5160-4-12: EAPG CPT and HCPCS list : EAPG CPT and HCPCS list : EAPG CPT and HCPCS list : EAPG CPT and HCPCS list : 5160-2-75: EAPG CPT and HCPCS list : EAPG CPT and ...
Applies to Medicaid, MyCare Ohio Medicaid Prior Authorization Codification List Effective: 10-1-19 Important Notices These codes are for outpatient services only. All inpatient services require Prior Authorization (PA). Any exceptions included in this prior auth code matrix applies to PAR providers only All non par providers require authorization regardless of services or codes. All codes listed require PA unless there is a plan-specific exception. Office visits; office-based surgical procedures at PAR/Network Providers do not require PA. Referrals to PAR/Network Specialists do not require PA. Some services listed may not be covered by the Centers for Medicare & Medicaid Services (CMS) or your local State Medicaid or Marketplace agency. Likewise, the absence of a code from this list should not be used to determine whether a service is or is not covered by your regulatory agency. This document should not be utilized to make benefit limitations and coverage determinations. Please refer to your regulatory agency for benefit limitations/coverage and specific non-covered codes. Non-PAR Offices/Providers/Facilities : PA required for Non-Par Office Visits, Surgical Procedures, Labs, Diagnostic Studies, In patient stays except for: Emergency Department Services, Professional Fees associated with an Emergency Department visit and approved Ambulatory Surgical Center (ASC) or inpatient stay, Local Health Department (LHD) Services, and other services based on State requirements. PA is not a guarantee of payment for services. Payment is made in accordance with a determination of the member's eligibility on the date of service (for Molina Marketplace members, this includes grace period status), benefit limitations/exclusions and other applicable standards during claim review, including the terms of any applicable provider agreement. For additional information on a member's grace period status, please contact Molina Healthcare. All Long Term Servcies and Support Codes Require PA regardless of the code(s). To search this document, use [Ctrl+F] keys, enter Service or Code in Navigation pane; press Enter Legend: PA: Prior Authorization | PAR: Participating Provider | Non-PAR: Non-Participating Provider To validate coverage by site of service, please reference the appropriate appendices below. Services not designated as a covered service in the applicable appendix, based on the location and type of service, are not reimbursable in accordance with Ohio Administrative Code (OAC) rules, unless PA is obtained. PA is always required for non-covered or non-grouper surgical codes (codes not listed in the appendices designated for the site of service). Site of Service Physician Services Provider-administered pharmaceuticals Ambulatory Surgical Centers Outpatient Hospital Surgical Services Outpatient Hospital Clinical Services Hospital Emergency Room Visits Outpatient Hospital Ancillary Services Outpatient Hospital Radiology Services Outpatient Hospital Laboratory Services Appendix Appendix DD EAPG CPT and HCPCS list EAPG CPT and HCPCS list EAPG CPT and HCPCS list EAPG CPT and HCPCS list EAPG CPT and HCPCS list EAPG CPT and HCPCS list EAPG CPT and HCPCS list OAC 5160-1-60 5160-4-12 5160-2-75 5160-2-75 5160-2-75 5160-2-75 5160-2-75 5160-2-75 5160-2-75 Abortion Services Submit clinical information supporting these codes. 