News

Ambetter Prior Authorization Change Summary

Date: 06/21/23

Ambetter from Sunshine Health requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Ambetter products offered by Sunshine Health.

Ambetter from Sunshine Health is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice.

Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.

For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on our website at https://ambetter.sunshinehealth.com/provider-resources/manuals-and-forms/pre-auth.html

Effective August 1, 2023, the following are changes to prior authorization requirements:

Behavioral Health

PA Rule	Services	Procedure Codes
PA Required	BH short-term residential	H0018
No PA Required	Alcohol and/or drug services	H0004, H0005, H0007, H0014
No PA Required	Crisis intervention services	H2011
No PA Required	Substance abuse/detoxification and mental health services	S9475, S9484

Breast reconstruction

PA Rule	Services	Procedure Codes
PA Required except with breast cancer diagnosis	Breast reconstruction, prosthesis	19316, 19318, 19325, 19328, 19340, 19342, 19350, 19370, 19371, 19499, L8031

PA Rule

Services

Procedure Codes

PA Required except with breast cancer diagnosis

Breast reconstruction, prosthesis

19316, 19318, 19325, 19328,

19340, 19342, 19350, 19370,

19371, 19499, L8031

Cardiovascular

PA Rule	Services	Procedure Codes
PA Required	Revascularization	37220, 37221
PA Required	Unlisted procedure	37799
PA Required	Implantable wireless pulmonary artery wireless pressure sensor	C2624
No PA Required	Other cardiac procedures	93797, 93798
No PA Required	Intense cardiac rehab	G0422, G0423
No PA Required	Cardiac rehab program	S9472

Diagnostic and Therapeutic Radiology services

PA Rule	Services	Procedure Codes
PA Required	Indium in-111 ibritumomab, dx	A9542
PA Required	Ablation Liver Tumor	47382

DME & Supplies

PA Rule	Services	Procedure Codes
PA Required	Repair/maintenance for home hemodialysis equipment	A4870, A4890
PA Required	Osteogenesis stimulator	E0749
PA Required	Wheelchairs and accessories	E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613, E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2624
PA Required	Personal care item	S5199
No PA Required	Wheelchair and accessories	E2611
No PA Required	Respiratory equipment	E0550, E0565, E1390
No PA Required	Infusion pumps and supplies	K0455, B9002

Gastroenterology

PA Rule	Services	Procedure Codes
PA Required	Gastrointestinal transit and pressure measurement	91112

Home care

PA Rule	Services	Procedure Codes
PA Required	Home Care Management Services	G0087
PA Required	Home therapy	G2168
No PA Required	Home dialysis (ESRD)	90966
No PA Required	Home visit for prenatal monitoring and assessment	99500
No PA Required	In-home visit post-discharge and care plan oversight	G2001, G2002 G2004, G2005, G2006, G2007, G2008, G2009, G2013, G2014, G2015
No PA Required	BCPI home visit	G9187
No PA Required	Remote in-home visits	G9978, G9979, G9980, G9981, G9982, G9983, G9984, G9985, G9986, G9987
No PA Required	Management of patient home care	S0270, S0271, S0272, S0273, S0274
No PA Required	Medical home program	S0280, S0281
No PA Required	Home visit, wound care	S9097, S9098
No PA Required	Home therapy hemodialysis and peritoneal dialysis	S9335, S9339

Infusion services

PA Rule	Services	Procedure Codes
No PA Required	Home infusion therapy	S5035, S5036, S5108, S5109, S5110, S5111, S5115, S5116, S9347

Laboratory

PA Rule	Services	Procedure Codes
PA Required	Genetic testing	0089U
No PA Required	Blood and blood products	P9010, P9011, P9016, P9021, P9022, P9051, P9054, P9056, P9057, P9058
No PA Required	Routine venipuncture	S9529
No PA Required	Multianalyte assays with algorithmic analyses	81508

Nutrition

PA Rule	Services	Procedure Codes
PA Required	Medical food nutritionally complete (oral)	S9433

Obstetric care

PA Rule	Services	Procedure Codes
No PA Required	Vaginal delivery	59400, 59409

Oncology

PA Rule	Services	Procedure Codes
PA Required	Radiation therapy services	77372, 77373, G0339, G0340

Orthopedic

PA Rule	Services	Procedure Codes
PA Required	Procedures lower extremities	28285, 28299
PA Required	Endoscopy wrist	29848

Other medical items or services

PA Rule	Services	Procedure Codes
PA Required unless performed on the same day as surgery	Injection, anesthetic agent or steroid	62320, 62321, 62322, 62323, 62325, 62327, 64400, 64405, 64415, 64417, 64418, 64420, 64421, 64430, 64445, 64447, 64448, 64450, 64451, 64454, 64479, 64480, 64483, 64484, 64505, 64510, 64517, 64520
PA Required	Injection procedure for sacroiliac joint	G0260
No PA Required	Transversus abdominis plane (TAP) block	64486, 64488
No PA Required	Nerve block	64632

Preventive

PA Rule	Services	Procedure Codes
PA Required	Direct skilled RN services	G0299
No PA Required	Physician or other qualified health care professional supervision	G0068, G0069, G0070, G0179, G0182
No PA Required	Services performed in the hospice setting	G9473, G9474, G9475, G9476, G9477, G9478, G9479

PA Rule

Services

Procedure Codes

PA Required

Direct skilled RN services

G0299

No PA Required

Physician or other qualified health care professional supervision

G0068, G0069, G0070, G0179,

G0182

No PA Required

Services performed in the hospice setting

G9473, G9474, G9475, G9476, G9477, G9478, G9479

Skin substitute

PA Rule	Services	Procedure Codes
PA Required	Skin substitute products	Q4114, Q4130, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226

Sleep Medicine

PA Rule	Services	Procedure Codes
No PA Required	Sleep medicine testing	95800, 95806