WPS Health Plan

• Oxford Add Genetic and Apr. 1

Genetic Testing Benefits are available for genetic testing and genetic counseling if it is not experimental

Genetic Testing Benefits are available for genetic testing and genetic counseling if it is not experimental

Genetic Testing Benefits are available for genetic testing and genetic counseling if it is not experimental

Genetic Testing Benefits are available for genetic testing and genetic counseling if it is not experimental

Genetic Testing Benefits are available for genetic testing and genetic counseling if it is not experimental

01-12-2017 (view) Genetic Testing

–

Molecular 2020

0022U – 0023U 0094U

Molecular 2020

Molecular 2020

0087U – 0091U 0011M –

Dental Anesthesia Benefits are available with prior authorization for hospital or ambulatory surgery center Facility ; Anesthesia

0087U – 0091U 0011M –

0087U – 0091U 0011M –

0087U – 0091U 0011M –

81105 – 81111 87480 –

81105 – 81111 87480 –

0097U – 0100U 81120 –

0097U – 0100U 81120 –

0097U – 0100U 81120 –

0097U – 0100U 81120 –

0097U – 0100U 81120 –

0097U – 0100U 81120 –

0097U – 0100U 81120 –

0097U – 0100U 81120 –

0097U – 0100U 81120 –

–

–

0111U 81212 87623 0045U

– 0050U 0113U 81215 –

Nursing Home Jefferson, Kenosha, La Crosse, Manitowoc, of Service- -001

LP (HMO SNP) /0

UnitedHealthcare Brown, Manitowoc, Milwaukee, HMO SNP -003

– –

–

–

0296T 0297T 0298T 0298T 0308T 0340T 0341T 0342T

– 87801 0068U – 0076U

–

–

PCA-1-19- -Optum-FL_08302019 v1.3

–

–

–

–

–

0296T 0297T 0298T 0298T 0308T 0340T 0341T 0342T

–

0296T 0297T 0298T 0298T 0308T 0340T 0341T 0342T

–

0152U – 0162U 81542

• Oxford Add Genetic and Apr. 1

Testing

–

–

–

–

–

81105 – 81111 87480 –

–

–

–

–

–

87510 – 87512 0040U

– 0050U 0113U 81215 –

– –

–

) to be submitted with the claim; which is available on the Forward Health

Any procedure resulting in sterilization: Requires submission of the Consent for Sterilization form (F- ) with the claim

– 87801 0068U – 0076U

Genetic Testing Benefits are available for genetic testing and genetic counseling if it is not experimental

Genetic Testing Benefits are available for genetic testing and genetic counseling if it is not experimental

Genetic Testing Benefits are available for genetic testing and genetic counseling if it is not experimental

PCA-1-19- -M&R-QRG_10302019

Genetic Testing Benefits are available for genetic testing and genetic counseling if it is not experimental

Genetic Testing Benefits are available for genetic testing and genetic counseling if it is not experimental

or investigational and found to be medically necessary in the treatment/management of 81110; 81111; 81112; 81120; 81121; 81161; 81162; 81163; 81164; 81165; 81166;

or investigational and found to be medically necessary in the treatment/management of 81110; 81111; 81112; 81120; 81121; 81161; 81162; 81163; 81164; 81165; 81166;

or investigational and found to be medically necessary in the treatment/management of 81110; 81111; 81112; 81120; 81121; 81161; 81162; 81163; 81164; 81165; 81166;

or investigational and found to be medically necessary in the treatment/management of 81110; 81111; 81112; 81120; 81121; 81161; 81162; 81163; 81164; 81165; 81166;

or investigational and found to be medically necessary in the treatment/management of 81110; 81111; 81112; 81120; 81121; 81161; 81162; 81163; 81164; 81165; 81166;

PCA-1-19- -UHN-WEB_11062019

• UnitedHealthcare Add Chemotherapy J9199, J9309 Feb. 1,

• UnitedHealthcare Add Chemotherapy J9199, J9309 Feb. 1,

• UnitedHealthcare Add Chemotherapy J9199, J9309 Feb. 1,

• UnitedHealthcare Add Chemotherapy J9199, J9309 Feb. 1,

• UnitedHealthcare Add Chemotherapy J9199, J9309 Feb. 1,

• UnitedHealthcare Add Chemotherapy J9199, J9309 Feb. 1,

• UnitedHealthcare Add Chemotherapy J9199, J9309 Feb. 1,

• UnitedHealthcare Add Chemotherapy J9199, J9309 Feb. 1,

• UnitedHealthcare Add Chemotherapy J9199, J9309 Feb. 1,

• UnitedHealthcare Add Chemotherapy J9199, J9309 Feb. 1,

• UnitedHealthcare Add Chemotherapy J9199, J9309 Feb. 1,

PCA-1-19- -M&R-WEB_12202019

PCA-2-19- -M&R-WEB_12032019

PCA-1-19- -M&R-FAQ_01062020

0296T 0297T 0298T 0298T 0308T 0340T 0341T 0342T

0296T 0297T 0298T 0298T 0308T 0340T 0341T 0342T

Unlisted Codes Submit documentation to describe the service requested and why a standard

