Prior authorization request form Form

Questions? Please call the Alliance Provider Department Monday – Friday, 7:30 am – 5 pm Phone Number: 1.510.747.4501 www.alamedaalliance.org OPUM_OUTPATIENT REHAB AUTH 05/2022; FAXED 8.29.22 Important Update: Outpatient Rehab (PT, ST, OT, Cardiac, Pulmonary, and Aquatic) Codes That Require Authorization

Alameda Alliance for Health (Alliance) values our dedicated provider partner community. We have an important update we would like to share with you.
Our provider partner satisfaction is a top priority. We are working to improve our Utilization Management and Claims processes to help ensure proper claim payment to our provider partners, and alignment of authorized services. To accomplish this goal, we are reviewing each benefit and we will be sending you updates, as the information is ready to share. This communication provides an update on Outpatient Rehab (PT, ST, OT, Cardiac, and Aquatic) codes that require prior authorization (PA). This will affect claims with date(s) of service starting Monday, September 26, 2022, and onward. Enclosed with this notice is a code-specific list for Outpatient Rehab (PT, ST, OT, Cardiac, and Aquatic) codes that show which codes require PA. The list may include codes that newly require authorization and/or previously required authorization. This list can be found on our website at www.alamedaalliance.org/providers/authorizations. Please refer to our website for the most up-to-date information about codes or benefits that require authorization. In addition to the codes, our claims system will also validate that claims received match the authorization when an authorization is required. The following items will be validated: • Member name
• Provider NPI • CPT and HCPC coding
• Date(s) of service is within the authorized range • Number of units and/or visits
• Place of service matches site of care submitted on the authorization request form
This update has been validated based on current and published billable coding for 2021 and was confirmed to be covered by the California Department of Health Care Services (DHCS). If you have questions, please call the Alliance Provider Services Department at 1.510.747.4510. Thank you for your continued partnership and for providing high-quality care to our members and the community.

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO Aquatic Therapy 97113 AQUATIC THERAPY/EXERCISES The Alliance or Delegate G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session The Alliance or Delegate G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring without exercise, per session The Alliance or Delegate 93797 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitor (per session) The Alliance or Delegate 93798 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session) The Alliance or Delegate 97012 MECHANICAL TRACTION THERAPY The Alliance or Delegate 97014 ELECTRIC STIMULATION THERAPY The Alliance or Delegate 97016 VASOPNEUMATIC DEVICE THERAPY The Alliance or Delegate 97018 PARAFFIN BATH THERAPY The Alliance or Delegate 97022 WHIRLPOOL THERAPY The Alliance or Delegate 97024 DIATHERMY EG MICROWAVE The Alliance or Delegate 97026 INFRARED THERAPY The Alliance or Delegate 97028 ULTRAVIOLET THERAPY The Alliance or Delegate 97032 ELECTRICAL STIMULATION The Alliance or Delegate 97033 ELECTRIC CURRENT THERAPY The Alliance or Delegate 97034 CONTRAST BATH THERAPY The Alliance or Delegate 97035 ULTRASOUND THERAPY The Alliance or Delegate 97036 HYDROTHERAPY The Alliance or Delegate 97039 PHYSICAL THERAPY TREATMENT The Alliance or Delegate 97110 THERAPEUTIC EXERCISES The Alliance or Delegate 97112 NEUROMUSCULAR REEDUCATION The Alliance or Delegate 97113 AQUATIC THERAPY/EXERCISES The Alliance or Delegate 97116 GAIT TRAINING THERAPY The Alliance or Delegate 97124 MASSAGE THERAPY The Alliance or Delegate 97129 THER IVNTJ 1ST 15 MIN The Alliance or Delegate ALAMEDA ALLIANCE FOR HEALTH REFERRAL AND PRIOR AUTHORIZATION (PA) PROCEDURE CODES FOR OUTPATIENT REHAB (AQUATIC, CARDIAC, OT, PT, PULMONARY, AND ST) Before services are provided, please check: Member Eligibility ▪ Medical Group ▪ Benefit Coverage ▪ Contracted Provider ▪ Medi-Cal Excluded Code Questions? Please call the Alliance Provider Services Department at 1.510.747.4510 Please Note: Effective Monday, September 26, 2022, the bold procedure codes highlighted in gray require PA. Cardiac Therapy Physical Therapy Please note: This list does not include all services. Page 1 of 3 PS_OUTPATIENT REHAB PROC CODES REQ PA 06/2022

