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WellMed Texas Medicare AdvantagePrior Authorization RequirementsEffective January 1, 2020General InformationThis list contains prior authorization requirements for participating care providers in Texas for inpatient and outpatientservices. Prior authorization is not required for emergency or urgent care.Included PlansThe following listed plans1 require prior authorization in San Antonio, Austin, Corpus Christi, El Paso, Rio Grande Valley,Dallas & Fort Worth for in-network services:AARP Medicare Advantage (HMO POS)Cigna-HealthSpring Advantage (HMO)AARP Medicare Advantage (NEW HMO-POS)Cigna-HealthSpring Preferred (HMO)AARP Medicare Advantage Focus (HMO)Cigna-HealthSpring TotalCare (HMO SNP)AARP Medicare Advantage Focus Essential (HMO)Humana Gold Plus (HMO SNP)AARP Medicare Advantage SecureHorizons (HMO)Humana Gold Plus (HMO)AARP Medicare Advantage SecureHorizons EssentialHumana Gold Plus (SNP)AARP Medicare Advantage SecureHorizons Plan 1 (HMO POS)Humana Gold Plus SNP-DE (HMO SNP)AARP Medicare Advantage SecureHorizons Plan 2 (HMO POS)United Healthcare Dual Complete (HMO SNP)AARP Medicare Advantage Walgreens (PPO)United Healthcare Medicare Advantage Choice (LPPO)AARP Medicare Complete Focus (HMO)UnitedHealthcare Chronic Complete (HMO CSNP)AARP Medicare Complete SecureHorizons Essential (HMO)UnitedHealthcare Chronic Complete (NEW HMO CSNP)Amerivantage Classic (HMO)UnitedHealthcare Dual Complete (HMO DSNP)Amerivantage Dual Coordination (HMO SNP)UnitedHealthcare Dual Complete (HMO SNP)Amerivantage Dual Secure (HMO SNP)UnitedHealthcare Dual Complete Focus (HMO SNP)Amerivantage ESRD (HMO-POS SNP)UnitedHealthcare Group Retiree Plans (HMO)Amerivantage Select (HMO)Excluded PlansWellMed Prior Authorization Requirements do not apply to the following excluded benefit plans in El Paso, New Mexico,Waco, and Houston: AARP Medicare Advantage Choice (PPO), AARP Medicare Advantage Plan 1 (HMO-POS), AARPMedicare Advantage Plan 2 (HMO), AARP MedicareComplete (HMO-POS), UnitedHealthcare Dual Complete (PPODSNP).These benefit plans must follow UnitedHealthcare Prior Authorization Program. For details, please refer to theUnitedHealthcare Care Provider Administrative guide at UHCprovider.com/guides1Subject to Change 2019 WellMed Medical Management, Inc.1
Please Verify Eligibility and Medical Benefits Before Requesting Prior Authorization (PA)Members are required to utilize contracted providers for all non-emergent services, unless prior authorization has beenobtained.How to submit the request?StandardFor prompt determination,submit ALL STANDARDrequests using the WebPortal (ePRG):https://eprg.wellmed.netFax: l InpatientAdmissionsONLY submit EXPEDITEDrequests when the healthcare provider believesthat waiting for a decisionunder the standard reviewtime frame may seriouslyjeopardize the life or healthof the patient or the patient’sability to regain maximumfunction.Fax: 1-866-322-7276Phone:1-877-757-4440Fax: 1-877-757-8885Phone:1-877-490-8982Specialist Referral ProgramReferrals to specialists arerequired in some markets.Please follow your market’scurrent referral process (ifyour market currently doesnot have a referral process,then this does not apply).All referral requests mustbe submitted through theprovider portal (ePRG):https://eprg.wellmed.netThe Following Services Require Prior Authorization Before Scheduling/Rendering the ServicesInpatient AdmissionsProcedures and ServicesAdditional InformationElective/scheduled admission (acutecare facility)Acute Inpatient RehabilitationLong Term Acute Care (LTAC)Skilled Nursing Facility (SNF)Subacute admissionsEmergency Room admissionInpatient and Observation staysPrior Authorization requiredNotification is requiredFacilities are responsible for notification for ALLservices even if the coverage approval is on file.Notification must be received within 24 hoursHow to obtain PriorAuthorizationFax: 