050A21:A59T 0510T 0511T 0512T 0513T 0514T 0515T 0516T

0296T 0297T 0298T 0298T 0308T 0340T 0341T 0342T

0296T 0297T 0298T 0298T 0308T 0340T 0341T 0342T

0296T 0297T 0298T 0298T 0308T 0340T 0341T 0342T

0345T 0346Y 0347T 0348T 0349T 0350T 0351T 0352T

0345T 0346Y 0347T 0348T 0349T 0350T 0351T 0352T

0345T 0346Y 0347T 0348T 0349T 0350T 0351T 0352T

0345T 0346Y 0347T 0348T 0349T 0350T 0351T 0352T

0315T 0316T 0317T L8680

0315T 0316T 0317T L8680

0315T 0316T 0317T L8680

L8685 L8686 L8687 L8688

L8685 L8686 L8687 L8688

L8685 L8686 L8687 L8688

0345T 0346Y 0347T 0348T 0349T 0350T 0351T 0352T

0345T 0346Y 0347T 0348T 0349T 0350T 0351T 0352T

0345T 0346Y 0347T 0348T 0349T 0350T 0351T 0352T

0353T 0354T 0355T 0356T 0357T 0358T 0359T 0360T

0353T 0354T 0355T 0356T 0357T 0358T 0359T 0360T

0353T 0354T 0355T 0356T 0357T 0358T 0359T 0360T

0353T 0354T 0355T 0356T 0357T 0358T 0359T 0360T

0353T 0354T 0355T 0356T 0357T 0358T 0359T 0360T

0353T 0354T 0355T 0356T 0357T 0358T 0359T 0360T

0353T 0354T 0355T 0356T 0357T 0358T 0359T 0360T

0353T 0354T 0355T 0356T 0357T 0358T 0359T 0360T

0361T 0362T 0363T 0364T 0365T 0366T 0367T 0368T

0361T 0362T 0363T 0364T 0365T 0366T 0367T 0368T

0361T 0362T 0363T 0364T 0365T 0366T 0367T 0368T

0361T 0362T 0363T 0364T 0365T 0366T 0367T 0368T

0361T 0362T 0363T 0364T 0365T 0366T 0367T 0368T

0361T 0362T 0363T 0364T 0365T 0366T 0367T 0368T

0361T 0362T 0363T 0364T 0365T 0366T 0367T 0368T

0361T 0362T 0363T 0364T 0365T 0366T 0367T 0368T

0369T 0370T 0372T 0373T 0374T 0375T 0376T 0377T

0369T 0370T 0372T 0373T 0374T 0375T 0376T 0377T

0369T 0370T 0372T 0373T 0374T 0375T 0376T 0377T

0369T 0370T 0372T 0373T 0374T 0375T 0376T 0377T

0369T 0370T 0372T 0373T 0374T 0375T 0376T 0377T

0369T 0370T 0372T 0373T 0374T 0375T 0376T 0377T

0369T 0370T 0372T 0373T 0374T 0375T 0376T 0377T

0369T 0370T 0372T 0373T 0374T 0375T 0376T 0377T

0378T 0379T 0380T 0394T 0395T 0396T 0397T 0398T

0378T 0379T 0380T 0394T 0395T 0396T 0397T 0398T

0378T 0379T 0380T 0394T 0395T 0396T 0397T 0398T

0378T 0379T 0380T 0394T 0395T 0396T 0397T 0398T

0378T 0379T 0380T 0394T 0395T 0396T 0397T 0398T

0378T 0379T 0380T 0394T 0395T 0396T 0397T 0398T

0378T 0379T 0380T 0394T 0395T 0396T 0397T 0398T

0378T 0379T 0380T 0394T 0395T 0396T 0397T 0398T

0399T 0400T 0401T 0402T 0403T 0404T 0405T 0406T

0399T 0400T 0401T 0402T 0403T 0404T 0405T 0406T

0399T 0400T 0401T 0402T 0403T 0404T 0405T 0406T

0399T 0400T 0401T 0402T 0403T 0404T 0405T 0406T

0399T 0400T 0401T 0402T 0403T 0404T 0405T 0406T

0399T 0400T 0401T 0402T 0403T 0404T 0405T 0406T

0399T 0400T 0401T 0402T 0403T 0404T 0405T 0406T

0399T 0400T 0401T 0402T 0403T 0404T 0405T 0406T

0407T 0408T 0409T 0410T 0411T 0412T 0413T 0414T

0407T 0408T 0409T 0410T 0411T 0412T 0413T 0414T

0407T 0408T 0409T 0410T 0411T 0412T 0413T 0414T

0407T 0408T 0409T 0410T 0411T 0412T 0413T 0414T

0407T 0408T 0409T 0410T 0411T 0412T 0413T 0414T

0407T 0408T 0409T 0410T 0411T 0412T 0413T 0414T

0407T 0408T 0409T 0410T 0411T 0412T 0413T 0414T

0407T 0408T 0409T 0410T 0411T 0412T 0413T 0414T

0415T 0416T 0417T 0418T 0419T 0420T 0421T 0422T

0415T 0416T 0417T 0418T 0419T 0420T 0421T 0422T

0415T 0416T 0417T 0418T 0419T 0420T 0421T 0422T

0415T 0416T 0417T 0418T 0419T 0420T 0421T 0422T

0415T 0416T 0417T 0418T 0419T 0420T 0421T 0422T

0415T 0416T 0417T 0418T 0419T 0420T 0421T 0422T

0415T 0416T 0417T 0418T 0419T 0420T 0421T 0422T

0415T 0416T 0417T 0418T 0419T 0420T 0421T 0422T

0423T 0424T 0425T 0426T 0427T 0428T 0429T 0430T

0423T 0424T 0425T 0426T 0427T 0428T 0429T 0430T

0423T 0424T 0425T 0426T 0427T 0428T 0429T 0430T

0423T 0424T 0425T 0426T 0427T 0428T 0429T 0430T

0423T 0424T 0425T 0426T 0427T 0428T 0429T 0430T

0423T 0424T 0425T 0426T 0427T 0428T 0429T 0430T

0423T 0424T 0425T 0426T 0427T 0428T 0429T 0430T

0423T 0424T 0425T 0426T 0427T 0428T 0429T 0430T

0431T 0432T 0433T 0434T 0435T 0436T 0439T 0440T

0431T 0432T 0433T 0434T 0435T 0436T 0439T 0440T

0431T 0432T 0433T 0434T 0435T 0436T 0439T 0440T

0431T 0432T 0433T 0434T 0435T 0436T 0439T 0440T

0431T 0432T 0433T 0434T 0435T 0436T 0439T 0440T

0431T 0432T 0433T 0434T 0435T 0436T 0439T 0440T

0431T 0432T 0433T 0434T 0435T 0436T 0439T 0440T

0431T 0432T 0433T 0434T 0435T 0436T 0439T 0440T

0441T 0442T 0443T 0444T 0445T 0449T 0450T 0451T

