ACA: Prior Authorization

For the Skilled Nursing Services, does it require prior authorization?

• No, because this is a code-dependent service.

• Yes, based on the BPT this requires prior authorization from AIM.

• Yes, based on the BPT this requires prior authorization from UM.

• No, because pre-determination is recommended for the service.

Based on the image, the provider had a procedure code of 29806. Service would be rendered in the office setting. Will Prior authorization is required?

• NO

• YES, from UM since this is an MSK procedure code.

• YES, from AIM.

• Maybe

Based on the image, the procedure code 45378 is being rendered in the Ambulatory Surgery Center, Outpatient as a place of service. Does prior authorization is required?

• Yes, from AIM

• No, check predeterm

• No

• Maybe

Based on the BPT, ABA - applied behavioral analysis, prior authorization is required through what department?

In the event, COB stating that Anthem is secondary, prior authorization is not required.

• TRUE

• FALSE

• MAYBE

• TRUE, AND WELLPOINT NEEDS TO COORDINATE WITH TERTIARY FOR PA REQUIREMENT.

For the services acupuncture and chiropractic, prior authorization is required from ASH for the states of CA, GA, NY, CO​, VA.

• Yes, prior authorization is required as long as there's ASH indicator

• No, we have to get the procedure code.

• No, there should be a CCB access to know if prior auth is required

• Maybe

For routine or regular outpatient mental health services, prior authorization is not required.

• They have to coordinate with BH or get procedure code to identify precert requirement.

• True

• False, prior auth is automatically required from BH.

• Maybe

Does prior authorization be required for this code: 64479

Tax ID: 223120814

Provider's Name: SOCKIN STEVEN M

State: NY

Member's ID: VFG 798A79019

Member's Name: PATRICIA M ROY

DOB: 03/18/1960

• Prior authorization is not required due to PAP Program

• Prior authorization is required due to PAP Program.