1-877-757-8885Phone: 1-877-490-8982Out-of-Network ServicesProcedures and ServicesAdditional InformationAll out-of-network inpatient andoutpatient hospital admissions,surgeries, procedures, referrals,evaluations, specialty services and/ortreatmentsPrior Authorization required for all recommendationsfrom a network physician or health care provider to ahospital, physician or other health care provider whoisn’t contracted with WellMedHow to obtain PriorAuthorizationFax: 1-866-322-7276Phone: 1-877-757-4440Other Services That May Require PAProcedures and ServicesAdditional InformationBehavioral Health ServicesBehavioral Health Services through adesignated behavioral health networkFor specific codes requiring prior authorization, pleasecall the number on the member’s health plan IDcard to refer for mental health and substance abuse/substance use servicesClinical TrialsFor specific codes requiring prior authorization, pleasecall the number on the member’s health plan ID cardfor detailed information regarding coverage 2019 WellMed Medical Management, Inc.2How to obtain PriorAuthorization
Surgeries/Procedure/Testing (Inpatient or Outpatient Services)Procedures and ServicesAdditional InformationCPT or HCPCS CodesBone Growth StimulatorElectronic stimulation orultrasound to heal fracturesPrior Authorization Required20974Botox InjectionsPrior Authorization RequiredJ0585J0586J0587J0588Cochlear andOsseointegrated ImplantsSurgically implanteddevices to help persons withprofound deafness achieveconversational speechPrior Authorization 692Enhanced ExternalCounter Pulsation (EECP)Prior Authorization RequiredG0166G0177Gender DysphoriaTreatmentPrior Authorization requiredregardless of DX codes5597055980Prior Authorization requiredONLY if billed with thefollowing DX 79Hyperbaric OxygenPrior Authorization Required9918399184G0277Implantable Pain PumpsNeurostimulators(Implantation of a devicethat sends electricalimpulses)Prior Authorization 13727138274122744527446Orthopedic Surgeries(Spine and joint surgeries) 2019 WellMed Medical Management, Inc.3
Procedures and ServicesAdditional InformationCPT or HCPCS CodesImplantable Pain PumpsNeurostimulators (cont’d)Prior Authorization 999J7330Molecular Diagnostic/Genetic TestingPrior Authorization 47981518815198152881541815458499987999Mohs micrographicsurgeryPrior Authorization l/TMJSurgery/OrthognathicSurgeryTreatment of maxillofacial(jaw) functional impairmentPrior Authorization 21021215Other codes not listed inany category, includingunlisted/unspecifiedPrior Authorization 96595966Plastic, Reconstructive, orCosmetic ProceduresPrior Authorization NOTrequired if surgical codesbilled with the listed breastcancer DX 10Z90.11Z90.12Z90.13Orthopedic Surgeries(cont’d)Breast reconstruction(non-mastectomy)Reconstruction of the breastexcept when followingmastectomy 2019 WellMed Medical Management, Inc.4212402124221244212452124621247
Procedures and ServicesAdditional InformationCPT or HCPCS CodesPlastic, Reconstructive,or Cosmetic Procedures(cont’d)Prior Authorization 902679036790467906679086790967912Site of ServiceOphthalmologyPrior Authorization requiredfor ONLY DFW marketAND ONLY if servicesare rendered in HospitalOutpatient 286703667040672286731167312Venous ProceduresRemoval and ablationof the main trunks andnamed branches of thesaphenous veins in thetreatment of venous diseaseand varicose veins of theextremitiesPrior Authorization 766Ventricular Assist Devices Prior Authorization Required(VAD)A mechanical pump thattakes over the function ofthe damaged ventricle of theheart and restores normalblood 0339G0340Cosmetic andreconstructive proceduresCosmetic proceduresthat change or improvephysical appearance withoutsignificantly improving orrestoring physiologicalfunctionReconstructive proceduresthat treat a medicalcondition or improve orrestore physiologic functionRhinoplastyTreatment of nasalfunctional impairment andseptal 2026Radiation TreatmentProcedures and ServicesAdditional InformationIntensity modulatedradiation therapy (IMRT)Prior Authorization RequiredG6015G60167738577386Proton Beam TherapyPrior Authorization Required77520775227752377525Stereotactic radiosurgery(SRS) and stereotacticbody radiation therapy(SBRT)Prior Authorization Required773717737277373G0173G0251 2019 WellMed Medical Management, Inc.CPT or HCPCS Codes5
