Prior authorization request form Form

Questions? Please call the Alliance Provider Services Department Monday – Friday, 7:30 am – 5 pm Phone Number: 1.510.747.4510 www.alamedaalliance.org 1/1 UMPRVDRCRCMSN, DIALYSIS, GEN TST PA UPDATE 01/2025 FAXED 01/13/2025 Important Update: Utilization Management (UM) Circumcision, Dialysis, and Genetic Testing Codes That Require Prior Authorization At Alameda Alliance for Health (Alliance), we appreciate our dedicated provider partner community and strive to deliver the highest levels of service and satisfaction.
We have an important update we want to share with you about Circumcision, Dialysis, and Genetic Testing codes that require prior authorization for in-network providers. This does not include outpatient pharmacy services through the member’s pharmacy benefit. This update affects claims with the date(s) of service starting Monday, February 17, 2025, and onward for the code-specific list of Circumcision, Dialysis, and Genetic Testing codes that require prior authorization. The previous notice we shared on Friday, August 20, 2021, included dialysis codes that are now omitted in this new list. The updated list is also available on the Alliance website at www.alamedaalliance.org/providers/authorizations. Please refer to our website for the most up- to-date information about codes and benefits that require prior authorization. Please Note: For service codes that do not require prior authorization but are associated with a prior authorization required service, there must be an approved authorization on file for the primary service requiring authorization for the associated code(s) to be paid. Associated codes not on the prior authorization list will not be paid separately if the primary service was denied or does not have prior authorization.
In addition to the codes, our claims system will validate that the claim received matches the authorization when 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 • National Drug Codes (NDCs) approved by the FDA are required on claims submissions. Claims missing and/or without a matching NDC on a claim will be denied. This update has been validated based on current and published billable coding and was confirmed to be covered by the California Department of Health Care Services (DHCS). 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 Circumcision 54161 CIRCUM 28 DAYS OR OLDER Alameda Alliance for Health or Delegate 54162 LYSIS PENIL CIRCUMIC LESION Alameda Alliance for Health or Delegate 54163 REPAIR OF CIRCUMCISION Alameda Alliance for Health or Delegate 54164 FRENULOTOMY OF PENIS Alameda Alliance for Health or Delegate Genetic Testing 81163 BRCA1&2 GENE FULL SEQ ALYS Alameda Alliance for Health or Delegate 81164 BRCA1&2 GEN FUL DUP/DEL ALYS Alameda Alliance for Health or Delegate 81165 BRCA1 GENE FULL SEQ ALYS Alameda Alliance for Health or Delegate 81166 BRCA1 GENE FULL DUP/DEL ALYS Alameda Alliance for Health or Delegate 81167 BRCA2 GENE FULL DUP/DEL ALYS Alameda Alliance for Health or Delegate 81170 ABL1 GENE Alameda Alliance for Health or Delegate 81173 AR GENE FULL GENE SEQUENCE Alameda Alliance for Health or Delegate 81174 AR GENE KNOWN FAMIL VARIANT Alameda Alliance for Health or Delegate 81177 ATN1 GENE DETC ABNOR ALLELES Alameda Alliance for Health or Delegate 81178 ATXN1 GENE DETC ABNOR ALLELE Alameda Alliance for Health or Delegate 81179 ATXN2 GENE DETC ABNOR ALLELE Alameda Alliance for Health or Delegate 81180 ATXN3 GENE DETC ABNOR ALLELE Alameda Alliance for Health or Delegate 81181 ATXN7 GENE DETC ABNOR ALLELE Alameda Alliance for Health or Delegate 81182 ATXN8OS GEN DETC ABNOR ALLEL Alameda Alliance for Health or Delegate 81183 ATXN10 GENE DETC ABNOR ALLEL Alameda Alliance for Health or Delegate 81184 CACNA1A GEN DETC ABNOR ALLEL Alameda Alliance for Health or Delegate 81185 CACNA1A GENE FULL GENE