WellMed Texas Medicare Advantage Prior Authorization ...

1 2019 WellMed Medical Management, InformationThis list contains Prior Authorization requirements for participating care providers in Texas for inpatient and outpatient services. Prior Authorization is not required for emergency or urgent PlansThe following listed plans1 require Prior Authorization in San Antonio, Austin, Corpus Christi, El Paso, Rio Grande Valley, Dallas & Fort Worth for in-network services:AARP Medicare Advantage (HMO POS)AARP Medicare Advantage (NEW HMO-POS)AARP Medicare Advantage Focus (HMO)AARP Medicare Advantage Focus Essential (HMO)AARP Medicare Advantage SecureHorizons (HMO)AARP Medicare Advantage SecureHorizons Essential AARP Medicare Advantage SecureHorizons Plan 1 (HMO POS) AARP Medicare Advantage SecureHorizons Plan 2 (HMO POS)AARP Medicare Advantage Walgreens (PPO) AARP Medicare Complete Focus (HMO)AARP Medicare Complete SecureHorizons Essential (HMO) Amerivantage Classic (HMO)Amerivantage Dual Coordination (HMO SNP)Amerivantage Dual Secure (HMO SNP)Amerivantage ESRD (HMO-POS SNP)Amerivantage Select (HMO)Cigna-HealthSpring Advantage (HMO)Cigna-HealthSpring Preferred (HMO)

2 Cigna-HealthSpring TotalCare (HMO SNP)Humana Gold Plus (HMO SNP)Humana Gold Plus (HMO)Humana Gold Plus (SNP)Humana Gold Plus SNP-DE (HMO SNP)United Healthcare Dual Complete (HMO SNP)United Healthcare Medicare Advantage Choice (LPPO) unitedhealthcare Chronic Complete (HMO CSNP) unitedhealthcare Chronic Complete (NEW HMO CSNP) unitedhealthcare Dual Complete (HMO DSNP) unitedhealthcare Dual Complete (HMO SNP) unitedhealthcare Dual Complete Focus (HMO SNP) unitedhealthcare group Retiree Plans (HMO) WellMed Texas Medicare Advantage Prior Authorization requirements Effective January 1, 2020 Excluded PlansWellMed Prior Authorization requirements do not apply to the following excluded benefit plans in El Paso, New Mexico, Waco, and Houston: AARP Medicare Advantage Choice (PPO), AARP Medicare Advantage Plan 1 (HMO-POS), AARP Medicare Advantage Plan 2 (HMO), AARP MedicareComplete (HMO-POS), unitedhealthcare Dual Complete (PPO DSNP).

3 These benefit plans must follow unitedhealthcare Prior Authorization Program. For details, please refer to the unitedhealthcare Care Provider Administrative guide at 1 Subject to Change 2019 WellMed Medical Management, Verify Eligibility and Medical Benefits Before Requesting Prior Authorization (PA) Members are required to utilize contracted providers for all non-emergent services, unless Prior Authorization has been obtained. How to submit the request?StandardExpeditedHospital Inpatient AdmissionsSpecialist Referral ProgramFor prompt determination, submit ALL STANDARD requests using the Web Portal (ePRG): Fax: 1-866-322-7276 Phone:1-877-757-4440 ONLY submit EXPEDITED requests when the health care provider believes that waiting for a decision under the standard review time frame may seriously jeopardize the life or health of the patient or the patient s ability to regain maximum function.

4 Fax: 1-866-322-7276 Phone:1-877-757-4440 Fax: 1-877-757-8885 Phone:1-877-490-8982 Referrals to specialists are required in some markets. Please follow your market s current referral process (if your market currently does not have a referral process, then this does not apply). All referral requests must be submitted through the provider portal (ePRG): Inpatient AdmissionsProcedures and ServicesAdditional InformationHow to obtain Prior AuthorizationElective/scheduled admission (acute care facility)Acute Inpatient RehabilitationLong Term Acute Care (LTAC)Skilled Nursing Facility (SNF)Subacute admissionsEmergency Room admissionInpatient and Observation staysPrior Authorization requiredNotification is required Facilities are responsible for notification for ALL services even if the coverage approval is on file.

5 Notification must be received within 24 hoursFax: 1-877-757-8885 Phone: 1-877-490-8982 Out-of-Network ServicesProcedures and ServicesAdditional InformationHow to obtain Prior AuthorizationAll out-of-network inpatient and outpatient hospital admissions, surgeries, procedures, referrals, evaluations, specialty services and/or treatmentsPrior Authorization required for all recommendations from a network physician or health care provider to a hospital, physician or other health care provider who isn t contracted with WellMedFax: 1-866-322-7276 Phone: 1-877-757-4440 Other Services That May Require PAProcedures and ServicesAdditional InformationHow to obtain Prior AuthorizationBehavioral Health ServicesBehavioral Health Services through a designated behavioral health networkFor specific codes requiring Prior Authorization , please call the number on the member s health plan ID card to refer for mental health and substance abuse/substance use servicesClinical TrialsFor specific codes requiring Prior Authorization , please call the number on the member s health plan ID card for detailed information regarding coverageThe Following Services Require Prior Authorization Before Scheduling/Rendering the Services 2019 WellMed Medical Management.