0441T 0442T 0443T 0444T 0445T 0449T 0450T 0451T

0441T 0442T 0443T 0444T 0445T 0449T 0450T 0451T

0441T 0442T 0443T 0444T 0445T 0449T 0450T 0451T

0441T 0442T 0443T 0444T 0445T 0449T 0450T 0451T

0441T 0442T 0443T 0444T 0445T 0449T 0450T 0451T

0441T 0442T 0443T 0444T 0445T 0449T 0450T 0451T

0441T 0442T 0443T 0444T 0445T 0449T 0450T 0451T

0452T 0453T 0454T 0455T 0456T 0457T 0458T 0459T

0452T 0453T 0454T 0455T 0456T 0457T 0458T 0459T

0452T 0453T 0454T 0455T 0456T 0457T 0458T 0459T

0452T 0453T 0454T 0455T 0456T 0457T 0458T 0459T

0452T 0453T 0454T 0455T 0456T 0457T 0458T 0459T

0452T 0453T 0454T 0455T 0456T 0457T 0458T 0459T

0452T 0453T 0454T 0455T 0456T 0457T 0458T 0459T

0452T 0453T 0454T 0455T 0456T 0457T 0458T 0459T

0460T 0461T 0462T 0463T 0464T 0465T 0466T 0467T

0460T 0461T 0462T 0463T 0464T 0465T 0466T 0467T

0460T 0461T 0462T 0463T 0464T 0465T 0466T 0467T

0460T 0461T 0462T 0463T 0464T 0465T 0466T 0467T

0460T 0461T 0462T 0463T 0464T 0465T 0466T 0467T

0460T 0461T 0462T 0463T 0464T 0465T 0466T 0467T

0460T 0461T 0462T 0463T 0464T 0465T 0466T 0467T

0460T 0461T 0462T 0463T 0464T 0465T 0466T 0467T

0468T 0249T 0487T 0489T 0490T 0491T 0492T 0493T

0468T 0249T 0487T 0489T 0490T 0491T 0492T 0493T

0468T 0249T 0487T 0489T 0490T 0491T 0492T 0493T

0468T 0249T 0487T 0489T 0490T 0491T 0492T 0493T

0468T 0249T 0487T 0489T 0490T 0491T 0492T 0493T

0468T 0249T 0487T 0489T 0490T 0491T 0492T 0493T

0468T 0249T 0487T 0489T 0490T 0491T 0492T 0493T

0468T 0249T 0487T 0489T 0490T 0491T 0492T 0493T

050A21:A59T 0510T 0511T 0512T 0513T 0514T 0515T 0516T

050A21:A59T 0510T 0511T 0512T 0513T 0514T 0515T 0516T

050A21:A59T 0510T 0511T 0512T 0513T 0514T 0515T 0516T

050A21:A59T 0510T 0511T 0512T 0513T 0514T 0515T 0516T

050A21:A59T 0510T 0511T 0512T 0513T 0514T 0515T 0516T

050A21:A59T 0510T 0511T 0512T 0513T 0514T 0515T 0516T

050A21:A59T 0510T 0511T 0512T 0513T 0514T 0515T 0516T

050A21:A59T

050A21:A59T

050A21:A59T

050A21:A59T

050A21:A59T

050A21:A59T

050A21:A59T

0526T 0527T 0528T 0529T 0530T 0531T 0532T 0525T

0526T 0527T 0528T 0529T 0530T 0531T 0532T 0525T

0526T 0527T 0528T 0529T 0530T 0531T 0532T 0525T

0526T 0527T 0528T 0529T 0530T 0531T 0532T 0525T

0526T 0527T 0528T 0529T 0530T 0531T 0532T 0525T

0526T 0527T 0528T 0529T 0530T 0531T 0532T 0525T

0526T 0527T 0528T 0529T 0530T 0531T 0532T 0525T

0526T 0527T 0528T 0529T 0530T 0531T 0532T 0525T

0533T 0534T 0535T 0536T 0537T 0538T 0539T 0540T

0533T 0534T 0535T 0536T 0537T 0538T 0539T 0540T

0533T 0534T 0535T 0536T 0537T 0538T 0539T 0540T

0533T 0534T 0535T 0536T 0537T 0538T 0539T 0540T

0533T 0534T 0535T 0536T 0537T 0538T 0539T 0540T

0533T 0534T 0535T 0536T 0537T 0538T 0539T 0540T

0533T 0534T 0535T 0536T 0537T 0538T 0539T 0540T

0533T 0534T 0535T 0536T 0537T 0538T 0539T 0540T

0541T 0542T

0541T 0542T

0541T 0542T

0541T 0542T

0541T 0542T

0541T 0542T

0541T 0542T

0541T 0542T

CATEGORY III CODES

CATEGORY III CODES

Cosmetic or Reconstructive The listed codes require a medical necessity determination for coverage. The

Cosmetic or Reconstructive The listed codes require a medical necessity determination for coverage. The

Cosmetic or Reconstructive The listed codes require a medical necessity determination for coverage. The

Cosmetic or Reconstructive The listed codes require a medical necessity determination for coverage. The

Cosmetic or Reconstructive The listed codes require a medical necessity determination for coverage. The

Cosmetic or Reconstructive The listed codes require a medical necessity determination for coverage. The

Cosmetic or Reconstructive The listed codes require a medical necessity determination for coverage. The

Cosmetic or Reconstructive The listed codes require a medical necessity determination for coverage. The

Cosmetic or Reconstructive Surgery Surgical or other services for cosmetic purposes performed to repair or reshape a body

Cosmetic or Reconstructive Surgery Surgical or other services for cosmetic purposes performed to repair or reshape a body

Cosmetic or Reconstructive Surgery Surgical or other services for cosmetic purposes performed to repair or reshape a body

Cosmetic or Reconstructive Surgery Surgical or other services for cosmetic purposes performed to repair or reshape a body

