Prior authorization changes

Category: Medicaid

Effective December 1, 2019, prior authorization (PA) requirements are changing for the codes listed below. The listed codes will require PA by Empire BlueCross BlueShield HealthPlus for Medicaid Managed Care members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services 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 are being added to the following:

• Lower extremity prosthesis — shank foot system with vertical loading pylon (L5987)
• Gait trainer, pediatric size — anterior support, includes all accessories and components (E8002)
• Wheelchair, pediatric size — tilt-in-space, folding, adjustable, without seating system (E1234)
• Wheelchair, pediatric size — tilt-in-space, rigid, adjustable, without seating system (E1233)
• Transport chair, pediatric size (E1037)
• Multi-positional patient transfer system with integrated seat, operated by care giver (E1035)
• Wheelchair accessory — ventilator tray, gimbaled (E1030)
• Water circulating heat pad with pump (E0217)

 

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

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-450-8753

 

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-800-450-8753 for PA requirements.

 

NYE-NU-0149-19 July 2019