Advanced Radiology & Radiation TreatmentsProcedures and ServicesAdditional Information3D ImagingCT and CTAMRI and MRANuclear MedicinePET ScanPrior Authorization RequiredCPT or HCPCS 721267212772128For TX Members, except: Plan Exclusions (seeabove), Humana Members fromAustin, El Paso, DFWcontact eviCore forPrior Authorization1-888-693-3211 OR go tohttps://myportal.medsolutions.comFor Humana Members fromAustin, El Paso, DFW:(Humana Gold Plus,Humana Gold Plus SNP-DE,Humana Choice MedicareAdvantage PPO, HumanaChoice Regional PPO):follow regular WellMedPrior Authorization requestprocessFor TX Members fromHouston, Waco, New Mexicoand El Paso:plan exclusions please visitUHCprovider.com/priorauth Radiology for more detailsand the CPT codes thatrequire prior authorization 2019 WellMed Medical Management, C8919C8920C8931C8932C8933C8934C8935C8936G0297
Cardiac ProceduresProcedures and ServicesAdditional InformationCardiac Rhythm ImplantableDevices (CRID)Cardiac Diagnostic CathECHO & ECHO STRESSMyocardial PerfusionImaging (Nuclear Stress)Radiology: NuclearMedicinePrior Authorization RequiredCPT or HCPCS CodesFor TX Members fromRio Grande Valley, Austin,Corpus Christi, El Pasoexcept: Plan Exclusions (seeabove), Humana Membersfrom Austin, El Pasocontact eviCore for PriorAuthorization1-888-693-3211 OR go 3326433270For Humana Members fromAustin, El Paso:(Humana Gold Plus,Humana Gold Plus SNP-DE)- follow regular WellMedPrior Authorization requestprocessFor TX Members fromHouston, Waco, New Mexicoand El Paso plan exclusionsplease visit UHCprovider.com/priorauth Cardiologyfor more details and theCPT codes that require priorauthorizationPrior Authorization RequiredFor TX Members from SanAntonio and DFWDME/Orthotics/ProstheticsProcedures and ServicesAdditional InformationCPT or HCPCS CodesDurable MedicalEquipment(For Prosthetics seeOrthotics and Prosthetics)Prior Authorization requiredREGARDLESS of the costA9999E0147E0170E0193E0194E0217E0225E0239 2019 WellMed Medical Management, K0825
Procedures and ServicesAdditional InformationCPT or HCPCS CodesDurable MedicalEquipment(For Prosthetics seeOrthotics and Prosthetics)Prior Authorization requiredREGARDLESS of the ve Pressure WoundTherapyPrior Authorization RequiredE2402 2019 WellMed Medical Management, K0879K0880K0884K0885K0886K0890K0891K0898K0899K0900
Procedures and ServicesAdditional InformationCPT or HCPCS CodesOrthotics and ProstheticsPrior Authorization requiredREGARDLESS of the 1680L1685L1690L1700L1710L1720 2019 WellMed Medical Management, L7405L7499L8035L8039L8040L8041
Procedures and ServicesAdditional InformationCPT or HCPCS CodesOrthotics and Prosthetics(Cont’d)Prior Authorization requiredREGARDLESS of the 8604L8609L8627L8628L8631L8659L8699OxygenPrior Authorization ry/Specialty ServicesProcedures and ServicesAdditional InformationCPT or HCPCS CodesTransplant Evaluation andProgramOrgan or tissue transplant ortransplant-related servicesprior to pre-treatment orevaluationPrior authorization required99205ONLY if billed with transplantrelated DX codesPrior Authorization RehabilitationPrior Authorization 424G0159G0160G0161G0162G0299G0300G0409G0493Home HealthProcedures and ServicesAdditional InformationCPT or HCPCS CodesSkilled Nursing VisitTherapiesHome Health AidePrior Authorization Required940059760597606B4185 2019 WellMed Medical Management, 4G0495G0496