58940 58941 58950 58951 58952 59840 59841 59850 59851 59852 59855 59856 59857 59866 PA Code List Effective Oct. 1, 2019 MHO-2290 1112 Applies to Medicaid, MyCare Ohio Medicaid Prior Authorization Codification List Effective: 10-1-19 Behavioral Health, Mental Health, Alcohol & Chemical Dependency Services Inpatient, Residential Treatment, Partial Hospitalization, Electroconvulsive Therapy (ECT), Applied Behavior Analysis (ABA) for treatment of Autism Spectrum Disorder (ASD), and *Transitional Substance Abuse Residential Treatment (*For Marketplace Members only) SUD partial hospitalization (20 or more hours per week). 0901 1001 90867 96112- H0015***< H0032* H2012* H2015 H2018 S0201 T1023* T1027* T2040* 0912 1002 90868 96113- H0017 H0035 H2013 H2016 H2019* S5150# T1025* T1028* 0913 2106 90869 H0012 H0031* H0046 H2014* H2017* H2020 S5111 T1026*+ T2013* # PA required regardless of Dx. (Marketplace and Medicaid) - PA not required by CBHC agencies certified by Ohio MHAS for up to 20 hours per calendar year, additional visits/hours and all other provider types PA required *** H0015 + modifier TG requires PA due to OAC Community Behavioral Health Services rule for MMP < H0015 + Rev codes 912-913 & modifier HE require PA due to OAC Hospital services rule for MMP * PA required for all plans only when submitted with Autism Dx. [ICD10: F84.0, F84.2, F84.3, F84.4, F84.5, F84.8 or F84.9 and 299.00, 299.01, 299.10, 299.11, 299.80, 299.81, 299.90, 299.91] + PA required after 1 each per billing provider per patient per year. Cannot be billed by biller type 95 MMP: Code + modifier TG requires PA due to OAC Community Behavioral Health Services rule for MMP (Code + Rev codes 912-913 & modifier HE require PA) Cosmetic, Plastic & Reconstructive Procedures [In Any Setting] 11900 15775 15781 15788 15793 11901 15776 15782 15789 15820 11920* 15780 15783 15792 15821 *PA required, except with breast CA Dx. ICD10 codes: 15822 15823 15824 15825 15826 15828 15829 15832 15833 C50.011 C50.319 C50.622 D05.80 C50.012, C50.321 C50.629 D05.81 C50.019 C50.322 C50.811 DO5.82 C50.021 C50.329 C50.812 D05.90 C50.022 C50.411 C50.819 D05.91 C50.029 C50.412 C50.821 D05.92 C50.111 C50.419 C50.822 C50.112 C50.421 C50.829 15834 15835 15836 C50.119 C50.422 C50.911 15837 15838 15839 C50.121 C50.429 C50.912 15847 15876 15877 C50.122 C50.511 C50.919 15878 15879 17380 C50.129 C50.512 C50.921 19300* 19316* 19318* C50.211 C50.519 C50.922 19324* 19325* 19328* C50.212 C50.521 C50.929 19330* 19340* 19342* C50.219 C50.522 D05.00 19350* 19355* 19396* C50.221 C50.529 D05.01 30400 30410 30420 C50.222 C50.611 D05.02 30430 30435 30450 C50.229 C50.612 D05.10 30460 30462 67904 C50.311 C50.619, D05.11 67906 67908 69300 C50.312 C50.621 D05.12 Durable Medical Equipment (DME) A5514 A7025 A9274 A9276 A9277 A9278 A9900 A9901 C2624 E0194 E0255 E0256 E0260 E0261 E0265 E0266 E0277 E0292 E0293 E0294 E0295 E0296 E0297 E0300 E0301 E0302 E0303 E0304 E0328 E0329 E0371 E0372 E0373 E0447 E0462 E0465 E0466 E0467 E0481 E0483 E0652 E0691 E0692 E0693 E0694 E0747 E0748 E0749 E0760 E0762 E0764 E0766 E0782 E0783 E0784 E0785 E0786 E0849 E0855 E0983 E0984 E0986 E0988 E1002 E1003 E1004 E1005 E1006 E1007 E1008 E1010 E1012 E1014 E1020 E1028 E1029 E1030 E1035 E1036 E1161 E1225 E1226 E1227 E1230 E1232 E1233 E1234 E1235 E1236 E1237 E1238 E1296 E1298 E1310 E1399 E1700 E2201 E2202 E2203 E2204 E2227 E2228 E2291 E2292 E2293 E2294 E2295 E2300 E2310 E2311 E2312 E2313 E2321 E2322 E2325 E2326 E2327 E2328 E2329 E2330 E2340 E2341 E2342 E2343 E2351 E2361 E2366 E2367 E2368 E2369 E2370 E2373 E2374 E2375 E2376 E2377 E2378 E2397 E2500 E2502 E2504 