News

Ambetter from WellCare of New Jersey Prior Authorization

Date: 04/28/23

Ambetter from WellCare of New Jersey 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 WellCare of New Jersey.

Ambetter from WellCare of New Jersey 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.wellcarenewjersey.com/provider-resources/provider-toolkit.html.

Effective July 1^st, 2023, the following are changes to prior authorization requirements:

Behavioral Health

PA Rule	Services	Procedure Codes
No PA Required	Developmental and behavioral screening	96110, 96112
No PA Required	BH counseling	H0007, H2011, S9484

Breast reconstruction

PA Rule	Services	Procedure Codes
PA Required	Mastectomy, Reconstruction Breast	19300, 19330

Cardiovascular

PA Rule	Services	Procedure Codes
PA Required	Insertion/removal of Cardiac Rhythm Monitor	33285
PA Required	Revascularization	37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37799
PA Required	Wireless Pressure Sensor	C2624
PA Required	External circulatory counterpulsation	G0166
No PA Required	Cardiac Rehab	G0422, G0423, S9472

DME

PA Rule	Services	Procedure Codes
PA Required	Osteogenesis stimulator	E0749
PA Required	Wheelchairs, power operated vehicles, and accessories	E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613, E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2624, K0813
PA Required	Supplies for home delivery of infant	S8415
PA Required	Electrical Nerve Stimulator	K1023
PA Required	Non-Pneumatic Compression	K1024, K1025
PA Required	Whirlpool tub Walk In	K1003
PA Required except if billed with cancer diagnosis	Breast prosthesis	L8031
No PA Required	Infusion Pumps	B9002, E0781, K0455
No PA Required	Wheelchair and accessories	E2611, K0001
No PA Required	Respiratory equipment	E0550, E0565

Gastroenterology

PA Rule	Services	Procedure Codes
PA Required	GI capsule transit and pressure measurement	91112

Home care

PA Rule	Services	Procedure Codes
PA Required	Home Care Services	S5165, S5170, S5175, S9110, S9122, T1022, T1028
PA Required	Home therapy	G2168, G2169, S5180, S5181
PA Required	Chore Services	S5120, S5121
PA Required	Hemodialysis Equipment	A4870, A4890
PA Required	Respite Care Services- Home	S5150, S5151, S9125
PA Required	Nursing care	G0162, T1001, Rev code: 657
PA Required	Attendant and Companion Care Services	S5125, S5126, S5130, S5131, S5135, S5136, T1020
PA Required	Care Management Home Visit	G0076, G0077, G0078, G0079, G0080, G0081, G0082, G0083, G0084, G0085, G0086, G0087
PA Required	Pregnancy Home Services	S9208, S9209, S9211, S9212, S9213, S9214

Hospice

PA Rule	Services	Procedure Codes
PA Required	Physician Services in Hospice	Rev Code: 657

Laboratory

PA Rule	Services	Procedure Codes
PA Required	Genetic analysis/studies, surgical pathology procedures	81235, 81263, 81265, 81267, 81268, 81270, 81275, 81310, 81315, 88237, 88377

Orthopedic

PA Rule	Services	Procedure Codes
PA Required	Procedures lower extremities	28285, 28299
PA Required	Endoscopy Wrist	29848
PA Required	Spine Procedures	62264, 62350, 62362, 63650, 63655, 63685
PA Required	TLSO Orthotics	L0464

Pain management

PA Rule	Services	Procedure Codes
PA Required	Trigger Point Injection	20552, 20553
PA Required	Neurostimulators on Nerves	64555, 64561, 64566, 64590
PA Required	Destruction by Neurolytic Agent	64620, 64624, 64625, 64640, 64650, 64680, 64681
No PA Required	Transversus abdominis plane (TAP) block	64486, 64488
No PA Required	Destruction by neurolytic agent	64632

Professional Services

PA Rule	Services	Procedure Codes
PA Required	Respite Care Services not in home	H0045
No PA Required	Hospitalist Services	S0310

Radiology Treatments

PA Rule	Services	Procedure Codes
PA Required	Ablation of liver tumor	47382
PA Required	Stereotactic radiosurgery	77372, 77373, G0339, G0340

Skin substitute

PA Rule	Services	Procedure Codes
PA Required	Skin substitute products	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