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Medicaid Prior Authorization Codes - Update

Date: 04/15/22

Magnolia is committed to ongoing quality assurance and ensuring that the information we provide is accurate. During Magnolia’s annual audit of the PA Tool response versus claim configuration, it was noted that 162 codes were not accurate. These codes indicate on the PA Tool that no authorization is required but the configuration for claims actually requires an authorization. Magnolia’s plan to correct this issue includes updating the PA Tool response to indicate that an auth is required in order to align with claims configuration and provide advanced notice to our providers of this change. Also, Claims will be monitoring these codes and ensure claims payment based on the PA Tool response prior to 6/1/2022 as Magnolia wants to ensure we honor the information currently provided to our providers. The PA Tool will be updated to indicate that these codes require authorization for all providers on 6/1/2022. The impacted codes are listed below: 

Code

Description

570

HH AIDE                                                                

571

HH AIDE-VISIT                                                          

572

HH AIDE-HOUR                                                           

579

HH AIDE-OTHER                                                          

580

HH-OTH VIS                                                             

581

HH-OTH VIS/VISIT                                                       

582

HH-OTH VIS/HOUR                                                        

583

HH-OTH VIS/ASSESS                                                      

589

HH-OTH VIS/OTHER                                                       

590

HH-SVCS/UNIT                                                            

600

O2/HOME HEALTH                                                         

657

HOSPICE/PHYSICIAN                                                      

659

HOSPICE/OTHER                                                           

21159

LEFORT III W/FHDW/O LEFORT I                                           

21433

TREAT CRANIOFACIAL FRACTURE                                            

81254

GJB6 GENE COM VARIANTS                                                  

99500

HOME VISIT PRENATAL                                                    

99501

HOME VISIT POSTNATAL                                                   

99502

HOME VISIT NB CARE                                                     

99503

HOME VISIT RESP THERAPY                                                

99504

HOME VISIT MECH VENTILATOR                                             

99505

HOME VISIT STOMA CARE                                                  

99506

HOME VISIT IM INJECTION                                                

99507

HOME VISIT CATH MAINTAIN                                               

99509

HOME VISIT DAY LIFE ACTIVITY                                           

99510

HOME VISIT SING/M/FAM COUNS                                            

99511

HOME VISIT FECAL/ENEMA MGMT                                            

99600

HOME VISIT NOS                                                         

99602

HOME INFUSION EACH ADDTL HR                                            

A9542

IN-111 IBRITUMAB TIUXTN DX TO 5 MCI                                    

C9259

INJECTION, PRALATREXATE, 1 MG                                          

C9260

INJECTION, OFATUMUMAB, 10 MG                                            

C9265

INJECTION, ROMIDEPSIN, 1 MG                                            

C9284

INJECTION, IPILIMUMAB                                                  

C9287

INJ, BRENTUXIMAB VEDOTIN                                                

C9289

INJ ERWINIA CHRYSANTHEMI                                               

E0575

NEBULIZER ULTRASONIC LARGE VOLUME                                      

E0668

SEG PNEUMAT APPLINC COMPRS FULL ARM                                     

G0068

PROF SRVC ADM ANTI-INFEC PM ADM CD IND HM E 15 M                       

G0069

PROF SRVC ADM SUBQ IMT ADM CAL DA IND HM EA 15 M                       

G0070

PROF SRVC ADM CHEMO ADM CAL DA IND HOME EA 15 M                        

H1004

PRENATAL @RISK ENHNCD SRVC F/U HOM                                     

J9001

DOXORUBICIN HCL LIPOSOME INJ                                           

J9015

INJ ALDESLEUKIN PER SINGLE USE VIAL                                    

J9032

INJECTION BELINOSTAT 10 MG                                             