E2506 E2508 E2510 E2511 E2605 E2606 E2607 E2608 E2609 E2611 E2612 E2613 E2614 E2615 E2616 E2617 E2620 E2621 E2622 E2623 E2624 E2625 E2626 E2627 E2628 E2629 E2630 E2631 K0008 K0009 K0010 K0011 K0012 K0014 K0108 K0553 K0554 K0606 K0800 K0801 K0802 K0806 K0807 K0808 K0813 K0814 K0815 K0816 K0820 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0830 K0831 K0835 K0836 K0837 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0864 K0868 K0869 K0870 K0871 K0877 K0878 K0879 K0880 K0884 K0885 K0886 K0890 K0891 K0900 L3761 L7700 L8625 L8694 Q4183 Q4184 Q4185 Q4186 Q4187 Q4188 Q4190 Q4191 Q4193 Q4194 Q4198 Q4200 Q4201 Q4202 Q4203 Q4204 S1034 S1035 S1036 S1037 V2530 V2531 V5171 V5172 V5181 V5211 V5212 V5213 V5214 V5215 V5221 Experimental/Investigational 22899 31299 33440 33866 67299 81503 82016 82017 83987 84145 86316 86343 93264 95983 99499 0042T 0054T 0055T 0058T 0071T 0072T 0075T 0076T 0085T 0095T 0098T 0107T 0108T 0109T 0110T 0111T 0126T 0163T 0164T 0165T 0174T 0175T 0184T 0191T 0205T 0206T 0207T 0208T 0209T 0210T 0211T 0212T 0213T 0214T 0215T 0216T 0217T 0222T 0228T 0229T 0230T 0231T 0234T 0235T 0236T 0237T 0238T 0249T 0253T 0254T 0267T 0268T 0269T 0270T 0271T 0272T 0273T 0274T 0275T 0278T 0290T 0295T 0296T 0314T 0315T 0316T 0317T 0329T 0330T 0331T 0332T 0333T 0335T 0338T 0339T 0342T 0351T 0352T 0353T 0354T 0355T 0356T 0357T 0358T 0362T 0373T 0394T 0395T 0396T 0401T 0402T 0403T 0404T 0405T 0408T 0409T 0410T 0411T 0412T 0413T 0414T 0415T 0420T 0421T 0422T 0423T 0424T 0425T 0426T 0427T 0428T 0429T 0430T 0431T 0432T 0437T 0439T 0440T 0441T 0442T 0443T 0444T 0445T 0446T 0447T 0448T 0469T 0470T 0475T 0476T 0477T 0478T 0479T 0480T 0481T 0482T 0483T 0484T 0485T 0486T 0487T 0492T 0493T 0494T 0495T 0496T 0497T 0498T 0499T 0500T 0501T 0502T 0503T 0504T 0509T 0510T 0511T 0512T 0513T 0514T 0515T 0516T 0517T 0518T 0519T 0520T 0521T 0526T 0527T 0528T 0529T 0530T 0531T 0532T 0533T 0534T 0535T 0536T 0541T 0542T C9752 C9753 C9754 C9755 L8608 Q4161 Q4162 Q4163 Q4164 Q4165 Q4189 Q4192 Q4195 PA Code List Effective Oct. 1, 2019 MHO-2290 1112 Applies to Medicaid, MyCare Ohio Medicaid Prior Authorization Codification List Effective: 10-1-19 93998 95836 95976 95977 0100T 0101T 0102T 0106T 0198T 0200T 0201T 0202T 0218T 0219T 0220T 0221T 0263T 0264T 0265T 0266T 0297T 0298T 0312T 0313T 0347T 0348T 0349T 0350T 0397T 0398T 0399T 0400T 0416T 0417T 0418T 0419T 0433T 0434T 0435T 0436T 0471T 0472T 0473T 0474T 0488T 0489T 0490T 0491T 0505T 0506T 0507T 0508T 0522T 0523T 0524T 0525T A4563 C1823 C8937 C9751 Q4196 Q4197 Genetic Counseling & Testing Except for Prenatal diagnoses of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations. 53854 81167 81187 81225 81246 81287 81320 81361 81414 81438 81519 86153 0013U 0048U S3854 81105 81171 81188 81226 81247 81289 81321 81362 81415 81439 81520 88261 0014U 0049U S3861 81106 81172 81189 81227 81248 81291 81323 81363 81416 81440 81521 88271 0016U 0050U S3865 81107 81173 81190 81228 81249 81292 81324 81364 81417 81442 81525 88369 0017U 0053U S3866 81108 81174 81201 81229 81258 81294 81325 81400 81420 81443 81528 88373 0022U 0055U S3870 81109 81175 81203 81230 81259 81295 81328 81401 81422 81445 81535 88374 0026U 0056U 81110 81176 81204 81231 81265 81297 81329 81402 81425 81448 81536 88377 0027U 0057U 81111 81177 81210 81232 81266 81298 81333 81403 81426 81450 81538 0004M 0029U 0058U 81112 81178 81212 81233 81269 81300 81334 81404 81427 81455 81540 0006M 0030U 0059U 81120 81179 81215 81234 81271 81305 81335 81405 81430 81460 81541 0007M 0031U 0060U 81121 81180 81216 81235 81272 81306 81336 81406 