TransportationProcedures and ServicesAdditional InformationCPT or HCPCS CodesNon-emergency airtransportNon-urgent ambulancetransportation by airbetween specified locationsPrior Authorization RequiredA0430A0431A0435A0436Routine TransportationPrior Authorization 999Sleep Studies and TreatmentProcedures and ServicesAdditional InformationCPT or HCPCS CodesFacility Based SleepStudiesPrior Authorization NOTrequired if servicesperformed at HOME9578295783Oral AppliancesPrior Authorization RequiredE0486Sleep apnea proceduresand surgeriesMaxillomandibularadvancement or oralpharyngeal tissue reductionfor treatment of obstructivesleep apneaPrior Authorization 201J7202J7205J7207J7209Medicare Part B MedicationsProcedures and ServicesAdditional InformationCPT or HCPCS CodesAntihemophilic AgentsPrior authorization 511AntimicrobialsAsthma AgentsBlood ModifiersBotulinum Toxins A & BCalcimimeticsEnzymesErythropoiesis StimulatingAgents (ESA)Hyaluronic AcidPrior authorization is alsorequired for: Any newly releasedor unassigned PartB drug for Oncology,Oncology supportiveagents & Therapeuticradiopharmaceuticalscategories in addition tothe listed codes Any newly released orunassigned Part B drugwith a billed amountof 1000 or more perdose, for all other listedcategoriesImmune Globulins (IVIG/SCIG) 2019 WellMed Medical Management, Inc.J060611J3385
Procedures and ServicesAdditional InformationImmunologic AgentsPrior authorization requiredIron SupplementsNeurologic &Musculoskeletal AgentsOphthalmic AgentsOsteoporosisPulmonary ic Agents andOncologic SupportiveAgentsUnclassified AgentsCPT or HCPCS J3111J1325J3285J7686Q4074A9513A9606A9699Prior Authorization 117Q5118Prior authorization requiredONLY if specialty is NOTOphthalmologistJ9035Prior authorization requiredfor categories otherthan Oncology,Oncology supportiveagents & TherapeuticRadiopharmaceuticalsunclassified drug codes witha billed amount of 1000 ormore per doseA9699C9399J3490J3590J7999Prior authorization is alsorequired for: Any newly releasedor unassigned PartB drug for Oncology,Oncology supportiveagents & Therapeuticradiopharmaceuticalscategories in addition tothe listed codes Any newly released orunassigned Part B drugwith a billed amountof 1000 or more perdose, for all other listedcategories 2019 WellMed Medical Management, 9Q0138C9036J0222
Additional Services Provided by WellMedCare ManagementYou may refer patients for any of the services listed below by submitting a referral through https://eprg.wellmed.netComplex Care Management Transition Care ManagementThe Complex Care Management incorporates evidencebased national standards of practice, empowerment ofthe patient through self-management and coordinatedcare by the Primary Care Provider (PCP) and othermembers of the interdisciplinary care team.The program consists of early identification of patientsstratified as a population band 5. Patients are providedwith self-management support, education for selfmaintenance, linkage to community resources, andmaximization of their available benefits.The physician is a part of the plan of care and receivesall assessments completed and provided to theirpatients.Patients may be enrolled in Complex Care by: The primary care provider Self-referral Claims data Disease management Utilization management Discharge planningThe program includes: Health status assessment Home safety assessment Medication reconciliation Life Planning Development of Plan of Care Social Services support Coordination of Benefits (those provided by the healthplan and those available in the community) 2019 WellMed Medical Management, Inc.13 Inpatient Care Managers offer coordination of care tomembers in the inpatient setting in person or via phone.Inpatient Care Manager Provides: Navigation of the patient through the health care system Monitoring of medical necessity for ongoing inpatientservices Life Planning Development of Plan of Care Discharge planning Social Services support Medication Reconciliation Coordination of Benefits