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 97130 THER IVNTJ EA ADDL 15 MIN The Alliance or Delegate 97139 PHYSICAL MEDICINE PROCEDURE The Alliance or Delegate 97140 MANUAL THERAPY 1/> REGIONS The Alliance or Delegate 97530 THERAPEUTIC ACTIVITIES The Alliance or Delegate 97533 PT RE-EVAL EST PLAN CARE The Alliance or Delegate 97750 PHYSICAL PERFORMANCE TEST The Alliance or Delegate 97799 PHYSICAL MEDICINE PROCEDURE The Alliance or Delegate G0151 SRVC PT HOM HLTH/HOSPICE EA 15 MIN The Alliance or Delegate X3900 SINGLE MOD 1 AREA INIT 30 MIN The Alliance or Delegate X3902 SINGLE MOD 1 AREA EA.ADD 15 MIN The Alliance or Delegate X3904 SINGLE PROC 1 AREA INITIAL 30 MIN The Alliance or Delegate X3906 SINGLE PROC 1 AREA EA. ADD 15 MIN The Alliance or Delegate X3908 TREAT INCLUD COMB ANY MODS & PROCS The Alliance or Delegate X3910 TREAT INCLUD COMB ANY MODS & PROCS The Alliance or Delegate X3912 HUBBARD TANK INITIAL 30 MINUTES The Alliance or Delegate X3914 HUBBARD TANK EACH ADDITIONAL 15 MIN The Alliance or Delegate X3916 HUBBARD TNK OR POOL TX W/EXER 30 MI The Alliance or Delegate X3918 HUBBARD TNK OR POOL TX W/EXER 15 MI The Alliance or Delegate X3920 ANY TSTS & MEASURES INIT 30 MIN REP The Alliance or Delegate X3922 ANY TSTS & MEASURES ADD 15 MIN REP The Alliance or Delegate X3924 PHYSL TX PRELIM EVAL REHAB,SNF, ICF The Alliance or Delegate X3936 UNLISTED SERVICES The Alliance or Delegate Pulmonary Therapy 94626 Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring (per session) The Alliance or Delegate G0152 SRVC OT HOM HLTH/HOSPICE EA 15 MIN The Alliance or Delegate X4100 EVAL INIT 30 MIN PLUS RPT The Alliance or Delegate X4102 EVAL EA. ADD 15 MIN PLUS RPT The Alliance or Delegate X4104 CASE CONF AND RPT INIT 30 MIN The Alliance or Delegate X4106 CASE CONF AND RPT EA.ADDIT 15 MIN The Alliance or Delegate X4108 OT TX PRELIM EVAL REHAB,NF-B, NF-A The Alliance or Delegate X4110 TREATMENT INITIAL 30 MINUTES The Alliance or Delegate X4112 TREATMENT EACH ADDITIONAL 15 MINUTE The Alliance or Delegate X4114 HOME OR LTC FACILITY VISIT The Alliance or Delegate X4116 MILEAGE / MILE 1-WAY >10 MI RADIUS The Alliance or Delegate X4118 UNLISTED SERVICE The Alliance or Delegate X4120 CASE CONSULTATION AND REPORT The Alliance or Delegate Occupational Therapy Physical Therapy (cont.) Please note: This list does not include all services. Page 2 of 3 PS_OUTPATIENT REHAB PROC CODES REQ PA 06/2022

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 92507 SPEECH/HEARING THERAPY The Alliance or Delegate 92508 SPEECH/HEARING THERAPY The Alliance or Delegate 92521 EVALUATION OF SPEECH FLUENCY The Alliance or Delegate 92522 EVALUATE SPEECH PRODUCTION The Alliance or Delegate 92523 SPEECH SOUND LANG COMPREHEN The Alliance or Delegate 92524 BEHAVRAL QUALIT ANALYS VOICE The Alliance or Delegate 92526 ORAL FUNCTION THERAPY The Alliance or Delegate 92551 PURE TONE HEARING TEST AIR The Alliance or Delegate 92552 PURE TONE AUDIOMETRY AIR The Alliance or Delegate 92553 AUDIOMETRY AIR & BONE The Alliance or Delegate 92555 SPEECH THRESHOLD AUDIOMETRY The Alliance or Delegate 92556 SPEECH AUDIOMETRY COMPLETE The Alliance or Delegate 92557 COMPREHENSIVE HEARING TEST The Alliance or Delegate 92558 EVOKED AUDITORY TEST QUAL The Alliance or Delegate 92570 ACOUSTIC IMMITANCE TESTING The Alliance or Delegate 92579 VISUAL AUDIOMETRY (VRA) The Alliance or Delegate 92582 CONDITIONING PLAY AUDIOMETRY The Alliance or Delegate Speech Therapy Please note: This list does not include all services. Page 3 of 3 PS_OUTPATIENT REHAB PROC CODES REQ PA 06/2022