81431 81465 81545 0009M 0032U G9143 81161 81181 81217 81236 81273 81311 81337 81407 81432 81470 81551 0005U 0033U S3722 81162 81182 81218 81237 81274 81312 81343 81408 81433 81471 81595 0008U 0034U S3800 81163 81183 81219 81238 81283 81313 81344 81410 81434 81493 81596 0009U 0037U S3840 81164 81184 81221 81239 81284 81314 81345 81411 81435 81504 83006 0010U 0045U S3841 81165 81185 81222 81243 81285 81317 81346 81412 81436 81507 84999* 0011U 0046U S3842 81166 81186 81223 81244 81286 81319 81355 81413 81437 81518 86152 0012U 0047U S3852 *Code 84999: Including Oncotype Dx Healthcare Administered Drugs Pharmacy Drug Coverage Newly FDA approved medications such as "buy-and-bill" drugs are considered non-formulary and subject to non-formulary policies and other non-formulary utilization criteria until a coverage decision is rendered by the Molina Pharmacy and Therapeutics Committee. "Buy-and-bill" drugs are pharmaceuticals which a provider purchases and administers, and for which the provider submits a claim to Molina Healthcare for reimbursement. Many self-administered and office-administered injectable products require Prior Authorization (PA). In some cases they will be made available through Molina Healthcare's vendor, Caremark Specialty Pharmacy. Molina's pharmacy vendor will coordinate with MHC and ship the prescription directly to your office or the member's home. All packages are individually marked for each member, and refrigerated drugs are shipped in insulated packages with frozen gel packs. The service also offers the additional convenience of enclosing needed ancillary supplies (needles, syringes and alcohol swabs) with each prescription at no charge. Please contact your Provider Relations Representative with any further questions about the program. 90281 C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9025 J9130 90283 J0121 J0517 J0695 J1301 J1562 J1744 J2323 J2796 J3355 J7185 J7209 J7329 J9027 J9145 90284 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9032 J9150 90378 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7340 J9033 J9153 A9513 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7504 J9034 J9155 A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7511 J9035^ J9160 A9543 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7527 J9039 J9171 B4105 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7639 J9040 J9173 C9035 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7682 J9041 J9176 C9036 J0207 J0588 J0875 J1442 J1575 J1833 J2502 J3060 J3489 J7193 J7313 J7686 J9042 J9178 C9037 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J8520 J9043 J9179 C9038 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J8521 J9044 J9185 C9039 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J8655 J9045 J9190 C9130** J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8670 J9047 J9200 C9131** J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8700 J9050 J9201 C9132 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J9000 J9055 J9202 C9257^ J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J9015 J9057 J9203 C9293 J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J9017 J9065 J9204 C9399 J0364 J0637 J1096 J1557 J1652 J2182 J2783 J3285 J7180 J7202 J7325 J9019 J9070 J9205 C9407 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9022 J9098 J9206 C9408 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9023 J9120 J9207 ^J9035: No PA required when associated with ocular Dx's. (See Dx Codes tab for related ICD9 & ICD10 Codes). Not indicated for ocular