SEQ Alameda Alliance for Health or Delegate 81186 CACNA1A GEN KNOWN FAMIL VRNT Alameda Alliance for Health or Delegate 81187 CNBP GENE DETC ABNOR ALLELE Alameda Alliance for Health or Delegate 81188 CSTB GENE DETC ABNOR ALLELE Alameda Alliance for Health or Delegate 81189 CSTB GENE FULL GENE SEQUENCE Alameda Alliance for Health or Delegate 81190 CSTB GENE KNOWN FAMIL VRNT Alameda Alliance for Health or Delegate ALAMEDA ALLIANCE FOR HEALTH REFERRAL AND PRIOR AUTHORIZATION (PA) PROCEDURE CODES FOR CIRCUMCISION, DIALYSIS, AND GENETIC TESTING 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: This list does not include all services. Page 1 of 4 PS_CRCMSN, DIALYSIS, GEN TST PROC CODES REQ PA 12/2024

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO Genetic Testing (cont.) 81191 NTRK1 TRANSLOCATION ANALYSIS Alameda Alliance for Health or Delegate 81192 NTRK2 TRANSLOCATION ANALYSIS Alameda Alliance for Health or Delegate 81193 NTRK3 TRANSLOCATION ANALYSIS Alameda Alliance for Health or Delegate 81194 NTRK TRANSLOCATION ANALYSIS Alameda Alliance for Health or Delegate 81202 APC GENE KNOWN FAM VARIANTS Alameda Alliance for Health or Delegate 81204 AR GENE CHARAC ALLELES Alameda Alliance for Health or Delegate 81212 BRCA1&2 185&5385&6174 VRNT Alameda Alliance for Health or Delegate 81215 BRCA1 GENE KNOWN FAMIL VRNT Alameda Alliance for Health or Delegate 81216 BRCA2 GENE FULL SEQ ALYS Alameda Alliance for Health or Delegate 81217 BRCA2 GENE KNOWN FAMIL VRNT Alameda Alliance for Health or Delegate 81221 CFTR GENE KNOWN FAM VARIANTS Alameda Alliance for Health or Delegate 81222 CFTR GENE DUP/DELET VARIANTS Alameda Alliance for Health or Delegate 81223 CFTR GENE FULL SEQUENCE Alameda Alliance for Health or Delegate 81226 CYP2D6 GENE COM VARIANTS Alameda Alliance for Health or Delegate 81227 CYP2C9 GENE COM VARIANTS Alameda Alliance for Health or Delegate 81232 DPYD GENE COMMON VARIANTS Alameda Alliance for Health or Delegate 81234 DMPK GENE DETC ABNOR ALLELE Alameda Alliance for Health or Delegate 81239 DMPK GENE CHARAC ALLELES Alameda Alliance for Health or Delegate 81250 G6PC GENE Alameda Alliance for Health or Delegate 81260 IKBKAP GENE Alameda Alliance for Health or Delegate 81271 HTT GENE DETC ABNOR ALLELES Alameda Alliance for Health or Delegate 81274 HTT GENE CHARAC ALLELES Alameda Alliance for Health or Delegate 81278 IGH@/BCL2 TRANSLOCATION ALYS Alameda Alliance for Health or Delegate 81284 FXN GENE DETC ABNOR ALLELES Alameda Alliance for Health or Delegate 81285 FXN GENE CHARAC ALLELES Alameda Alliance for Health or Delegate 81286 FXN GENE FULL GENE SEQUENCE Alameda Alliance for Health or Delegate 81287 MGMT GENE PRMTR MTHYLTN ALYS Alameda Alliance for Health or Delegate 81288 MLH1 GENE Alameda Alliance for Health or Delegate 81289 FXN GENE KNOWN FAMIL VARIANT Alameda Alliance for Health or Delegate 81293 MLH1 GENE KNOWN VARIANTS Alameda Alliance for Health or Delegate 81296 MSH2 GENE KNOWN VARIANTS Alameda Alliance for Health or Delegate 81299 MSH6 GENE KNOWN VARIANTS Alameda Alliance for Health or Delegate 81306 NUDT15 GENE COMMON VARIANTS Alameda Alliance for Health or Delegate Please note: This list does not include all services. Page 2 of 4 PS_CRCMSN, DIALYSIS, GEN TST PROC CODES REQ PA 12/2024

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO Genetic Testing (cont.) 81309 PIK3CA GENE TRGT SEQ ALYS Alameda Alliance for Health or Delegate 81312 PABPN1 GENE DETC ABNOR ALLEL Alameda Alliance for Health or Delegate 81318 PMS2 KNOWN FAMILIAL VARIANTS Alameda Alliance for Health or Delegate 81321 PTEN GENE FULL SEQUENCE Alameda Alliance for Health or Delegate 81322 PTEN GENE KNOWN FAM VARIANT Alameda Alliance for Health or Delegate 81323 PTEN GENE DUP/DELET VARIANT Alameda Alliance for Health or Delegate 81331 SNRPN/UBE3A GENE Alameda Alliance for Health or Delegate 81335 TPMT GENE COM