Cosmetic or Reconstructive Surgery Surgical or other services for cosmetic purposes performed to repair or reshape a body

Cosmetic or Reconstructive Surgery Surgical or other services for cosmetic purposes performed to repair or reshape a body

P.O. Box , Green Bay, WI -1625 Phone: 888-711-1444; 920-490-6900 _____/_____/______

Web Links

15781 15782 25783 15786 15787 15788 15789 15792

15781 15782 25783 15786 15787 15788 15789 15792

15781 15782 25783 15786 15787 15788 15789 15792

Cosmetic or Reconstructive The listed codes require a medical necessity determination for coverage. The

Cosmetic or Reconstructive The listed codes require a medical necessity determination for coverage. The

Cosmetic or Reconstructive The listed codes require a medical necessity determination for coverage. The

Cosmetic or Reconstructive The listed codes require a medical necessity determination for coverage. The

Cosmetic or Reconstructive The listed codes require a medical necessity determination for coverage. The

Surgery following codes require prior authorization

Surgery following codes require prior authorization

Vision W Carmen Ave

North Corporate Parkway

• Submit a reconsideration request. Kingston, NY -5280

Doc#: PCA-1- -12112018_01102019

structure for the improvement of the person’s appearance or for psychological or

structure for the improvement of the person’s appearance or for psychological or

structure for the improvement of the person’s appearance or for psychological or

15770 15776 15820 15821 15822 15823 15824 15825

structure for the improvement of the person’s appearance or for psychological or

structure for the improvement of the person’s appearance or for psychological or

15770 15776 15820 15821 15822 15823 15824 15825

emotional reasons, and from which no improvement in physiological function can be

emotional reasons, and from which no improvement in physiological function can be

emotional reasons, and from which no improvement in physiological function can be

UnitedHealthcare Community Remove Site of Service Nov. 1, Effective Nov. 1, 2019

claims process. Mail check or money order to the claims Pittsburgh, Pennsylvania -6013

15826 15828 15829 15876 15877 15878 15879 17380

emotional reasons, and from which no improvement in physiological function can be

15826 15828 15829 15876 15877 15878 15879 17380

Surgery following codes require prior authorization

Surgery following codes require prior authorization

Surgery following codes require prior authorization

Surgery following codes require prior authorization

emotional reasons, and from which no improvement in physiological function can be

Surgery following codes require prior authorization

Surgery following codes require prior authorization

Surgery following codes require prior authorization

Surgery following codes require prior authorization

Surgery following codes require prior authorization

Surgery following codes require prior authorization

expected, except as such surgery or services are required to be covered by law

Surgery following codes require prior authorization

15836; 15837; 15838; 15839; 17106; 17107; 17108; 17360; 17999; 19300; 19316; 19318; 19324;

15836; 15837; 15838; 15839; 17106; 17107; 17108; 17360; 17999; 19300; 19316; 19318; 19324;

15836; 15837; 15838; 15839; 17106; 17107; 17108; 17360; 17999; 19300; 19316; 19318; 19324;

15836; 15837; 15838; 15839; 17106; 17107; 17108; 17360; 17999; 19300; 19316; 19318; 19324;

15836; 15837; 15838; 15839; 17106; 17107; 17108; 17360; 17999; 19300; 19316; 19318; 19324;

15836; 15837; 15838; 15839; 17106; 17107; 17108; 17360; 17999; 19300; 19316; 19318; 19324;

15836; 15837; 15838; 15839; 17106; 17107; 17108; 17360; 17999; 19300; 19316; 19318; 19324;

15836; 15837; 15838; 15839; 17106; 17107; 17108; 17360; 17999; 19300; 19316; 19318; 19324;

15836; 15837; 15838; 15839; 17106; 17107; 17108; 17360; 17999; 19300; 19316; 19318; 19324;

15836; 15837; 15838; 15839; 17106; 17107; 17108; 17360; 17999; 19300; 19316; 19318; 19324;

15836; 15837; 15838; 15839; 17106; 17107; 17108; 17360; 17999; 19300; 19316; 19318; 19324;

15836; 15837; 15838; 15839; 17106; 17107; 17108; 17360; 17999; 19300; 19316; 19318; 19324;

15836; 15837; 15838; 15839; 17106; 17107; 17108; 17360; 17999; 19300; 19316; 19318; 19324;

19325; 19328; 19330; 19340; 19342; 19350; 19357; 19361; 19364; 19366; 19367; 19368; 19369;

19325; 19328; 19330; 19340; 19342; 19350; 19357; 19361; 19364; 19366; 19367; 19368; 19369;

19325; 19328; 19330; 19340; 19342; 19350; 19357; 19361; 19364; 19366; 19367; 19368; 19369;

19325; 19328; 19330; 19340; 19342; 19350; 19357; 19361; 19364; 19366; 19367; 19368; 19369;

procedures, reduction procedures, scar revisions.

procedures, reduction procedures, scar revisions.

procedures, reduction procedures, scar revisions.

procedures, reduction procedures, scar revisions.

17360 17380 17999 19300 19316 19318 19324 19325

17360 17380 17999 19300 19316 19318 19324 19325

17360 17380 17999 19300 19316 19318 19324 19325

17360 17380 17999 19300 19316 19318 19324 19325

17360 17380 17999 19300 19316 19318 19324 19325

Unlisted Codes Submit documentation to describe the service requested and why a standard

19325; 19328; 19330; 19340; 19342; 19350; 19357; 19361; 19364; 19366; 19367; 19368; 19369;

19325; 19328; 19330; 19340; 19342; 19350; 19357; 19361; 19364; 19366; 19367; 19368; 19369;

19325; 19328; 19330; 19340; 19342; 19350; 19357; 19361; 19364; 19366; 19367; 19368; 19369;

19371; 19380; 19396; 21011; 21012; 21120; 21121; 21122; 21123; 21125; 21127;

19325; 19328; 19330; 19340; 19342; 19350; 19357; 19361; 19364; 19366; 19367; 19368; 19369;

