Revision Ambetter Prior Authorization List Effective 7.1.2023
Date: 06/22/23
Ambetter Prior Authorization Change Effective 7/1/2023-UPDATE!
Ambetter from Arizona Complete Health requires prior authorization (PA) as a condition of payment for designated services. It is the ordering/prescribing/referring provider’s responsibility to determine which specific codes require PA.
Please verify eligibility and benefits prior to rendering services for members. Payment, regardless of PA, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE PA FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.
To confirm if a CPT/HCPCS code requires PA, please use the Ambetter Pre-Auth Check Tool on the Arizona Complete Health Website > For Providers > Pre-Auth Check
UPDATE: Physical Medicine and Rehabilitation Codes 97010, 97012, 97014, 97032, 97035, 97110, 97112, 97116, 97140, 97530, and 97533 that were included in the table below on page 3 are being removed and will Not require prior auth effective 7/1/23.
Service Category | PA Rule | Services | Procedure Codes |
Audiology | No PA Required for Par providers | Dispensing fees | V5110, V5160, V5200, V5240, V5241 |
Hearing aid, molds, battery | V5264, V5265, V5266, V5267, V5275 | ||
Hearing aid repair/modification | V5014, V5336 | ||
Behavioral Health | PA Required | Alcohol and/or drug services | H0047 |
Mental health services | H0046 | ||
No PA Required for Par providers | Alcohol and/or drug services | H0005, H0014 | |
Breast reconstruction | PA Required except with breast cancer diagnosis | Breast reconstruction, prosthesis | 19316, 19318, 19325, 19328, 19340, 19342, 19350, 19370, 19371, 19499, L8031 |
Cardiovascular | PA Required | Revascularization | 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231 |
External counterpulsation | G0166 | ||
No PA Required for Par providers | Lead, pacemaker/cardioverter-defibrillator combination | C1899 |
DME & Supplies | PA Required | Compression burn garment | A6501, A6507, A6511 |
Miscellaneous DME supply | A9900 | ||
Respiratory assist device | E0471 | ||
Osteogenesis stimulator | E0749 | ||
Wheelchair accessories | E2620, E2622, E2624 | ||
Personal care item | S5199 | ||
Supplies for home delivery | S8415 | ||
No PA Required for Par providers | Respiratory equipment | E0565 | |
Infusion pumps and supplies | B9002, E0781 | ||
Wheelchair | K0001 | ||
Evaluation & Management | PA Required | Office visit for provision of esketamine | G2083 |
Home Health Services | PA Required (Except for Professional Cares (PHCN)) | Home health skilled nursing visit | Revenue Code 551 |
Home Care Management Services | G0087 | ||
Home therapy | G2168, G2169 | ||
Unskilled respite care | S5150, S5151 | ||
Nursing assessment/evaluation | T1001, T1028 | ||
No PA Required for Par providers | Home dialysis (ESRD) | 90966, S9335, S9339 | |
Prenatal home visit | 99500 | ||
Post-discharge home care and care plan oversight | G2001, G2002, G2003, G2004, G2005, G2006, G2007, G2008, G2009, G2013, G2014, G2015 | ||
BPCI home visit | G9187 | ||
Remote in-home visits | G9978, G9979, G9980, G9981, G9982, G9983, G9984, G9985, G9986, G9987 | ||
Practitioner home visit | S0270, S0271, S0272, S0273, S0274 | ||
Medical home program | S0280, S0281 | ||
Home visit, wound care | S9097, S9098 | ||
Home infusion therapy | Q2052, S5035, S5036, S9347 | ||
Home care training | S5108, S5109, S5110, S5111, S5115, S5116 | ||
Laboratory | PA Required | Genetic analysis/studies, surgical pathology procedures | 81235, 81263, 81265, 81267, 81268, 81270, 81275, 81310, 81315, 88237, 0089U |
No PA Required for Par providers | Blood and blood products | P9010, P9011, P9016, P9021, P9022, P9051, P9054, P9056, P9057, P9058 | |
Nutrition | PA Required | Medical food nutritionally complete (oral) | S9433 |
Orthopedic | PA Required | Procedures lower extremities | 28285, 28299 |
Endoscopy wrist | 29848 |
Orthotics | PA Required | Dynamic adjustable forearm device | E1802 |
Knee orthosis (ko) | L1851, L1852 | ||
No PA Required for Par providers | Ankle foot orthosis (AFO) | L2112 | |
Otolaryngology | PA Required | Tonsillectomy & adenoidectomy | 42820, 42821, 42825, 42826, 42830, 42831 |
Pain management | 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, 64530 |
No PA Required for Par providers | Transversus abdominis plane (TAP) block | 64486, 64488 | |
Nerve block | 64632 | ||
Preventive | No PA Required for Par providers | Developmental and behavioral screening | 96110, 96112 |
Professional services | No PA Required for Par providers | Medication administration | G0068, G0069, G0070 |
Services performed in the hospice setting | G9473, G9474, G9475, G9476, G9477, G9478, G9479 | ||
Admission to Medicare care choice model program (MCCM) | G9480 | ||
Radiology Treatments | PA Required | Radiation therapy services | 77372, 77373, G0339, G0340 |
Indium in-111 ibritumomab, dx | A9542 | ||
Ablation of prostate, liver tumor | 47382, 0421T | ||
Skin substitute | PA Required | Skin substitute products | Q4111, Q4114, Q4130, Q4137, Q4139, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226 |
Vision | PA Required | Procedures performed on Cornea | 0402T |
If you have questions, please contact your Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us: AzCHProviderEngagement@azcompletehealth.com