23-1011 Summary Update: Changes to Prior Authorization Requirements
Date: 09/01/23
New CMS codes effective July 1, and other changes effective October 2
Wellcare By Health Net (Health Net) is making changes to the Medicare Advantage HMO/PPO prior authorization (PA) requirements. These changes apply to Direct Network physicians, hospitals, ancillary providers, and non-delegated fee-for-service participating physician groups.
The comprehensive provider update contains procedure code changes to PA requirements on or after October 2, 2023. To view the comprehensive update, Select 23-1011, Changes to Prior Authorization Requirements (PDF).
PA requirement deletions, effective October 2, 2023
After completing an extensive assessment of our PA requirements, we are removing PA requirements for over 300 CPT® and HCPCS1 codes to help reduce your administrative burden. Refer to the comprehensive update for the full list of changes.
The following services will no longer require PA for direct network providers.
- Dermatology – skin tag removal
- Durable medical equipment – continuous glucose monitoring
- Flap procedures
- Hysterectomy (PA required for gender reassignment only)
- Diagnostic procedures – thyroid/parathyroid imaging
- Diagnostic procedures – bone marrow imaging
- Diagnostic procedures – liver/spleen and gallbladder imaging
- Laboratory – bone marrow culture
- Neurology – sinusoidal vertical axis and rotational testing
PA requirement additions effective October 2, 2023
Below are Part B drugs that require PA as of October 2:
CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
Additions | |
|---|---|
Code | Description |
J1950 | Injection, leuprolide acetate (for depot suspension), per 3.75 mg |
J9214 | Injection, interferon, alfa-2b, recombinant, 1 million units |
Part B Medications that require PA, effective July 1, 2023
Refer to the comprehensive update for a list of new Centers for Medicare & Medicaid Services Part B Drugs (medical benefit) medication codes that require authorization as of July 1, 2023.
Use the online prior authorization tool
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization. To check if a CPT or HCPCS code requires authorization, go to the Online Prior Authorization Tool. Note: Codes are updated on their effective date.
Additional information
If you have questions regarding the information contained in this update, contact the Provider Services Center at 800-929-9224.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.