19328 19330 19340 19342 19350 19355 19357 19361

19325; 19328; 19330; 19340; 19342; 19350; 19357; 19361; 19364; 19366; 19367; 19368; 19369;

19325; 19328; 19330; 19340; 19342; 19350; 19357; 19361; 19364; 19366; 19367; 19368; 19369;

GENDER REASSIGNMENT

GENDER REASSIGNMENT

(Breast Reconstruction Surgery cont.) ● Reconstruction of the breast on which the mastectomy was performed. 19364; 19366; 19367; 19368; 19369; S2066; S2067; S2068

(Breast Reconstruction Surgery cont.) ● Reconstruction of the breast on which the mastectomy was performed. 19364; 19366; 19367; 19368; 19369; S2066; S2067; S2068

(Breast Reconstruction Surgery cont.) ● Reconstruction of the breast on which the mastectomy was performed. 19364; 19366; 19367; 19368; 19369; S2066; S2067; S2068

19325; 19328; 19330; 19340; 19342; 19350; 19357; 19361; 19364; 19366; 19367; 19368; 19369;

19325; 19328; 19330; 19340; 19342; 19350; 19357; 19361; 19364; 19366; 19367; 19368; 19369;

19325; 19328; 19330; 19340; 19342; 19350; 19357; 19361; 19364; 19366; 19367; 19368; 19369;

19370; 19380; 19396; 19499; 21011; 21012; 21029; 21085; 21120; 21121; 21122; 21123; 21125;

19370; 19380; 19396; 19499; 21011; 21012; 21029; 21085; 21120; 21121; 21122; 21123; 21125;

19370; 19380; 19396; 19499; 21011; 21012; 21029; 21085; 21120; 21121; 21122; 21123; 21125;

19370; 19380; 19396; 19499; 21011; 21012; 21029; 21085; 21120; 21121; 21122; 21123; 21125;

19370; 19380; 19396; 19499; 21011; 21012; 21029; 21085; 21120; 21121; 21122; 21123; 21125;

19370; 19380; 19396; 19499; 21011; 21012; 21029; 21085; 21120; 21121; 21122; 21123; 21125;

19364 19366 19367 19368 19369 19370 19371 19380

19370; 19380; 19396; 19499; 21011; 21012; 21029; 21085; 21120; 21121; 21122; 21123; 21125;

19370; 19380; 19396; 19499; 21011; 21012; 21029; 21085; 21120; 21121; 21122; 21123; 21125;

19370; 19380; 19396; 19499; 21011; 21012; 21029; 21085; 21120; 21121; 21122; 21123; 21125;

19370; 19380; 19396; 19499; 21011; 21012; 21029; 21085; 21120; 21121; 21122; 21123; 21125;

19370; 19380; 19396; 19499; 21011; 21012; 21029; 21085; 21120; 21121; 21122; 21123; 21125;

19370; 19380; 19396; 19499; 21011; 21012; 21029; 21085; 21120; 21121; 21122; 21123; 21125;

19370; 19380; 19396; 19499; 21011; 21012; 21029; 21085; 21120; 21121; 21122; 21123; 21125;

21127; 21137; 21138; 21139; 21141; 21142; 21143; 21145; 21146; 21147; 21150; 21151; 21154;

19396 21141 21142 21143 21145 21146 21147 21150

21127; 21137; 21138; 21139; 21141; 21142; 21143; 21145; 21146; 21147; 21150; 21151; 21154;

21127; 21137; 21138; 21139; 21141; 21142; 21143; 21145; 21146; 21147; 21150; 21151; 21154;

21127; 21137; 21138; 21139; 21141; 21142; 21143; 21145; 21146; 21147; 21150; 21151; 21154;

837P (Professional) Loop ; Segment PRV Must follow this format: PRV*BI*

Electronic Claim Submission Payer ID

•Neighborhood Health Update Spinal Surgery See notes Originally notified

01-01-2019 Transplant

01-01-2019 Transplant

01-01-2019 Elective Surgery 53854 46762

21073 21116 21198 21199 21206 21208 21209 21210

21073 21116 21198 21199 21206 21208 21209 21210

21073 21116 21198 21199 21206 21208 21209 21210

MISCELLANEOUS

21073 21116 21198 21199 21206 21208 21209 21210

21127; 21137; 21138; 21139; 21141; 21142; 21143; 21145; 21146; 21147; 21150; 21151; 21154;

21127; 21137; 21138; 21139; 21141; 21142; 21143; 21145; 21146; 21147; 21150; 21151; 21154;

21127; 21137; 21138; 21139; 21141; 21142; 21143; 21145; 21146; 21147; 21150; 21151; 21154;

21073 21116 21198 21199 21206 21208 21209 21210

21073 21116 21198 21199 21206 21208 21209 21210

21073 21116 21198 21199 21206 21208 21209 21210

21215 21230 21235 21240 21242 21243 21244 21245

21080; 21081; 21082; 21083; 21084; 21085; 21086; 21087; 21088;

21080; 21081; 21082; 21083; 21084; 21085; 21086; 21087; 21088;

21080; 21081; 21082; 21083; 21084; 21085; 21086; 21087; 21088;

Prior Authorization List

Prior Authorization List

Prior Authorization List

Prior Authorization List

Prior Authorization List

11-25-2016 (view) Cosmetic and Reconstructive Surgery

Prior Authorization List

Prior Authorization List

Prior Authorization List

Unlisted Codes Submit documentation to describe the service requested and why a standard

Elective Surgeries Authorizations are granted for the procedure if the procedure requires inpatient

21215 21230 21235 21240 21242 21243 21244 21245

21127; 21137; 21138; 21139; 21141; 21142; 21143; 21145; 21146; 21147; 21150; 21151; 21154;

21127; 21137; 21138; 21139; 21141; 21142; 21143; 21145; 21146; 21147; 21150; 21151; 21154;

21127; 21137; 21138; 21139; 21141; 21142; 21143; 21145; 21146; 21147; 21150; 21151; 21154;

