Prior authorization requirement changes effective November 1, 2022

Effective November 1, 2022, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by Anthem Blue Cross and Blue Shield Medicaid. Federal and state law, as well as state contract language, and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

• 0214U: Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood O
• 0215U: Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood O
• 81415: Exome (such as unexplained constitutional or heritable disorder or syndrome); sequence analysis
• 81416: Exome (such as unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (such as parents, siblings) (List separately in addition to code for primary procedure)
• 81417: Exome (such as unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (such as updated knowledge or unrelated condition/syndrome)
• 81432: Hereditary breast cancer-related disorders (such as hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, and MLH1
• 81433: Hereditary breast cancer-related disorders (such as hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11
• L6026: Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device

To request a PA, you may use one of the following methods:

• Availity*: Once logged in to Availity at availity.com, select Patient Registration > Authorizations & Referrals, then select Authorizations or Auth/Referral Inquiry, as appropriate.
• Fax: 800-964-3627
• Phone: 855-661-2028

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at https://providers.anthem.com/ky. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at 855-661-2028 for assistance with PA requirements.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

 

AKY-NU-0404-22/ UM AROW 2892