J9039

INJECTION BLINATUMOMAB 1 MICROGRAM                                     

J9041

INJECTION BORTEZOMIB 0.1 MG                                            

J9043

INJECTION CABAZITAXEL 1 MG                                             

J9055

INJECTION CETUXIMAB 10 MG                                              

J9062

CISPLATIN 50 MG                                                         

J9090

CYCLOPHOSPHAMIDE 500 MG                                                

J9091

CYCLOPHOSPHAMIDE 1 G                                                   

J9092

CYCLOPHOSPHAMIDE 2 G                                                    

J9110

CYTARABINE HCL 500 MG INJ                                              

J9140

DACARBAZINE 200 MG                                                     

J9228

INJECTION IPILIMUMAB 1 MG                                               

J9264

INJ PACLITAXEL PROTBND PARTICL 1 MG                                    

J9290

MITOMYCIN 20 MG                                                        

J9291

MITOMYCIN 40 MG                                                        

J9301

OBINUTUZUMAB INJ                                                       

J9302

INJECTION OFATUMUMAB 10 MG                                             

J9303

INJECTION PANITUMUMAB 10 MG                                            

J9305

INJECTION PEMETREXED NOS10 MG                                          

J9308

INJECTION RAMUCIRUMAB 5 MG                                             

J9330

INJECTION TEMSIROLIMUS 1 MG                                            

J9350

TOPOTECAN INJECTION                                                     

J9375

VINCRISTINE SULFATE 2 MG                                               

J9380

VINCRISTINE SULFATE 5 MG                                               

L3916

WH ORTHOS 1/> NONTORSN JOINT PREFAB                                    

L5631

ADD LW EXT ABVE KNEE/DISARTC ACRYLC                                    

L5650

ADD LW EXTRM TOT CONTACT AK/DISARTC                                    

L5652

ADD LW EXTRM SUCTN SUSP AK/DISARTC                                     

L5679

ADD LW EXT BK/AK CSTM FAB XST MOLD                                     

L5920

ADD ENDOSKEL AK/HIP DISRTC ALIGNBL                                     

S5035

HOME INFUS TX ROUTINE INFUS DEVC                                        

S5036

HOME INFUS TX REPAIR INFUS DEVICE                                      

S5108

HOM CARE TRN HOM CARE CLIENT 15 MIN                                    

S5109

HOME CARE TRN HOME CARE CLIENT SESS                                    

S5110

HOME CARE TRAINING FAM PER 15 MIN                                      

S5111

HOME CARE TRAINING FAM PER SESSION                                     

S5115

HOME CARE TRN NON-FAM PER 15 MIN                                       

S5116

HOME CARE TRN NON-FAM PER SESSION                                      

S5165

HOME MODIFICATIONS PER SERVICE                                         

S5181

HOME HEALTH RESP TX NOS PER DIEM                                        

S5497

HOME INFUS TX CATH CARE NOC DIEM                                       

S5498

HOME INFUS TX CATH CARE/MAINT SIMPLE PER DIEM                          

S5501

HOME INFUS TX CATH CARE COMPLX DIEM                                    

S5502

HIT CATH CARE IMPL ACSS DEVC PD                                        

S5517

HIT SPL RESTOR CATH PATENCY/DECLOT                                     

S5518

HIT ALL SPL NECES FOR CATH REPAIR                                      

S5520

HIT ALL SPL NECES PICC LINE INSERT                                     

S5521

HIT SPL NECES MIDLINE CATH INSERT                                      

S5522

HIT INSRT PICC NURSE SRVC ONLY                                         

S5523

HIT INSRT ML VEN CATH NRS SRVC ONLY                                    

S9061

HOME ADMIN AEROSOLIZED DRUG TX DIEM                                    

S9098

HOME VISIT PHOTOTHERAPY SRVC DIEM                                      

S9127

SOCIAL WORK VISIT THE HOME PER DIEM                                    

S9208

HOME MGMT PRETERM LABOR PER DIEM                                       

S9209

HOME MANGEMENT PPROM DIEM                                               

S9211

HOME MGMT GESTATIONAL HTN DIEM                                         

S9212

HOME MANAGEMENT POSTPARTUM HTN DIEM                                    

S9213

HOME MANAGEMENT PREECLAMPSIA DIEM                                      

S9214

HOME MGMT GESTATIONAL DIABETES DIEM                                    

S9325