21127; 21137; 21138; 21139; 21141; 21142; 21143; 21145; 21146; 21147; 21150; 21151; 21154;

21127; 21137; 21138; 21139; 21141; 21142; 21143; 21145; 21146; 21147; 21150; 21151; 21154;

Accessory items related to the use of a cardiac mechanical device also require a

Accessory items related to the use of a cardiac mechanical device also require a

Accessory items related to the use of a cardiac mechanical device also require a

Accessory items related to the use of a cardiac mechanical device also require a

Accessory items related to the use of a cardiac mechanical device also require a

Accessory items related to the use of a cardiac mechanical device also require a

Accessory items related to the use of a cardiac mechanical device also require a

Accessory items related to the use of a cardiac mechanical device also require a

Accessory items related to the use of a cardiac mechanical device also require a

Accessory items related to the use of a cardiac mechanical device also require a

Accessory items related to the use of a cardiac mechanical device also require a

Accessory items related to the use of a cardiac mechanical device also require a

Accessory items related to the use of a cardiac mechanical device also require a

21195; 21196; 21198; 21199; 21206; 21208; 21209; 21210; 21215; 21230; 21235; 21240; 21242;

21195; 21196; 21198; 21199; 21206; 21208; 21209; 21210; 21215; 21230; 21235; 21240; 21242;

21195; 21196; 21198; 21199; 21206; 21208; 21209; 21210; 21215; 21230; 21235; 21240; 21242;

21195; 21196; 21198; 21199; 21206; 21208; 21209; 21210; 21215; 21230; 21235; 21240; 21242;

05-20-2016 (view) Cosmetic and Reconstructive Surgery It no longer requires prior authorization

21195; 21196; 21198; 21199; 21206; 21208; 21209; 21210; 21215; 21230; 21235; 21240; 21242;

21195; 21196; 21198; 21199; 21206; 21208; 21209; 21210; 21215; 21230; 21235; 21240; 21242;

21195; 21196; 21198; 21199; 21206; 21208; 21209; 21210; 21215; 21230; 21235; 21240; 21242;

21195; 21196; 21198; 21199; 21206; 21208; 21209; 21210; 21215; 21230; 21235; 21240; 21242;

21195; 21196; 21198; 21199; 21206; 21208; 21209; 21210; 21215; 21230; 21235; 21240; 21242;

21195; 21196; 21198; 21199; 21206; 21208; 21209; 21210; 21215; 21230; 21235; 21240; 21242;

21195; 21196; 21198; 21199; 21206; 21208; 21209; 21210; 21215; 21230; 21235; 21240; 21242;

21195; 21196; 21198; 21199; 21206; 21208; 21209; 21210; 21215; 21230; 21235; 21240; 21242;

21195; 21196; 21198; 21199; 21206; 21208; 21209; 21210; 21215; 21230; 21235; 21240; 21242;

21243; 21244; 21245; 21246; 21247; 21248; 21249; 21255; 21256; 21260; 21261; 21263; 21267;

21243; 21244; 21245; 21246; 21247; 21248; 21249; 21255; 21256; 21260; 21261; 21263; 21267;

21243; 21244; 21245; 21246; 21247; 21248; 21249; 21255; 21256; 21260; 21261; 21263; 21267;

21243; 21244; 21245; 21246; 21247; 21248; 21249; 21255; 21256; 21260; 21261; 21263; 21267;

21243; 21244; 21245; 21246; 21247; 21248; 21249; 21255; 21256; 21260; 21261; 21263; 21267;

21243; 21244; 21245; 21246; 21247; 21248; 21249; 21255; 21256; 21260; 21261; 21263; 21267;

21243; 21244; 21245; 21246; 21247; 21248; 21249; 21255; 21256; 21260; 21261; 21263; 21267;

21243; 21244; 21245; 21246; 21247; 21248; 21249; 21255; 21256; 21260; 21261; 21263; 21267;

21243; 21244; 21245; 21246; 21247; 21248; 21249; 21255; 21256; 21260; 21261; 21263; 21267;

21243; 21244; 21245; 21246; 21247; 21248; 21249; 21255; 21256; 21260; 21261; 21263; 21267;

21243; 21244; 21245; 21246; 21247; 21248; 21249; 21255; 21256; 21260; 21261; 21263; 21267;

21243; 21244; 21245; 21246; 21247; 21248; 21249; 21255; 21256; 21260; 21261; 21263; 21267;

21243; 21244; 21245; 21246; 21247; 21248; 21249; 21255; 21256; 21260; 21261; 21263; 21267;

21268; 21270; 21275; 21280; 21282; 21295; 21296; 21552; 21555; 21740; 22902; 22903; 23071;

21268; 21270; 21275; 21280; 21282; 21295; 21296; 21552; 21555; 21740; 22902; 22903; 23071;

21268; 21270; 21275; 21280; 21282; 21295; 21296; 21552; 21555; 21740; 22902; 22903; 23071;

21268; 21270; 21275; 21280; 21282; 21295; 21296; 21552; 21555; 21740; 22902; 22903; 23071;

21268; 21270; 21275; 21280; 21282; 21295; 21296; 21552; 21555; 21740; 22902; 22903; 23071;

21268; 21270; 21275; 21280; 21282; 21295; 21296; 21552; 21555; 21740; 22902; 22903; 23071;

21268; 21270; 21275; 21280; 21282; 21295; 21296; 21552; 21555; 21740; 22902; 22903; 23071;

21268; 21270; 21275; 21280; 21282; 21295; 21296; 21552; 21555; 21740; 22902; 22903; 23071;

21268; 21270; 21275; 21280; 21282; 21295; 21296; 21552; 21555; 21740; 22902; 22903; 23071;

21268; 21270; 21275; 21280; 21282; 21295; 21296; 21552; 21555; 21740; 22902; 22903; 23071;

21268; 21270; 21275; 21280; 21282; 21295; 21296; 21552; 21555; 21740; 22902; 22903; 23071;