conditions, use C5257. * Healthcare Administered Drug- PA required in the ambulatory surgical setting only for Medicaid LOB J9208 J9210 J9211 J9214 J9215 J9216 J9217 J9218 J9219 J9225 J9226 J9228 J9229 J9230 J9245 J9261 J9262 J9263 J9264 J9266 J9267 J9268 J9269 J9271 J9280 J9285 J9293 J9295 J9299 J9301 J9302 J9303 J9305 J9306 J9307 J9308 J9310 J9311 J9312 J9313 J9315 J9325 J9328 J9330 J9340 J9351^^ J9352 J9354 J9355 J9357 J9360 J9371 J9390 J9395 J9400 J9600 J9999 Q0138 Q0139 Q2043 Q2050 Q3027 Q3028 Q4074 Q5101 Q5103 Q5104 Q5107 Q5108 Q5109 Q5110 Q5111 Q5117 Q9991* Q9992* S0073 S0122 S0126 S0128 S0132 S0145 S0148 S0157 PA Code List Effective Oct. 1, 2019 MHO-2290 1112 Applies to Medicaid, MyCare Ohio Medicaid Prior Authorization Codification List Effective: 10-1-19 ** Medicaid only ^^PA Required for Marketplace only B39.4 B39.5 B39.9 E08.311 E08.319 E08.3211 E08.3212 E08.3213 E08.3219 E08.3311 E08.3312 E08.3313 E08.3319 E08.3411 E08.3412 E08.3413 E08.3419 E08.349 E08.3492 E08.3493 E08.3499 E08.3511 E08.3512 E08.3513 E08.3519 E08.3521 E08.3522 E08.3523 E08.3529 E08.3531 E08.3532 E08.3533 E08.3539 E08.3541 E08.3542 E08.3543 E08.3549 E08.3551 E08.3552 E08.3553 E08.3559 E08.3591 E08.3592 E08.3593 E08.3599 E09.311 E09.319 E09.3211 E09.3212 E09.3213 E09.3219 E09.3311 E09.3312 E09.3313 E09.3319 E09.3411 E09.3412 E09.3413, E09.3419 E09.3491 E09.3492 E09.3493 E09.3499 E09.3511 E09.3512 E09.3513 E09.3519 E09.3521 E09.3522 E09.3523 E09.3529 E09.3531 E09.3532 E09.3533 E09.3539 E09.3541 E09.3542 E09.3543 E09.3549 E09.3551 E09.3552 E09.3553 E09.3559 E09.3591 E09.3592 E09.3593 E09.3599 E10.311 E10.319 E10.3211 E10.3212 E10.3213 E10.3219 E10.3311 E10.3312 E10.3313 E10.3319 E10.3411 E10.3412 E10.3413 E10.3419 E10.3491 E10.3492 E10.3493 E10.3499 E10.3511 E10.3512 E10.3513 E10.3519 E10.3521 E10.3522 E10.3523 E10.3529 E10.3531 E10.3532 E10.3533 E10.3539 E10.3541 E10.3542 E10.3543 E10.3549 E10.3551 E10.3552 E10.3553 E10.3559 E10.3591 E10.3592 E10.3593 E10.3599 E11.311 E11.319 E11.3211 E11.3212 E11.3213 E11.3219 E11.3311 E11.3312 E11.3313 E11.3319 E11.3391 E11.3392 E11.3393 E11.3399 E11.3411 E11.3412 E11.3413 E11.3419 E11.3491 E11.3492 E11.3493 E11.3499 E11.3511 E11.3512 E11.3513 E11.3519 E11.3521 E11.3522 E11.3523 E11.3529 E11.3531 E11.3532 E11.3533 E11.3539 E11.3541 E11.3542 E11.3543 E11.3549 E11.3551 E11.3552 E11.3553 E11.3559 E11.3591 E11.3592 E11.3593 E11.3599 E13.311 E13.319 E13.3211 E13.3212 E13.3213 E13.3219 E13.3311 E13.3312 E13.3313 E13.3319 E13.3411 E13.3412 E13.3413 E13.3419 E13.3491 E13.3492 E13.3493 E13.3499 E13.3511 E13.3512 E13.3513 E13.3519 E13.3521 E13.3522 E13.3523 E13.3529 E13.3531 E13.3532 E13.3533 E13.3539 E13.3541 E13.3542 E13.3543 E13.3549 E13.3551 E13.3552 E13.3553 E13.3559 E13.3591 E13.3592 E13.3593 E13.3599 H21.1X1 H21.1X2 H21.1X3 H21.1X9 H32 H34.8110 H34.8111 H34.8112 H34.8120 H34.8121 H34.8122 H34.8130 H34.8131 H34.8132 H34.8190 H34.8191 H34.8192 H34.821 H34.822 H34.823 H34.829 H34.8310 H34.8311 H34.8312 H34.8320 H34.8321 H34.8322 H34.8330 H34.8331 H34.8332 H34.8390 H34.8391 H34.8392 H34.9 H35.00 H35.011 H35.012 H35.013 H35.019 H35.021 H35.022 H35.023 H35.029 H35.031 H35.032 H35.033 H35.039 H35.041 H35.042 H35.043 H35.049 H35.051 H35.052 H35.053 H35.059 H35.061 H35.062 H35.063 H35.069 H35.071 H35.072 H35.073 H35.079 H35.09 H35.141 H35.142 H35.143 H35.149 H35.151 H35.152 H35.153 H35.159 H35.161 H35.162 H35.163 H35.169 H35.20 H35.21 H35.22 H35.23 H35.3210 H35.3211 H35.3212 H35.3213 H35.3220 H35.3221 H35.3222 H35.3223 H35.3230 H35.3231 H35.3232 H35.3233 H35.3290 H35.3291 H35.3292 H35.3293 H35.33 H35.351 