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PRIOR AUTHORIZATION LISTFor dates of service on or after January 1, 2019Prior Authorization (PA) RequirementsThis IPA Prior Authorization list supersedes any lists that have been previously distributed or published–older lists are to be replaced with the latest version.Prior Authorization (PA) PolicyPCP’s or referring health care professionals should OBTAIN Prior Authorization BEFORE servicesrequiring Prior Authorizations are rendered. Prior Authorizations may be obtained via HSConnect(HSC) or as otherwise indicated in the Health Services section of the 2019 Provider Manual. Please seethe HSConnect section of the provider manual for an overview of the portal capabilities andinstructions for obtaining access.Rendering providers should VERIFY that a Prior Authorization has been granted BEFORE any servicerequiring a Prior Authorization is rendered. Prior Authorizations may be verified via HSConnect or asotherwise indicated in the Health Services section of the Provider Manual.IMPORTANT – Prior Authorization and/or Referral Number(s) is/are not a guarantee of benefits orpayment at the time of service. Remember, benefits will vary between plans, so always verify benefits.Referral PolicyThe IPA values the PCP’s role in directing the care of customers to theappropriate, participating health care professionals. Participating specialists arecontracted to work closely with our referring PCPs to enhance the quality andcontinuity of care provided to customers.Although a Prior Authorization may not be required for certain services, a REFERRAL from a PCPto a Specialist MUST BE in place. The Referral should indicate PCP approved for a consultationonly or for consultation and treatment, including the number of PCP approved visits.Refer to the online directory at or contact to locate an in-network health careprofessional or facility.
For easy searching, hit Ctrl F on your keyboard, and type the 5 digit code you are searching for.Admissions*For Blue Cross or Cigna City of Houston/HEB members, please contact Blue Cross or Cigna directlyto obtain authorization*All inpatient admissions including:› Inpatient Observation› Skilled Nursing Facility› Inpatient Medical and Behavioral Health› Inpatient Rehabilitation› 78Diagnostic ServicesUltrasound2Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.76979
Durable Medical Equipment (DME), Orthotics, and ProstheticsHome 8E1008K0827L5850E1010K0835L5856E1220K0837L5858*For Blue Cross or Cigna City of Houston/HEB members, please contact Blue Cross or Cignadirectly to obtain 0162S9123T1030G0157G0248S91283Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Invasive Diagnostic 60193461C9741Laboratory – Including Genetic 405S38540106T8125481406S38900107T8127581407*For Blue Cross or Cigna City of Houston/HEB members, please contact Blue Cross or CignaMental Health directly to obtain 20*59350*59855*59121*59514*59856*OB/GYN4Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Pain 6449264636270966447964493622636448064494*For Blue Cross or Cigna City of Houston/HEB members, please contact BluePart B Drugs and Biologics Cross or Cigna directly to obtain 3262J7322Q9995J1442J3357J73235Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Professional 587219774183C8908705597219874185S8037RadiologyCat scan (CT)Magnetic ResonanceImaging (MRI)6Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Radiology (continued)Nuclear 494A9543784537847378496A9606Positron EmissionTomography (PET)788117881378815788127881478816Radiation 90351T7228577074TherapeuticRadiologyOther7Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
*For Blue Cross or Cigna City of Houston/HEB members, please contact Blue Cross orRehab and Therapy Cigna directly to obtain 1759L6882Q4132C1764L8679Q4133Services and 0*8Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Surgery 236*33405*33517*32810*33237*33406*33518*9Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Surgery 0*92971*35341*35626*37145*92975*10Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Surgery 85Ear Nose ThroatGeneral Surgery11Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.C9604
Surgery (continued)General 77244136*12Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Surgery (continued)General 381*48150*44615*45805*4738248152*13Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Surgery (continued)General 6358605*5728858267*58611*57305*582705867014Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Surgery *61333*61566*61705*62192*15Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Surgery 0657566586516Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Surgery 674126793517Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Surgery Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Surgery 178*27457*243702612327181*27465*19Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Surgery 0*50328*Urology20Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Urology 974050760*51840*5440550770*51841*5440821Any code marked with an * is designated by the Centers for Medicare & Medicaid Services (CMS) for inpatient use only.
Prior Authorization (PA) Policy PCP's or referring health care professionals should OBTAIN Prior Authorization BEFORE services requiring Prior Authorizations are rendered. Prior Authorizations may be obtained via HSConnect (HSC) or as otherwise indicated in the Health Services section of the 2019 Provider Manual. Please see