WellMed Texas Medicare AdvantagePrior Authorization RequirementsEffective July 1, 2020General InformationThis list contains prior authorization requirements for participating care providers in Texas for inpatient and outpatientservices. Prior authorization is NOT required for emergency or urgent care.Included PlansThe following listed plans1 require prior authorization in Texas for in-network services:Austin:AARP Medicare Advantage Focus (HMO)AARP Medicare Advantage Focus Essential (HMO)UnitedHealthcare Dual Complete Focus (HMO SNP)UnitedHealthcare Chronic Complete (HMO CSNP)AARP Medicare Advantage Walgreens (PPO)Humana Gold Plus (HMO)Humana Gold Plus (HMO SNP)Amerivantage Classic (HMO)Amerivantage Dual Coordination (HMO SNP)Amerivantage Dual Secure (HMO SNP)Amerivantage ESRD (HMO-POS SNP)El Paso:AARP Medicare Advantage Focus (HMO)AARP Medicare Advantage Focus Essential (HMO)UnitedHealthcare Dual Complete Focus (HMO SNP)UnitedHealthcare Chronic Complete (HMO CSNP)Cigna-HealthSpring Preferred (HMO)Cigna-HealthSpring TotalCare (HMO SNP)Humana Gold Plus (HMO)Humana Gold Plus (HMO SNP)Humana Gold Plus (SNP)Amerivantage Classic (HMO)Corpus Christi:AARP Medicare Advantage SecureHorizons (HMO)UnitedHealthcare Dual CompleteUnitedHealthcare Group Retiree Plans (HMO)AARP Medicare Advantage Focus (HMO)AARP Medicare Advantage Focus Essential (HMO)UnitedHealthcare Dual Complete Focus (HMO SNP)UnitedHealthcare Chronic Complete (HMO CSNP)Dallas & Fort Worth:AARP Medicare Advantage SecureHorizons (HMO)AARP Medicare Advantage SecureHorizons Essential (HMO)UnitedHealthcare Dual CompleteAARP Medicare Advantage SecureHorizons Plan 2 (HMO POS)AARP Medicare Advantage (HMO POS)UnitedHealthcare Group Retiree Plans (HMO)Humana Gold Plus (HMO)Humana Gold Plus (HMO SNP)Humana Gold Plus (SNP)Rio Grande Valley:AARP Medicare Advantage Focus (HMO)AARP Medicare Advantage Focus Essential (HMO)UnitedHealthcare Dual Complete Focus (HMO SNP)UnitedHealthcare Chronic Complete (HMO CSNP)AARP Medicare Advantage Choice (PPO)Cigna-HealthSpring Preferred (HMO)Cigna-HealthSpring TotalCare (HMO SNP)Cigna-HealthSpring Advantage (HMO)Cigna-HealthSpring Preferred (HMO) Group Retiree PlanHumana Gold Plus (HMO)Humana Gold Plus (HMO SNP)San Antonio:AARP Medicare Advantage SecureHorizons (HMO)AARP Medicare Advantage SecureHorizons Essential (HMO)UnitedHealthcare Dual CompleteUnitedHealthcare Chronic CompleteUnitedHealthcare Group Retiree Plans (HMO)AARP Medicare Advantage Walgreens (PPO)Cigna-HealthSpring Preferred (HMO)Cigna-HealthSpring TotalCare (HMO SNP)Amerivantage Classic (HMO)Amerivantage Dual Coordination (HMO SNP)Amerivantage Dual Secure (HMO SNP)Amerivantage Select (HMO)Excluded PlansWellMed Prior Authorization Requirements do not apply to the following excluded benefit plans in Texas/New Mexico:TX/El Paso & New Mexico: AARP Medicare Advantage Choice (PPO)Houston: AARP Medicare Advantage Plan 1 (HMO-POS), AARP Medicare Advantage Plan 2 (HMO)Waco: AARP Medicare Advantage Focus Essential (HMO), AARP Medicare Advantage (HMO POS), AARP Medicare Advantage Walgreens(PPO)These benefit plans must follow UnitedHealthcare Prior Authorization Program. For details, please refer to theUnitedHealthcare Care Provider Administrative guide at UHCprovider.com1Subject to Change 2020 WellMed Medical Management, Inc.1
Please Verify Eligibility and Medical Benefits Before Requesting Prior Authorization (PA)Members are required to utilize contracted providers for all non-emergent services, unless prior authorization has beenobtained.How to submit the request?StandardFor prompt determination,submit ALL STANDARDrequests using the WebPortal (ePRG):https://eprg.wellmed.netFax: 1-866-322-7276
This list contains prior authorization requirements for participating care providers in Texas for inpatient and outpatient . United Healthcare Dual Complete (HMO SNP) United Healthcare Medicare Advantage Choice (LPPO) . Radiology for more details and the CPT codes that require prior authorization 0042T 70336 70450 70460 70470