H35.352 H35.353 H35.359 H35.81 H35.82 H40.50X0 H40.50X1 H40.50X2 H40.50X3 H40.50X4 H40.51X0 H40.51X1 H40.51X2 H40.51X3 H40.51X4 H40.52X0 H40.52X1 H40.52X2 H40.52X3 H40.52X4 H40.53X0 H40.53X1 H40.53X2 H40.53X3 H40.53X4 H40.89 H44.20 H44.21 H44.22 H44.23 Home Health Care Services PA required for all home health services after initial evaluation plus six (6) visits per calendar year. The visits are for a combination of services, not per discipline. This benefit is the member's benefit per calendar year, not per provider or each start of care. G0151 G0153 G0156 G0158 G0160 G0162 G0300 G0493 G0152 G0155* G0157 G0159 G0161 G0299* G0490 G0494 *Excluding Hospice **PA Required for Marketplace only **Contact Molina Case Manager or Waiver Service Coordinator for waiver services G0495 G0496 S9122 S9123 S9124 S9128 S9129 S9131 S5130 S5135 S5151 S9470 S9977 T1000 T1002** T1005 T1003** T1019*** T1022 T1030 T1031 Hyperbaric Therapy 99183 G0277 Q4176 Q4177 Q4178 Q4179 Q4180 Q4181 Q4182 Imaging Advanced & Specialty C8900 C8901 C8902 C8903 C8903 C8905 C8906 C8908 C8909 C8910 C8911 C8912 C8913 C8914 C8918 C8919 C8920 C8931 C8932 C8933 C8934 C8935 C8936 G0219 G0235 G0252 G0288 G0296 G0297 S8042 S8080 70336 70450 70460 70470 70480 70481 70482 70486 70487 70488 70490 70491 70492 70496 70498 70540 70542 70543 70544 70545 70546 70547 70548 70549 70551 70552 70553 70554 70555 71250 71260 71270 71275 71550 71551 71552 71555 72125 72126 72127 72128 72129 72130 72131 72132 72133 72141 72142 72146 72147 72148 72149 72156 72157 72158 72159 72191 72192 72193 72194 72195 72196 72197 72198 73200 73201 73202 73206 73218 73219 73220 73221 73222 73223 73225 73700 73701 73702 73706 73718 73719 73720 73721 73722 73723 73725 74150 74160 74170 74174 74175 74176 74177 74178 74181 74182 74183 74185 74261 74262 74263 74712 74713 75557 75559 75561 75563 75565 75571 75572 75573 75574 75635 76376 76377 76380 76390 76391 76497 76498 77046 77047 77048 77049 77084 78205 78206 78320 78451 78452 78453 78454 78459 78466 78468 78469 78472 78473 78481 78483 78491 78492 78494 78496 78607 78608 78609 78647 78710 78811 78812 78813 78814 78815 78816 Inpatient Admissions All inpatient admissions require PA, including Elective, Acute Hospital, Skilled Nursing Facilities (SNF), Rehabilitation, and Long Term. Long Term Services & Support [LTSS] All LTSS Codes/Services Require Prior Authorization regardless of code(s). Neuropsychological & Psychological Tests (in any setting) 95950 95953 95957 96113* 96121* 96130* 96132* 96136* 96138* 96146* 97152 97154 97156 97158 95951 95956 96112* 96116* 96125 96131* 96133* 96137* 96139* 97151 97153 97155 97157 *PA not required by CBHC agencies certified by Ohio MHAS for up to 20 hours per calendar year. Additional visits/hours and all other provider types, PA required. PA Code List Effective Oct. 1, 2019 MHO-2290 1112 Applies to Medicaid, MyCare Ohio Medicaid Prior Authorization Codification List Effective: 10-1-19 **PA required after 8 hours/encounters per patient per calendar year (only applies to providers certified by Ohio MHAS). Occupational Therapy Medicaid: PA required after 30 dates of service. 