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 UMPRVDRINFUSION CODES PA FAXED: 03/08/2024 Important Update: Infusion 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 infusion codes that require prior authorization. This will affect claims with the date(s) of service starting Monday, April 15, 2024, and onward. Enclosed with this notice is a code-specific list of infusion codes that shows which codes require prior authorization. This 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 or 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 in order 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. In addition to the codes, our claims system will also 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 for (enter year) 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 36260 INSERTION OF INFUSION PUMP Alameda Alliance For Health or Delegate A4222 INFUS SPL EXT RX INFUS PUMP CAS/BAG Alameda Alliance For Health or Delegate A4223 INFUS SPL NO EXT INFUS PUMP CAS/BAG Alameda Alliance For Health or Delegate A4224 All inclusive code for pump supplies Alameda Alliance For Health or Delegate A4230 INFUS SET EXT INSULIN PUMP NONNDLE Alameda Alliance For Health or Delegate A4231 INFUS SET EXT INSULIN PUMP NEEDLE Alameda Alliance For Health or Delegate A4232 SYRINGE NDLE EXT INSULIN PUMP STERL Alameda Alliance For Health or Delegate A9900 DME SUP/ACCESS/SRV‐COMPON/OTH HCPCS Alameda Alliance For Health or Delegate E0776 IV POLE Alameda Alliance For Health or Delegate E0779 AMB INFUS PUMP MECH INFUS 8 HR/> Alameda Alliance For Health or Delegate E0780 AMB INFUS PUMP MECH INFUS < 8 HR Alameda Alliance For Health or Delegate E0781 AMB INFUS PUMP 1/MX CHANNL W/ADMIN Alameda Alliance For Health or Delegate E0786 IMPLNT PROGRAM INFUSION PUMP‐REPL Alameda Alliance For Health or Delegate E1399 DME MISCELLANEOUS Alameda Alliance For Health or Delegate G0088 P SVC INI V ADM ANT‐INF PM H EA 15M Alameda Alliance For Health or Delegate G0089 PROF SVC INI V ADM SUB IMT/OTH INF Alameda Alliance For Health or Delegate 96379 UNL THER/PROP/DIAG INJ/INF Alameda Alliance For Health or Delegate K0455 INFUS PUMP UNINTRPT PARNTRAL MED Alameda Alliance For Health or Delegate Q2043 SIPULEUCEL‐T AUTO CD54+ Alameda Alliance For Health or Delegate ALAMEDA ALLIANCE FOR HEALTH REFERRAL AND PRIOR AUTHORIZATION (PA)  PROCEDURE CODES FOR INFUSION 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 Infusion Please note: This list does not include all services. Page 1 of 1 PS_INFUSION PROC CODES REQ PA 03/2024