Prior authorization requirements for high-level, definitive drug testing

Effective December 1, 2018, prior authorization (PA) requirements will change for high-level, definitive drug testing(s). The high-level, definitive drug testing(s) will require PA for Empire BlueCross BlueShield HealthPlus 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 will be added to the following:

• G0482 — Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, gas chromatography/mass spectrometry (GC/MS) (any type, single or tandem) and liquid chromatography/mass spectrometry (LC/MS) (any type, single or tandem and excluding immunoassays; e.g., immunoassays [IA]; enzyme immunoassay [EIA]; enzyme-linked immunosorbent assay [ELISA]; enzyme multiplied immunoassay technique [EMIT]; fluorescence polarization immunoassay [FPIA]; and enzymatic methods [e.g., alcohol dehydrogenase]); (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength); and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es) including metabolite(s) if performed.

• G0483 — Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays; e.g., IA; EIA; ELISA; EMIT; FPIA; and enzymatic methods [e.g., alcohol dehydrogenase]); (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength); and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es) including metabolite(s) if performed.

 

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 on the provider website at www.empireblue.com/nymedicaiddoc > Prior Authorization & Claims > Prior Authorization Lookup Tool. Contracted and noncontracted providers may call Provider Services at 1-800-450-8753 for assistance with PA requirements.