97110 97112 97763 Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures 10040 21154 22222 15730 21155 22224 15733 21159 22226 15786 21160 22505 15787 21172 22526 15819 21175 22527 15830 21240 22532 17004 21242 22533 17360 21243 22534 19294 21270 22548 20930 21280 22551 20939 21282 22552 21073 21295 22554 21120 21296 22556 21121 22100 22558 21122 22101 22585 21123 22102 22586 21125 22103 22590 21127 22110 22595 21137 22112 22600 21138 22114 22610 21139 22116 22612 21141 22206 22630 21142 22207 22632 21143 22208 22633 21145 22210 22800 21146 22212 22802 21147 22214 22804 21150 22216 22808 21151 22220 22810 *PA Required for Marketplace 22812 22818 22819 22830 22840 22841 22842 22843 22844 22846 22847 22848 22849 22850 22852 22855 22856 22857 22861 22862 22864 22865 22867 22868 22869 22870 23412 23470 25447 26499 27120 27122 27125 27130 27132 27134 27137 27138 27438 27440 27441 27442 27443 27445 27446 27447 27486 27487 28005 28008 28010 28011 28035 28060 28062 28080 28090 28092 28100 28102 28103 28104 28106 28107 28108 28110 28111 28112 28113 28114 28116 28118 28119 28120 28122 28124 28126 28130 28140 28150 28153 28160 28171 28173 28175 28200 28202 28208 28210 28220 28222 28225 28226 28230 28232 28234 28238 28240 28250 28260 28261 28262 28264 28270 28272 28280 28285 28286 28288 28289 28291 28292 28295 28296 28297 28298 28299 28300 28302 28304 28305 28306 28307 28308 28309 28310 28312 28313 28315 28320 28322 28340 28341 28344 28345 28360 28705 28715 28725 28730 28735 28737 28740 28750 28755 28760 28890 29806 29807 29819 29820 29821 29822 29823 29824 29825 29826 29827 29828 29873 29874 29875 29876 29877 29879 29880 29881 29882 29883 29884 29885 29886 29887 29888 29889 29891 29892 29893 29894 29895 29897 29898 29899 29914 29915 29916 30465 30520 30540 30545 31253 31257 31259 31295 31296 31297 31298 31660 31661 32491 32994 33206 33207 33208 33212 33213 33214 33221 33224 33225 33227 33228 33229 33230 33231 33240 33249 33262 33263 33264 33270 33251 33254 33261 33265 33266 33289 33274 33275 33979 34713 34714 34715 34716 36460 36465 36466 36468 36470 36471 36475 36476 36478 36479 36482 36483 36514 37191 37243 37700 37718 37722 37735 37760 37761 37765 37766 37780 37785 38204 38207 38208 38209 38210 38211 38212 38213 38214 38215 38232 38573 43644 43645 43647 43648 43653 43770 43771 43772 43773 43774 43775 43842 43843 43845 43846 43847 43848 43881 43882 43886 43887 43888 47380 47381 47382 47605 47610 47612 47620 49255 49904 49905 49906 50590* 52441 52442 52649 53850 53852 53854 54401 54405 55874 55970* 55980* 57288 57289 58150 58180 58152 58200 58210 58240 58260 58262 58263 58267 58270 58275 58280 58285 58290 58291 58292 58293 58294 58321 58322 58323 58345 58350 58356 58540 58541 58542 58543 58544 58545 58546 58548 58550 58552 58553 58554 58570 58571 58572 58573 58660 58661 58662 58672 58673 58700 58720 58740 58750 58752 58760 58770 58940 58943 58950 58951 58952 58953 58954 58956 58957 58958 58970 58974 58976 59070 59072 59074 59076 61863 61864 61867 61868 61885 61886 62324 62325 62326 62327 62380 63001 63003 63005 63011 63012 63015 63016 63017 63020 63030 63035 63040 63042 63043 63044 63045 63046 63047 63048 63050 63051 63055 63056 63057 63064 63066 63075 63076 63077 63078 63081 63082 63085 63086 63087 63088 63090 63091 63101 63102 63103 64553 64568 64569 64570 64590 64595 64912 64913 65771 65772 65775 67900 67901 67902 67903 67909 67950 69714 69715 69717 69718 69930 90867 90868 90869 95249 93229 96567 96570 96571 96573 96574 96900 96902 96904 96910 96912 96913 96920 96921 96922 96931 96932 96933 96934 96935 96936 C2616 C9734 C9738 C9739 C9740 C9746 C9747 C9748 S2095 Pain Management Procedures 27096 62264 62322 62323 62362 63650 63662 63685 64461 64479 64484 64488 64491 64494 64633 64636 97810* 97814* 27279 62320 62350 62360 62367 63655 63663 63688 64462 64480 64486 64489 64492 64495 64634 64640 97811* G0260 62263 62321 62351 62361 62368 63661 63664 64450 64463 64483 64487 64490 64493 64600 64635 77003 97813* S8930 ** *PA at the 31st visit per calendar year. Ohio Department of Medicaid allows up to 30 visits per calendar year for low back or migraines without PA (total of 30 units and not code specific. Once 30 units are met, the codes will hit the PA edit). **Marketplace only Physical Therapy Medicaid: PA required after 30 dates of service. 