VARIANTS Alameda Alliance for Health or Delegate 81336 SMN1 GENE FULL GENE SEQUENCE Alameda Alliance for Health or Delegate 81337 SMN1 GEN NOWN FAMIL SEQ VRNT Alameda Alliance for Health or Delegate 81338 MPL GENE COMMON VARIANTS Alameda Alliance for Health or Delegate 81339 MPL GENE SEQ ALYS EXON 10 Alameda Alliance for Health or Delegate 81340 TRB@ GENE REARRANGE AMPLIFY Alameda Alliance for Health or Delegate 81341 TRB@ GENE REARRANGE DIRPROBE Alameda Alliance for Health or Delegate 81342 TRG GENE REARRANGEMENT ANAL Alameda Alliance for Health or Delegate 81343 PPP2R2B GEN DETC ABNOR ALLEL Alameda Alliance for Health or Delegate 81344 TBP GENE DETC ABNOR ALLELES Alameda Alliance for Health or Delegate 81345 TERT GENE TARGETED SEQ ALYS Alameda Alliance for Health or Delegate 81351 TP53 GENE FULL GENE SEQUENCE Alameda Alliance for Health or Delegate 81352 TP53 GENE TRGT SEQUENCE ALYS Alameda Alliance for Health or Delegate 81353 TP53 GENE KNOWN FAMIL VRNT Alameda Alliance for Health or Delegate 81400 MOPATH PROCEDURE LEVEL 1 Alameda Alliance for Health or Delegate 81401 MOPATH PROCEDURE LEVEL 2 Alameda Alliance for Health or Delegate 81402 MOPATH PROCEDURE LEVEL 3 Alameda Alliance for Health or Delegate 81403 MOPATH PROCEDURE LEVEL 4 Alameda Alliance for Health or Delegate 81404 MOPATH PROCEDURE LEVEL 5 Alameda Alliance for Health or Delegate 81405 MOPATH PROCEDURE LEVEL 6 Alameda Alliance for Health or Delegate 81406 MOPATH PROCEDURE LEVEL 7 Alameda Alliance for Health or Delegate 81407 MOPATH PROCEDURE LEVEL 8 Alameda Alliance for Health or Delegate 81408 MOPATH PROCEDURE LEVEL 9 Alameda Alliance for Health or Delegate 81412 ASHKENAZI JEWISH ASSOC DIS Alameda Alliance for Health or Delegate 81413 CAR ION CHNNLPATH INC 10 GNS Alameda Alliance for Health or Delegate 81414 CAR ION CHNNLPATH INC 2 GNS Alameda Alliance for Health or Delegate Please note: This list does not include all services. Page 3 of 4 PS_CRCMSN, DIALYSIS, GEN TST PROC CODES REQ PA 12/2024

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO Genetic Testing (cont.) 81419 EPILEPSY GEN SEQ ALYS PANEL Alameda Alliance for Health or Delegate 81432 HRDTRY BRST CA-RLATD DSORDRS Alameda Alliance for Health or Delegate 81434 HEREDITARY RETINAL DISORDERS Alameda Alliance for Health or Delegate 81445 TARGETED GENOMIC SEQ ANALYS Alameda Alliance for Health or Delegate 81455 TARGETED GENOMIC SEQ ANALYS Alameda Alliance for Health or Delegate 81457 SO NEO GSAP DNA MCRSTL INS Alameda Alliance for Health or Delegate 81458 SO GSAP DNA CPY NMBR&MCRSTL Alameda Alliance for Health or Delegate 81462 SO GSAP CLL FR DNA/DNA&RNA Alameda Alliance for Health or Delegate 81479 UNLISTED MOLECULAR PATHOLOGY Alameda Alliance for Health or Delegate 81518 ONC BRST MRNA 11 GENES Alameda Alliance for Health or Delegate 81519 ONCOLOGY BREAST MRNA Alameda Alliance for Health or Delegate 81520 ONC BREAST MRNA 58 GENES Alameda Alliance for Health or Delegate 81521 ONC BREAST MRNA 70 GENES Alameda Alliance for Health or Delegate 81522 ONC BREAST MRNA 12 GENES Alameda Alliance for Health or Delegate 81523 ONC BRST MRNA 70 CNT 31 GENE Alameda Alliance for Health or Delegate 81541 ONC PROSTATE MRNA 46 GENES Alameda Alliance for Health or Delegate 81542 ONC PROSTATE MRNA 22 CNT GEN Alameda Alliance for Health or Delegate 81546 ONC THYR MRNA 10,196 GEN ALG Alameda Alliance for Health or Delegate 81599 UNLISTED MAAA Alameda Alliance for Health or Delegate 89398 UNLISTED REPROD MED LAB PROC Alameda Alliance for Health or Delegate J0222 INJECTION PATISIRAN 0.1 MG Alameda Alliance for Health or Delegate J3399 INJ AVSX-101-XIOI P-TX TO 5X10^15VG Alameda Alliance for Health or Delegate S3620 NEWBORN METABOLIC SCREENING PANEL Alameda Alliance for Health or Delegate Please note: This list does not include all services. Page 4 of 4 PS_CRCMSN, DIALYSIS, GEN TST PROC CODES REQ PA 12/2024