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• Effective July 1, 2012 indicated in red text

Important pre-authorization reminders

1. Reference the Centers for Medicare & Medicaid Services (CMS) for guidelines on medical necessity.
2. Before requesting pre-authorization and providing services, please verify eligibility and benefits via the Provider Center.
3. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
4. Member contracts determine benefits. Contract exclusions will not be pre-authorized. Denials may be appealed through Customer Service. The member's contract language will apply.
5. Pre-authorizations obtained within 30 business days prior to service are valid except in the case of misrepresentation.
6. Urgent/Emergent services do not require pre-authorization.
7. Pre-authorization approval will be communicated by phone and a pre-authorization approval number will be provided.
8. Pre-authorization denials will be communicated both in writing and by phone.

Criteria used to determine if pre-authorization is needed:

1. Service is specifically listed as requiring pre-authorization on the Regence Medicare Products Pre-authorization List.
2. There are specific criteria for review in Centers for Medicare & Medicaid Services (CMS) policy (e.g., NCD, LCD, Newsletters etc).
3. CMS clearly states the service is covered when medically necessary; (Medicare non-covered codes will not be accepted for pre-authorization review).
4. Codes that may be listed as a Medicare Pass Through Code and are not accepted for payment therefore, the codes will not be reviewed.
5. The service is not set up on the Physician’s Relative Value Fee Schedule database therefore, the codes will not be reviewed.
6. Experimental, investigational, or potentially cosmetic procedures using related approved codes may be pre-authorized if Medicare medical necessity guidelines or policy statements are available to be used for the review. 
7. Unlisted codes may be subject to post-service review with operative report and medical necessity documentation.

Exceptions

Pre-authorization is NOT required for the following DME categories regardless of line item charges: Apnea monitors, bilirubin lights, cardiac monitors, CPAP/BiPAP, CPM (knee only), dynamic splints, home dialysis equipment, infusion pumps, insulin pumps, ocular prostheses, orthotics, oxygen and oxygen equipment, psoriasis lights, SIDS monitors, suction pumps and ventilators (including maintenance), vacuum assisted wound closure and negative pressure wound therapy pumps.

Pre-authorization IS required for the following DME codes regardless of line item charges:

• Wheelchairs / power chairs:  E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1220, K0005, K0823, K0856
• Bone Growth Stimulators: E0747, E0748, E0749, 20974, 20975

All hospital admissions require notification

Pre-authorization is required prior to patient admission.  Concurrent review will occur after 7 days.
Phone calls are preferred over faxes for clinical updates. Milliman criteria are used for the clinical reviews.

Long Term Acute Care Facility (LTAC)

Pre-authorization is required prior to patient admission.
Part A Medicare covers admission for special intensive rehabilitation services only.

Acute Rehabilitation

Pre-authorization is required prior to patient admission.
Refer to the Medicare Benefit Policy Manual, Chapter 1 - Inpatient Hospital Services Covered Under Part A, Section 110 - Inpatient Stays for Rehabilitation Care.

Skilled Nursing Facility (SNF) - sometimes referred to as "sub-acute rehabilitation"

Pre-authorization is required prior to patient admission. Refer to the Medicare Benefit Policy Manual, Chapter 8 - SNF for Medicare guidelines.

SNF is required to fax the Notice of Medicare Non-Coverage (NOMNC) on discharge from services.

Regence uses Milliman Care Guideline as the basis for determining medical necessity for Mental Health and Substance Abuse services. Visit Milliman’s website for information on purchasing their criteria, or contact Regence at the phone number(s) above and we will be happy to provide you with a copy of guidelines for specific services. 

• Detox/Inpatient/Partial admissions: Notification upon admission required. Concurrent review will occur after 2 business days.
• Chemical dependency intensive outpatient: Notification upon admission required. Concurrent review will occur after 8 weeks.
• Outpatient mental health, outpatient chemical dependency, and intensive outpatient mental health: Concurrent review will occur after 20 visits.

Transplants
Note:  Corneal and kidney transplant procedures do not require pre-authorization.

Transplants: G0341, G0342

• Lung: 32850, 32851, 32852, 32854
• Heart/Lung: 33930, 33935, 33940, 33945
• Bone Marrow/Stem Cell: 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38230, 38232, 38240, 38241, 38242
• Intestinal: 44132, 44133, 44135, 44136
• Liver: 47133, 47135, 47136, 47140, 47141, 47142
• Pancreas: 48160, 48550, 48554, 48556,

Related testing: 0141T, 0142T, 0143T 

Ventricular Assistive Devices: 0048T, 0050T, 0051T, 0052T, 0053T, 33975, 33976, 33977, 33978, 33979, 33980.

Regence uses Milliman Care Guideline as the basis for determining medical necessity on the following procedures. Visit Milliman’s website for information on purchasing their criteria, or contact Regence at the phone number(s) above and we will be happy to provide you with a copy of the specific guideline.   

• 22554, 22551 - Milliman Care Guideline ORG S-320
• 22600 - Milliman Care Guideline ORG S-330
• 22533 (Effective July 1, 2012), 22558, 22612, 22630, 22633 - Milliman Care Guideline ORG S-820

The following procedures use the Centers for Medicare & Medicaid Services (CMS) policy as the basis for determining medical necessity:

• 22520, 22521, 22522, 22523, 22524, 22525, 22865, 72291, 72292, 0095T, 0171T, 0172T

Obesity surgery

43633, 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43843, 43845, 43846, 43847, 43848, 43850, 43855, 43860, 43865 43886, 43887, 43888.

Medicare coverage applies to physicians, other health care professionals and Medicare Centers of Excellence facility only.

21120, 21121, 21122, 21123, 21125, 21127, 21137, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21230.

General surgery

50250

19300, 19316, 19318 (reduction mammoplasty), 19324, 19325, 19328, 19330, 19340*, 19342, 19350, 19355, 19357*, 19361*, 19364*, 19366*,19367*, 19368*, 19369*, 19370, 19371, 19396*

*No preauthorization is required: for broken/failed/extruded implants, painful/infected breasts, or initial breast reconstruction for diagnosis of CA* (198.81, 173.5, 174, 175) for one or two stages and nipple/areola reconstruction following mastectomy.

Venous Procedures

36468, 36469, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37765, 37766, 37780, 37785, 75960, 92971

Radiation Therapy

Intensity Modulated Radiation Therapy (IMRT), Stereotactic Radiotherapy, Radiosurgery Procedures, and navigational procedures

61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, 77520, 77522, 77523, 77525, G0340, G0173, G0251, G0173.

77301, 77338, 77418, 0073T

Wireless Capsule Enteroscopy, CT Colonography

74261, 74262 (virtual colonoscopy); 91110 (wireless capsule endoscopy).