Form, or provide the information online using EpicLink. If you have questions about Prior Authorization, please consult your plan documents and/or call Member Services at (608) 828-4853 or (800) 605-4327.

This Prior Authorization list does not replace or supersede a member's plan documents (Member Certificate, Benefits Summary, and Summary of Benefits and Coverage).

Terms and Conditions

This distribution list of CPT codes is, “CPT copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.”

You will need to check “YES” as this will indicate that you accept this to be informational only and does not constitute medical advice on how a procedure/services should be provided. This is a guide which identifies specifically for GHC-SCW what services/procedures require medical necessity review.

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Code Description Prior Auth Required Code Type

The columns in the spreadsheet identify whether a service/procedure meets medical necessity as an outpatient service versus an inpatient service.
The description for N, Y, and N/Y:

  • N means NO PA required
  • Y means PA required
  • N/Y means NO for outpatient and YES for inpatient

Questions

If you need more information about what requires prior authorization or questions about member’s benefits, please contact Member Services at (608) 828-4583 or toll free at (800) 605-4327, and ask to speak with Member Services.