6 (Inpatient or Outpatient Services)Procedures and ServicesAdditional InformationCPT or HCPCS CodesBone Growth StimulatorElectronic stimulation or ultrasound to heal fracturesPrior Authorization Required20974 20975 20979 Botox InjectionsPrior Authorization RequiredJ0585J0586J0587J0588 Cochlear and Osseointegrated Implants Surgically implanted devices to help persons with profound deafness achieve conversational speechPrior Authorization Required69714697156971869930L8614L8619L8 690L8691L8692 Enhanced External Counter Pulsation (EECP) Prior Authorization RequiredG0166G0177 Gender Dysphoria TreatmentPrior Authorization required regardless of DX codes5597055980 Prior Authorization required ONLY if billed with the following DX OxygenPrior Authorization Required9918399184G0277 Implantable Pain Pumps Neurostimulators(Implantation of a device that sends electrical impulses)Orthopedic Surgeries(Spine and joint surgeries)

7 Prior Authorization Required0200T0201T0375T22100221012210222 1032211022112221142220622207222082221022 2122221422216222202222222224222262261022 6122261422630226322263322634228002280222 8042280822810228122281822819228302284022 8412284222843228442286822869228702289923 4702347224360243612436224363271202712227 1252713027132271342713727138274122744527 4466236062361623626300163003630056301163 0126301563016630176302063030630356304063 0426304363044630456304663047630916310163 1026310363170631726317363180631826318563 1906319163194631956319663197631986319963 2006325063251632876329063295633006330163 3026330363304633056330663307633086365063 65563661636626366363664636856368864553 2019 WellMed Medical Management, and ServicesAdditional InformationCPT or HCPCS CodesImplantable Pain Pumps Neurostimulators (cont d)Orthopedic Surgeries (cont d)

8 Prior Authorization Required22510225112251222513225142251522 5322253322534225482255122552225542255622 5582258522590225952260022845228462284722 8482284922850228522285322854228552285622 8572285822859228612286222864228652286727 4472748627487298662986729868299142991529 9166185061860618636186461867618686188561 8866235062351630486305063051630556305663 0576306463066630756307663077630786308163 0826308563086630876308863090632526326563 2666326763268632706327163272632736327563 2766327763278632806328163282632836328563 2866455564561645666456864569645706457564 580645816458564590645956472264999J7330 Molecular Diagnostic/Genetic TestingPrior Authorization Required81120811218116281163811648116581 1668116781170812018121281214812158121681 2178122581226812278123081231812328124081 2418124281247813218133581400814018140281 4038140481405814068140781408814508145581 47981518815198152881541815458499987999 Mohs micrographic surgeryPrior Authorization Required1731117312173131731417315 Oral-maxillofacial/TMJ Surgery/Orthognathic SurgeryTreatment of maxillofacial (jaw)

9 Functional impairmentPrior Authorization Required21085210892112021121211222112321 1252112721141211422114321145211462114721 1502115121154211552115921160211882119321 1942119521196211982119921206212102121521 2402124221244212452124621247 Other codes not listed in any category, including unlisted/unspecifiedPrior Authorization Required28890365145389964405647446618069 799699499596595966 Plastic, Reconstructive, or Cosmetic ProceduresBreast reconstruction (non-mastectomy)Reconstruction of the breast except when following mastectomyPrior Authorization NOT required if surgical codes billed with the listed breast cancer DX 2019 WellMed Medical Management, and ServicesAdditional InformationCPT or HCPCS CodesPlastic, Reconstructive, or Cosmetic Procedures (cont d)

10 Cosmetic and reconstructive procedures Cosmetic procedures that change or improve physical appearance without significantly improving or restoring physiological functionReconstructive procedures that treat a medical condition or improve or restore physiologic functionRhinoplastyTreatment of nasal functional impairment and septal deviationPrior Authorization Required11960119711582015821158221582315 8301584717106171071710817999211722117521 1792118021181211822118321184212302123521 2482124921255212562126021261212632126721 2682127521299217402174221743283443040030 4103042030430304353045030460304623046530 5403054530560306203099931295312963129731 2984079967900679016790267903679046790667 9086790967912679506796167966679996939992 70096999L2200Q2026 Site of ServiceOphthalmology Prior Authorization required for ONLY DFW market AND ONLY if services are rendered in Hospital Outpatient setting654266573065855661706676166821669 8266984670286703667040672286731167312 Venous ProceduresRemoval and ablation of the main trunks and named branches of the saphenous veins in the treatment of venous disease