Prior Authorization (PA) Look-Up Tool

The Prior Authorization (PA) Look-Up Tool allows you to check if a specific procedure code or medication requires prior authorization.  To check if a procedure code requires prior authorization, use the “Procedure Codes” tab.  To check if a Medicare Part B medication requires prior authorization when it is delivered in the physician’s office, clinic, outpatient or home setting through home health or infusion companies, use the “Medications” tab.  When searching for medications, do not use J-codes.

The PA Look-Up Tool is not inclusive of all services that require prior authorization (e.g., non-Medicare covered items, HCPC codes and Rev codes are not listed.)  Services must be provided according to the Medicare Coverage Guidelines, established by the Center for Medicare & Medicaid Services (CMS), and are subject to review.  According to the guidelines, all medical care, services, supplies and equipment must be medically necessary.  You may review the Medicare Coverage Guidelines online at:   https://www.medicare.gov/coverage/your-medicare-coverage.html.  Investigational and experimental procedures are not usually covered benefits.  Please consult the member’s Evidence of Coverage or contact the Health Plan for confirmation of coverage.

For a list of services requiring prior authorization, please refer to the Prior Authorization List (PAL).


Procedure CodesMedications
CPT Codes with Prior Authorization Requirements
Enter CPT Code:
  Prior Authorization List updated as of 1/25/2019.
  Do not use to search for medications.  Use the Medications tab above to search for medications that require prior authorization.
Procedure Code Details
CPT Code: Effective Date:
Description:
Notes:
NOTE:  All procedures performed in an Inpatient setting require Prior Authorization, unless it is an emergency.  For emergency admissions, you must notify us by the next business day by submitting a facesheet and clinical documentation.

If you have any questions about the services and/or procedures that require prior authorization, please call us at the phone numbers listed below.