97110 97112 97763 Prosthetics & Orthotics L0452 L0480 L0482 L0484 L0486 L0622 L0637 L0640 L0650 L0700 L0710 L1000 L1005 L1110 L1640 L1680 L1685 L1700 L1710 L1720 L1730 L1755 L1834 L1840 L1844 L1846 L1860 L1900 L1904 L1907 L1920 L1940 L1945 L1950 L1960 L1970 L1980 L1990 L2000 L2005 L2010 L2020 L2030 L2034 L2036 L2037 L2038 L2050 L2060 L2080 L2090 L2106 L2108 L2126 L2128 L2232 L2800 L4631 L5856 L6026 L7259 L8614 L8692 S1040 PA Code List Effective Oct. 1, 2019 MHO-2290 1112 Applies to Medicaid, MyCare Ohio Medicaid Prior Authorization Codification List Effective: 10-1-19 Radiation Therapy & Radio Surgery 77520 77522 77523 77525 G0339 G0340 G6015 G6016 G6017 Q9950 Sleep Studies 95800^ 95801** 95803** 95805 95806** 95807 ^Home Sleep Studies non-covered *Non-covered if done in POS 12 **PA Required for Marketplace only, Non-covered for Medicaid 95808 95810* 95811* Speech Therapy Medicaid: PA required after 30 dates of service. 92507 92508 \ Transplant Services (Including Solid Organ and Bone Marrow) Corneal Transplants do not require PA. 0537T 0540T 38230 38242 0538T 38205 38240 38243 0539T 38206 38241 44715 44720 44721 47133 47135 47140 47141 47142 47143 47144 47145 47146 47147 48160 48550 48551 48552 48554 48556 50300 50320 50323 50325 50327 50328 50329 50340 50360 50365 50370 50380 S2053 S2054 S2055 Transportation Services PA required for Non-Emergent Air Ambulance transportation services. Emergency transport does not require PA. A0430 A0431 A0999 S9960 S9961 Unlisted/Miscellaneous Codes Molina Healthcare requires PA, as well as medically necessity documentation and rationale be submitted with the PA request for all Unlisted/Miscellaneous codes. 01999 26989 37799 43659 48999 58999 69399 78199 80321** 80335** 80349** 80363** 80377** 87999 93799 15999 27299 38129 43999 49329 59897 69799 78299 80322** 80336** 80350** 80364** 81099 88099 94799 17999 27599 38589 44238 49659 59898 69949 78399 80323** 80337** 80351** 80365** 81479 88199 95199 19499 27899 38999 44799 49999 59899 69979 78499 80324** 80338** 80352** 80366** 81599 88299 95999 20999 28899 39499 44899 50549 60659 76496 78599 80325** 80339** 80353** 80367** 83992** 88399 96379 21089 29999 39599 44979 50949 60699 76497 78699 80326** 80340** 80354** 80368** 84999 88749 96549 21299 30999 40799 45399 51999 64999 76498 78799 80327** 80341** 80355** 80369** 85999 89240 96999 21499 31299 40899 45499 53899 66999 76499 78999 80328** 80342** 80356** 80370** 86486 89398 97039 21899 31599 41599 45999 54699 67299 76999 79999 80329** 80343** 80357** 80371** 86849 90399 97139 22899 31899 42299 46999 55559 67399 77299 80299 80330** 80344** 80358** 80372** 86999 90749 97799 22999 32999 42699 47379 55899 67599 77399 80305* 80331** 80345** 80359** 80373** 87797 90899 99199 S2060 S2061 S2065 S2107 S2140 S2142 S2150 S2152 Q2041 A0999 A4421 A4641 A4649 A4913 A6261 A6262 A9698 A9699 A9900 A9999 E0769 E0770 E1399 E1699 G0480** G0481** G0482** G0483** G0501 G0659** G9012 J7999 J8498 J8499 J8597 J8999 J9999 K0812 K0898 K0899 L0999 L1499 Q2042 L7499 L8039 L8499 L8698 L8699 L8701 L8702 P9603 P9604 Q0507 Q0508 Q4082 Q4100 S0590 S3870 S8189 S8930 S9110 T1999 T2025 T5999 V2199 PA Code List Effective Oct. 1, 2019 MHO-2290 1112Molina Healthcare Adobe PDF Library 15.0