Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.11-022 - Physician Update #5-10 and Hospital Update #6-10

Current through Register Vol. 49, No. 6, June, 2024
Section II Physician/Independent
			 Lab/CRNA/Radiation therapy Center roc
262.000
			 Procedures That Require Prior Authorization
The following procedure codes require prior
				authorization:
Procedi
ire Codes
D9220*
J7319
J7320
J7330
S2112
V2623
V2625
01966
11960
11970
11971
15400
15830
15847
19318
19324
19325
19328
19330
19340
19342
19350
19355
19357
19361
19364
19366
19367
19368
19369
19370
19371
19380
20974
20975
21076
21077
21079
21080
21081
21082
21083
21084
21085
21086
21087
21088
21089
21120
21121
21122
21123
21125
21127
21137
21138
21139
21141
21142
21143
21145
21146
21147
21150
21151
21154
21155
21159
21160
21172
21175
21179
21180
21181
21182
21183
21184
21188
21193
21194
21195
21196
21198
,21199
21208
21209
21244
21245
21246
21247
21248
21249
21255
21256
27412
27415
27416
28446
29866
29867
29868
30220
30400
30410
30420
30430
30435
30450
30460
30462
32851
32852
32853
32854
33140
33282
33284
33945
36470
36471
37785
37788
38240
38241
38242
42820
42821
42825
42826
42842
42844
42845
42860
42870
43257
43644
43645
43770
43771
43772
43773
43774
43842
43845
43846
43847
43848
43850
43855
43860
43865
47135
48155
48160
48554
48556
50320
50340
50360
50365
50370
50380
51925
54360
54400
54415
54416
54417
55400
57335
58150
58152
58180
58260
58262
58263
58267
58270
58275
58280
58290
58291
58292
58293
58294
58345
58541
58542
58543
58544
58550
58552
58553
58554
58570
58571
58572
58573
58672
58673
58750
58752
59135
59840
59841
59850
59851
59852
59855
59856
59857
59866
61850
61860
61862
61870
61875
61880
61885
61886
61888
63650
63655
63660
63685
63688
64555
64573
64585
64809
64818
65710
65730
65750
65755
67900
69300
69310
69320
69714
69715
69717
69718
69930
87901
87903
87904
92326
* Manually Priced
244.000 Procedures that Require Prior
			 Authorization
The procedures represented by the CPT and HCPCS codes in the
				following table require prior authorization (PA). The performing physician or
				dentist (or the referring physician or dentist, when lab work is ordered or
				injections are given by non-physician staff) is responsible for obtaining
				required PA and forwarding the PA control number to appropriate hospital staff
				for documentation and billing purposes. A claim for any hospital services that
				involve a PA-required procedure must contain the assigned PA control number or
				Medicaid will deny it. (See Sections
				240.000 -244.000 of this manual
				for instructions for obtaining prior authorization.)
J2501
J7330
J9300
S2066
S2067
S2ri2
S3800
11960
11970
11971
15400
15830
19318
19324
19325
19328
19330
19340
19342
19350
19355
19357
19361
19364
19366
19367
19368
19369
19370
19371
19380
20974
20975
21076
21077
21079
21080
21081
21082
21083
21084
21085
21086
21087
21088
21089
21120
21121
21122
21123
21125
21127
21137
21138
21139
21141
21142
21143
21145
21146
21147
21150
21151
21154
21155
21159
21160
21172
21175
21179
21180
21181
21182
21183
21184
21188
21193
21194
21195
21196
21198
21199
21208
21209
21244
21245
21246
21247
21248
21249
21255
21256
27412
27415
27416
28446
29866
29867
29868
30220
30400
30410
30420
30430
30435
30450
30460
30462
33282
33284
36470
36471
37785
37788
38242
42820
42821
42825
42826
42842
42844
42845
42860
42870
43257
43644
43645
43842
43845
43846
43847
43848
43850
43855
43860
43865
48155
50320
50340
50360
50365
50370
50380
51925
54360
54400
54415
54416
54417
55400
57335
58150
58152
58180
58260
58262
58263
58267
58270
58275
58280
58290
58291
58292
58293
58294
58345
58541
58542
58543
58544
58550
58552
58553
58554
58570
58571
58572
58573
58672
58673
58750
58752
59135
59840
59841
59850
59851
59852
59855
59856
59857
61850
61860
61870
61875
61880
61885
61888
63650
63655
63660
63685
64555
64573
64809
64818
65710
65730
65750
65755
65756
67900
69300
69310
69320
69714
69715
69717
69718
69930
87901
87903
87904
92607
92608
Procedure Code
Modifier
Description
Z1930
Non-emergency hysterectomy following c-section