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_HOME HEALTH/PALLIATIVE AUTH 11/2021 Important Update: Home Health and Palliative Care Codes That Require Authorization

Alameda Alliance for Health (Alliance) values our dedicated provider partner community. 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 home health and palliative care codes that require prior authorization (PA). These codes will require a PA starting Monday, December 6, 2021, and onward. Enclosed with this notice is a code specific list for Home Health and Palliative Care codes that shows 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 99341 HOME VISIT NEW PATIENT The Alliance or Delegate 99342 HOME VISIT NEW PATIENT The Alliance or Delegate 99343 HOME VISIT NEW PATIENT The Alliance or Delegate 99344 HOME VISIT NEW PATIENT The Alliance or Delegate 99345 HOME VISIT NEW PATIENT The Alliance or Delegate 99347 HOME VISIT EST PATIENT The Alliance or Delegate 99348 HOME VISIT EST PATIENT The Alliance or Delegate 99349 HOME VISIT EST PATIENT The Alliance or Delegate 99350 HOME VISIT EST PATIENT The Alliance or Delegate 99501 HOME VISIT POSTNATAL The Alliance or Delegate 99502 HOME VISIT NB CARE The Alliance or Delegate 99600 HOME VISIT NOS The Alliance or Delegate E0465 HOME VENT ANY TYPE USED INVASV INTF The Alliance or Delegate E0466 HOME VENT TYPE USED NON-INVASV INTF The Alliance or Delegate E0467 HOME VENTILATOR MULTI-FUNC RESP DVC The Alliance or Delegate G0151 SRVC PT HOM HLTH/HOSPICE EA 15 MIN The Alliance or Delegate G0152 SRVC OT HOM HLTH/HOSPICE EA 15 MIN The Alliance or Delegate G0153 SRVC SPCH&LANG PATH HH/HOSPIC EA 15 The Alliance or Delegate G0155 SRVC CLINICAL SW HH/HOSPICE EA 15 The Alliance or Delegate G0156 SRVC HH/HOSPICE AIDE EA 15 MIN The Alliance or Delegate G0162 SKILLED SRVC RN M&E POC; EA 15 MINS The Alliance or Delegate S5110 HOME CARE TRAINING FAM; PER 15 MIN The Alliance or Delegate S5111 HOME CARE TRAINING FAM; PER SESSION The Alliance or Delegate S5130 HOMEMAKER SERVICE NOS; PER 15 MIN The Alliance or Delegate Home Health ALAMEDA ALLIANCE FOR HEALTH REFERRAL AND PRIOR AUTHORIZATION (PA) PROCEDURE CODES FOR HOME HEALTH AND PALLIATIVE CARE 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 2 PS_HH PALLIATIVE CARE PROC CODES REQ PA 11/2021

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 99304 NURSING FACILITY CARE INIT The Alliance or Delegate 99305 NURSING FACILITY CARE INIT The Alliance or Delegate 99306 NURSING FACILITY CARE INIT The Alliance or Delegate 99307 NURSING FAC CARE SUBSEQ The Alliance or Delegate 99334 DOMICIL/R-HOME VISIT EST PAT The Alliance or Delegate 99341 HOME VISIT NEW PATIENT The Alliance or Delegate 99342 HOME VISIT NEW PATIENT The Alliance or Delegate 99343 HOME VISIT NEW PATIENT The Alliance or Delegate 99344 HOME VISIT NEW PATIENT The Alliance or Delegate 99345 HOME VISIT NEW PATIENT The Alliance or Delegate 99347 HOME VISIT EST PATIENT The Alliance or Delegate 99348 HOME VISIT EST PATIENT The Alliance or Delegate 99349 HOME VISIT EST PATIENT The Alliance or Delegate 99350 HOME VISIT EST PATIENT The Alliance or Delegate 99497 ADVNCD CARE PLAN 30 MIN The Alliance or Delegate 99498 ADVNCD CARE PLAN ADDL 30 MIN The Alliance or Delegate Palliative Care Please note: This list does not include all services. Page 2 of 2 PS_HH PALLIATIVE CARE PROC CODES REQ PA 11/2021