21268; 21270; 21275; 21280; 21282; 21295; 21296; 21552; 21555; 21740; 22902; 22903; 23071;

21268; 21270; 21275; 21280; 21282; 21295; 21296; 21552; 21555; 21740; 22902; 22903; 23071;

23075; 24071; 24075; 30120; 30400; 30410; 30420; 30430; 30435; 30450; 30460; 30462; 30465;

23075; 24071; 24075; 30120; 30400; 30410; 30420; 30430; 30435; 30450; 30460; 30462; 30465;

23075; 24071; 24075; 30120; 30400; 30410; 30420; 30430; 30435; 30450; 30460; 30462; 30465;

23075; 24071; 24075; 30120; 30400; 30410; 30420; 30430; 30435; 30450; 30460; 30462; 30465;

23075; 24071; 24075; 30120; 30400; 30410; 30420; 30430; 30435; 30450; 30460; 30462; 30465;

23075; 24071; 24075; 30120; 30400; 30410; 30420; 30430; 30435; 30450; 30460; 30462; 30465;

23075; 24071; 24075; 30120; 30400; 30410; 30420; 30430; 30435; 30450; 30460; 30462; 30465;

MISCELLANEOUS

MISCELLANEOUS

23075; 24071; 24075; 30120; 30400; 30410; 30420; 30430; 30435; 30450; 30460; 30462; 30465;

23075; 24071; 24075; 30120; 30400; 30410; 30420; 30430; 30435; 30450; 30460; 30462; 30465;

Sleep apnea procedures and Prior authorization required

23075; 24071; 24075; 30120; 30400; 30410; 30420; 30430; 30435; 30450; 30460; 30462; 30465;

23075; 23076; 24071; 24073; 24075; 24076; 27045; 27047; 27048; 27327; 27328;

23075; 23076; 24071; 24073; 24075; 24076; 27045; 27047; 27048; 27327; 27328;

Unlisted Codes Submit documentation to describe the service requested and why a standard

23075; 23076; 24071; 24073; 24075; 24076; 27045; 27047; 27048; 27327; 27328;

Spinal surgery Prior authorization required

Spinal surgery Prior authorization required

Spinal surgery Prior authorization required

Spinal surgery Prior authorization required

Maxillomandibular advancement and

Maxillomandibular advancement and

admission, the hospital must notify Together with CCHP of the admission according to

admission, the hospital must notify Together with CCHP of the admission according to

admission, the hospital must notify Together with CCHP of the admission according to

admission, the hospital must notify Together with CCHP of the admission according to

admission, the hospital must notify Together with CCHP of the admission according to

admission, the hospital must notify Together with CCHP of the admission according to

admission, the hospital must notify Together with CCHP of the admission according to

admission, the hospital must notify Together with CCHP of the admission according to

admission, the hospital must notify Together with CCHP of the admission according to

admission, the hospital must notify Together with CCHP of the admission according to

the Inpatient Admission process. If the procedure is performed as an outpatient, the

10-14-2019 Elective Surgery ; ; ; (Effective December 1, 2019)

10-14-2019 Elective Surgery ; ; ; (Effective December 1, 2019)

the Inpatient Admission process. If the procedure is performed as an outpatient, the

the Inpatient Admission process. If the procedure is performed as an outpatient, the

the Inpatient Admission process. If the procedure is performed as an outpatient, the

the Inpatient Admission process. If the procedure is performed as an outpatient, the

the Inpatient Admission process. If the procedure is performed as an outpatient, the

the Inpatient Admission process. If the procedure is performed as an outpatient, the

the Inpatient Admission process. If the procedure is performed as an outpatient, the

the Inpatient Admission process. If the procedure is performed as an outpatient, the

(Elective Surgeries cont.) authorization for the procedure will cover the related services required at the

(Elective Surgeries cont.) authorization for the procedure will cover the related services required at the

(Elective Surgeries cont.) authorization for the procedure will cover the related services required at the

(Elective Surgeries cont.) authorization for the procedure will cover the related services required at the

(Elective Surgeries cont.) authorization for the procedure will cover the related services required at the

(Elective Surgeries cont.) authorization for the procedure will cover the related services required at the

(Elective Surgeries cont.) authorization for the procedure will cover the related services required at the

(Elective Surgeries cont.) authorization for the procedure will cover the related services required at the

(Elective Surgeries cont.) authorization for the procedure will cover the related services required at the

(Elective Surgeries cont.) authorization for the procedure will cover the related services required at the

(Elective Surgeries cont.) authorization for the procedure will cover the related services required at the

ambulatory surgical center or the hospital outpatient surgical department

ambulatory surgical center or the hospital outpatient surgical department

ambulatory surgical center or the hospital outpatient surgical department

ambulatory surgical center or the hospital outpatient surgical department

ambulatory surgical center or the hospital outpatient surgical department

ambulatory surgical center or the hospital outpatient surgical department

ambulatory surgical center or the hospital outpatient surgical department

ambulatory surgical center or the hospital outpatient surgical department

22830 22849 22850 22852

22830 22849 22850 22852

22855 22856 22861 22864

22855 22856 22861 22864

22855 22856 22861 22864

22855 22856 22861 22864

22865 22899 63001 63003

10-14-2019 Elective Surgery ; ; ; (Effective December 1, 2019)

ambulatory surgical center or the hospital outpatient surgical department

27279; 43647; 43648; Added to Non-covered List

27279; 43647; 43648; Added to Non-covered List

24160; 24164; 24320; 24330; 24331; 24360; 24361; 24362; 24363; 24365; 24366;

27279; 43647; 43648; Added to Non-covered List

24160; 24164; 24320; 24330; 24331; 24360; 24361; 24362; 24363; 24365; 24366;

Unlisted Codes Submit documentation to describe the service requested and why a standard

23075; 23076; 24071; 24073; 24075; 24076; 27045; 27047; 27048; 27327; 27328;

23075; 23076; 24071; 24073; 24075; 24076; 27045; 27047; 27048; 27327; 27328;