HIT PAIN MANAGEMENT INFUS PER DIEM                                     

S9326

HIT CONT PAIN MGMT INFUS PER DIEM                                      

S9327

HIT INTERMIT PAIN MGMT INFUS DIEM                                      

S9328

HIT IMPLANTED PUMP PAIN MGMT DIEM                                      

S9335

HOM TX HD ADMIN SPL AND EQP PER DIEM                                    

S9336

HIT CONT ANTICOAGULNT INFUS TX DIEM                                    

S9338

HOME INFUS TX IMMUOTHAPY PER DIEM                                      

S9339

HOME TX PERITONL DIALYSIS PER DIEM                                     

S9340

HOME TX ENTERAL NUTRITION DIEM                                         

S9341

HT ENTERL NUTRIT VIA GRAVITY DIEM                                      

S9345

HIT ANTI-HEMOPHILIC AGENT PER DIEM                                     

S9346

HIT ALPHA-1-PROTENAS INHIBITR DIEM                                     

S9347

HIT UNINTRPED LNG-TERM IV/SUBQ DIEM                                    

S9348

HIT SYMPATHOMIMETIC/INOTROPIC DIEM                                      

S9349

HOME INFUS TX TOCOLYTIC PER DIEM                                       

S9351

HIT CONT ANTI-EMETIC PER DIEM                                          

S9353

HOME INFUS TX CONT INSULIN DIEM                                        

S9355

HOME INFUS TX CHELATION PER DIEM                                       

S9357

HIT ENZYME REPL IV TX PER DIEM                                         

S9359

HIT ANTI-TUMR NECROS FACTOR IV TX                                      

S9361

HIT DIURETIC IV TX PER DIEM                                            

S9363

HIT ANTI-SPASMOTIC TX PER DIEM                                         

S9366

HIT TPN >1 L BUT NOT > 2 L-DA-DIEM                                      

S9367

HIT TPN >2 L BUT NOT >3 L-DAY-DIEM                                     

S9368

HOM INFUS TX TPN > 3 L-DAY-DIEM                                        

S9370

HT INTERMITTENT ANTI-EMETIC INJ TX                                     

S9372

HT INTERMIT ANTICOAGULANT INJ TX                                       

S9373

HIT HYDRATION TX PER DIEM                                              

S9374

HIT HYDRATION TX 1 LITER DAY                                           

S9375

HIT HYDRAT >1 LITR NO>2 LITR DAY                                       

S9376

HIT HYDRAT >2 LITR NO>3 LITR DAY                                       

S9377

HIT HYDRATION TX >3 LITERS DAY                                          

S9460

DIABETIC MGMT PROGM NURSE VISIT                                        

S9474

ENTRSTML TX RN CERT ENTRSTML TX DAY                                    

S9490

HIT CORTICOSTEROID INFUS ADMN SRVC                                     

S9494

HIT ANTIBIOTIC/ANTIFUNGAL DIEM                                         

S9497

HIT ANTIBIOTIC/ANTIFUNGAL Q3 HRS                                       

S9500

HIT ANTIBIOTIC/ANTIFUNGAL Q24 HRS                                      

S9502

HIT ABX ANTIVIRL/ANTIFUNGAL Q8 HRS                                     

S9503

HIT ABX ANTIVIRL/ANTIFUNGAL Q6 HRS                                     

S9504

HIT ABX ANTIVIRL/ANTIFUNGAL Q4 HRS                                     

S9538

HOME TRANSFUSION BLOOD PROD DIEM                                       

S9542

HOME INJECTABLE THERAPY NOC-DIEM                                       

S9558

HOME INFUS TX GROWTH HORMONE-DIEM                                      

S9559

HOME INFUS TX INTERFERON PER DIEM                                      

S9560

HOME INJ TX HORMONAL THERAPY DIEM                                      

S9562

HOM INJ TX PALIVIZUMAB-PER DIEM                                        

S9590

HOM TX IRRIG TX W/ADMN-PER DIEM                                        

S9810

HOME THERAPY NOC PER HOUR                                              

T1000

PRIV DUTY/INDEPENDENT NRS TO 15 MIN                                     

T1002

RN SERVICES UP TO 15 MINUTES                                           

T1003

LPN/LVN SERVICES UP TO 15 MINUTES                                      

T1004

SRVC QUALIFIED NRS AIDE TO 15 MIN                                      

T1028

ASSESS HOME PHYSICAL AND FAMILY ENVIR                                  

T1029

COMP ENVIR LEAD INVESTIGAT-DWELL                                       

T1031

NURSING CARE THE HOME LPN PER DIEM                                     

T1502

ADMN ORL IMAND/SUBQ MED HLTH PROF                                      

T1503

ADMN MED NOT ORALAND/INJ AGENCY/PROF                                   

T2035

UTILITY SERVICES MED EQP WAIVER