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All lines of business except
MedAdvantage, Preferred Choice Sixty-Five and First
Choice Sixty-Five
The CPT and HCPCS Code List was developed to help you
identify services we require be pre-authorized. In some
cases no CPT or HCPCS code specifically identifies a
service we preauthorize. For example, new services we
consider investigational may not yet have a code. Please
refer to the Pre-authorization
List to determine which lines of business the
pre-authorization applies to and information concerning
benefits and eligibility.
Effective January 1, 2006
| Mental
Health and Chemical Dependency |
| Participating, preferred and access members
(except FEP)
Phone: (800) 547-9718 Fax: (800) 331-3505
- Inpatient/residential
- Outpatient at 9th visit
PEBB members/preferred providers only
|
| FEP members
Phone: (866) 873-9743 Fax: (800) 331-3505
- Inpatient/residential
- Outpatient
Basic Option at 1st visit, Standard Option at
9th visit
- Partial hospitalization/intensive outpatient
services by preferred facilities/providers
|
Durable
Medical Equipment
DME pre-authorization is not required for FEP members
Phone: (503) 220-4795 or
(800) 824-8563 Fax: (503) 525-6595 |
| Equipment purchase or repair with billed
charges over $1,500 for any single line item or
component unless listed as an exception below. |
| Equipment rental with billed charges over
$500/month for any single line item or component
unless listed as an exception below. |
| Extremity prosthetics with billed charges
over $5,000 for any single line item or component.
|
Exceptions (the following
items do not require pre-authorization, regardless
of line item charges)
Apnea monitors, bilibrubin lights, cardiac monitors,
CPAP/BiPAP, CPM (knee only), dynamic splints, home
dialysis equipment, infusion pumps, insulin pumps,
ocular prostheses, orthotics, oxygen and oxygen
equipment, psoriasis lights, SIDS monitors, suction
pumps, ventilators (including maintenance) |
Home Services:
Phone: (503) 220-4795 or
(800) 824-8563 Fax: (503) 525-6595 |
Home health services including
initial evaluations (pre-authorization not required
for FEP)
|
All other members: G0151, G0152,
G0153, G0154, G0155, G0156, S5108 through S5116,
S5180, S5181, S9097, S9098, S9122, S9123, S9124,
S9127, S9128, S9129, S9131, S9208, S9209, S9211,
S9212, S9213, S9214, S9590, 99500, 99501, 99502,
99503, 99504, 99505, 99506, 99507, 99509, 99511,
99512, 99600 |
| Hospice |
All members
S0255, S9125, S9126 |
| Inpatient
Admissions:
Phone: (503) 220-4795 or
(800) 824-8563 Fax: (503) 525-6595
|
| All out-of-area admissions
from first day of stay |
All members |
| Length of stay greater than 10 days at
all Regence BCBSO contracted facilities |
All other members |
| Hospice |
All members: 99377, 99378 |
| Rehabilitation |
All members |
| Skilled Nursing Facility (SNF) |
All members |
Transplants and ventricular
assist devices (pre-authorization not required
for corneal transplants)
Phone: (800) 560-0749
Fax: (503) 226-8754 |
All other members
Transplants
G0267, G0341, G0342, G0343, S2053, S2054, S2055,
S2060, S2061, S2065, S2102, S2103, S2140, S2142,
S2150, S2152, 32850, 32851, 32852, 32853, 32854,
33930, 33935, 33940, 33945 38204, 38205, 38206,
38207, 38208, 38209, 38210, 38211, 38230, 38240,
38241, 38242, 44132, 44133, 44135, 44136, 47133,
47135, 47136, 47140, 47141, 47142, 48160, 48550,
48554, 48556, 50300, 50320, 50340, 50360, 50365,
50370, 50380, 0141T, 0142T, 0143T
Ventricular assist devices
33975, 33976, 33977, 33978, 33979, 33980, 0048T,
0049T, 0050T, 0051T, 0052T,0053T |
Other
Services:
(Pre-authorization not required for FEP members)
Phone: (503) 220-4795 or
(800) 824-8563 Fax: (503) 525-6595 |
| Cosmetic or potentially cosmetic procedures
|
Pre-authorization not required for upper lid
blepharoplasty, 15822, 15823, 67901 thru 67908,
or initial breast reconstruction [1 or 2 stages
and nipple/areola reconstruction] following mastectomy,
19340, 19342, 19350, 19357, 19361, 19364, 19366,
19367, 19368 or 19369, includes 1 or 2 stages
and nipple/areola reconstruction.
The following codes should be pre-authorized
as potentially cosmetic:
S2130, S2131, S2202, 11920, 11921, 11922, 11950,
11951, 11952, 11954, 11960, 11970, 11971, 15780,
15781, 15782, 15783, 15786, 15787, 15788, 15789,
15792, 15793, 15820, 15821, 15824, 15825, 15826,
15828, 15829, 15831, 15832, 15833, 15834, 15835,
15836, 15837,, 15838, 15839, 15876, 15877, 15878,
15879, 17360, 17380, 19140, 19316, 19318, 19324,
19325, 19355, 19370, 19371, 19380, 19396, 21120,
21121, 21122, 21123, 21125, 21127, 21137, 21141,
21142, 21143, 21145, 21146, 21147, 21150, 21151,21154,
21155, 21159, 21160, 21198, 21199, 21206, 21208,
21209, 21210, 21215, 21230, 21235, 21740, 21742,
21743, 30400, 30410, 30420, 30430, 30435, 30450,
30460, 30462, 36468, 36469, 36470, 36471, 37204,
37500, 37501, 37700, 37718, 37722, 37735, 37760,
37765, 37766, 37780, 37785, 67900, 69300, 75894 |
| Investigational or potentially investigational
services |
Please refer to the current List
of Investigational Services for the most up-to-date
listing of possible investigational codes. The
investigational list is updated monthly and the
most reliable source.
|
| Obesity services |
Including but not limited to work-up, treatment
and surgery
S2085, 43770, 43771, 43772, 43773, 43774, 43886,
43887, 43888, 43842, 43843, 43846, 43847, 43848 |
| Orthognathic surgery |
21120, 21121, 21123, 21125, 21127,
21137, 21141, 21142, 21143, 21145, 21146, 21147,
21150, 21151, 21154, 21155, 21159, 21160, 21198,
21199, 21206, 21208, 21209, 21210, 21215,21230,
21193, 21194, 21195, 21196, D7940 through D7950,
D7995, D7996, S8262 |
| Notifications
Required |
- All inpatient admissions: Regence BCBSO
contracted facilities are required to notify
us of all inpatient admissions and discharges
via faxed inpatient census logs. Exception:
Routine two-day vaginal delivery stays and four-day
Cesarean section delivery stays do not require
notification. Fax: (503) 375-4343.
|
- Pregnancy: Physicians are required
to notify Special
Beginnings® of pregnancies within two
weeks of the member's first prenatal visit.
Phone: (503) 525-6550 or (888) 569-2229 Fax:
(503) 391-8696.
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