23075; 24071; 24075; 30120; 30400; 30410; 30420; 30430; 30435; 30450; 30460; 30462; 30465;

23075; 24071; 24075; 30120; 30400; 30410; 30420; 30430; 30435; 30450; 30460; 30462; 30465;

Unlisted Codes Submit documentation to describe the service requested and why a standard

23075; 24071; 24075; 30120; 30400; 30410; 30420; 30430; 30435; 30450; 30460; 30462; 30465;

23075; 23076; 24071; 24073; 24075; 24076; 27045; 27047; 27048; 27327; 27328;

30520; 30545; 30620; 30630; 30999; 36470; 36471; 36473; 36474; 36475; 36476; 36478; 37700;

27337; 27339; 27618; 27619; 27632; 27634; 28039; 28041; 28043; 28045; 30400;

837I (Institutional) Loop ; Segment NM1

837P (Professional) Loop ; Segment NM1

go to our provider website at: Claim Status, PO Box Virginia Beach, VA 1599 PO Box 933657

24160; 24164; 24320; 24330; 24331; 24360; 24361; 24362; 24363; 24365; 24366;

24160; 24164; 24320; 24330; 24331; 24360; 24361; 24362; 24363; 24365; 24366;

24160; 24164; 24320; 24330; 24331; 24360; 24361; 24362; 24363; 24365; 24366;

24160; 24164; 24320; 24330; 24331; 24360; 24361; 24362; 24363; 24365; 24366;

secure.wecareforwisconsin.com/documents/providers/provider-forms/ -arise

24160; 24164; 24320; 24330; 24331; 24360; 24361; 24362; 24363; 24365; 24366;

24160; 24164; 24320; 24330; 24331; 24360; 24361; 24362; 24363; 24365; 24366;

CPT/HCPCS code cannot be used. Unlisted codes may be used for potentially

30520; 30545; 30620; 30630; 30999; 36470; 36471; 36473; 36474; 36475; 36476; 36478; 37700;

27337; 27339; 27618; 27619; 27632; 27634; 28039; 28041; 28043; 28045; 30400;

30520; 30545; 30620; 30630; 30999; 36470; 36471; 36473; 36474; 36475; 36476; 36478; 37700;

27337; 27339; 27618; 27619; 27632; 27634; 28039; 28041; 28043; 28045; 30400;

24160; 24164; 24320; 24330; 24331; 24360; 24361; 24362; 24363; 24365; 24366;

24370; 24371; 24420; 24498; 24940; 25332; 25335; 25441; 25442; 25443; 25444;

24370; 24371; 24420; 24498; 24940; 25332; 25335; 25441; 25442; 25443; 25444;

24370; 24371; 24420; 24498; 24940; 25332; 25335; 25441; 25442; 25443; 25444;

24370; 24371; 24420; 24498; 24940; 25332; 25335; 25441; 25442; 25443; 25444;

24370; 24371; 24420; 24498; 24940; 25332; 25335; 25441; 25442; 25443; 25444;

24370; 24371; 24420; 24498; 24940; 25332; 25335; 25441; 25442; 25443; 25444;

24370; 24371; 24420; 24498; 24940; 25332; 25335; 25441; 25442; 25443; 25444;

24370; 24371; 24420; 24498; 24940; 25332; 25335; 25441; 25442; 25443; 25444;

24370; 24371; 24420; 24498; 24940; 25332; 25335; 25441; 25442; 25443; 25444;

24370; 24371; 24420; 24498; 24940; 25332; 25335; 25441; 25442; 25443; 25444;

24370; 24371; 24420; 24498; 24940; 25332; 25335; 25441; 25442; 25443; 25444;

25445; 25446; 25447; 25449; 25800; 25805; 25810; 25820; 25825; 25830; 25915;

25445; 25446; 25447; 25449; 25800; 25805; 25810; 25820; 25825; 25830; 25915;

25445; 25446; 25447; 25449; 25800; 25805; 25810; 25820; 25825; 25830; 25915;

25445; 25446; 25447; 25449; 25800; 25805; 25810; 25820; 25825; 25830; 25915;

25445; 25446; 25447; 25449; 25800; 25805; 25810; 25820; 25825; 25830; 25915;

CPT/HCPCS code cannot be used. Unlisted codes may be used for potentially

25445; 25446; 25447; 25449; 25800; 25805; 25810; 25820; 25825; 25830; 25915;

25445; 25446; 25447; 25449; 25800; 25805; 25810; 25820; 25825; 25830; 25915;

25445; 25446; 25447; 25449; 25800; 25805; 25810; 25820; 25825; 25830; 25915;

25445; 25446; 25447; 25449; 25800; 25805; 25810; 25820; 25825; 25830; 25915;

25445; 25446; 25447; 25449; 25800; 25805; 25810; 25820; 25825; 25830; 25915;

25445; 25446; 25447; 25449; 25800; 25805; 25810; 25820; 25825; 25830; 25915;

26530; 26531; 26535; 26536; 26551; 26553; 26554; 26555; 26556; 26568; 26580;

26530; 26531; 26535; 26536; 26551; 26553; 26554; 26555; 26556; 26568; 26580;

26530; 26531; 26535; 26536; 26551; 26553; 26554; 26555; 26556; 26568; 26580;

26530; 26531; 26535; 26536; 26551; 26553; 26554; 26555; 26556; 26568; 26580;

• Bind Benefits Inc. is the payer. Payer ID

15793 15820 15821 15822 15823 15824 15825 15826

26530; 26531; 26535; 26536; 26551; 26553; 26554; 26555; 26556; 26568; 26580;

26530; 26531; 26535; 26536; 26551; 26553; 26554; 26555; 26556; 26568; 26580;

26530; 26531; 26535; 26536; 26551; 26553; 26554; 26555; 26556; 26568; 26580;

26530; 26531; 26535; 26536; 26551; 26553; 26554; 26555; 26556; 26568; 26580;

26530; 26531; 26535; 26536; 26551; 26553; 26554; 26555; 26556; 26568; 26580;