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_HEARING AID/FEEDING SUPPLIES AUTH 11/2021 Important Update: Hearing Aid and Enteral/Parenteral 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 Hearing Aid and Enteral/Parenteral codes that require prior authorization (PA). These codes will require a PA starting Monday, December 13, 2021, and onward. Enclosed with this notice is a code specific list for Hearing Aid and Enteral/Parenteral 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 B4034 ENTERAL FEED SPL KIT; SYRINGE DAY The Alliance or Delegate B4035 ENTERAL FEED SPL KIT; PUMP FED-DAY The Alliance or Delegate B4036 ENTERAL FD SPL KIT; GRAVITY FED-DAY The Alliance or Delegate B4081 NASOGASTRIC TUBING WITH STYLET The Alliance or Delegate B4082 NASOGASTRIC TUBING WITHOUT STYLET The Alliance or Delegate B4083 STOMACH TUBE - LEVINE TYPE The Alliance or Delegate B4087 GASTROSTOMY/J-TUBE STANDARD EACH The Alliance or Delegate B4088 GASTROSTOMY/J-TUBE LOW-PROFILE EA The Alliance or Delegate B4105 IN-LINE CART CTG DIG ENZYME EF EACH The Alliance or Delegate B4164 PARNTRAL NUT SOL; CARBS 50%/< HOM The Alliance or Delegate B4168 PARNTRAL NUT SOL; AMINO ACID 3.5% The Alliance or Delegate B4176 PARNTRAL NUT SOL; AMINO ACID 7-8.5% The Alliance or Delegate B4178 PARNTRAL NUT SOL; AMINO ACID > 8.5% The Alliance or Delegate B4180 PARNTRAL NUT SOL; CARBS > 50% HOM The Alliance or Delegate B4185 PARENTERAL NUTR SOL NOS 10 G LIPIDS The Alliance or Delegate B4216 PARNTRAL NUT; ADDITIVES-HOM MIX-DAY The Alliance or Delegate B9002 ENTERAL NUTR INFUSION PUMP ANY TYPE The Alliance or Delegate B9998 NOC FOR ENTERAL SUPPLIES The Alliance or Delegate B9999 NOC FOR PARENTERAL SUPPLIES The Alliance or Delegate E0776 IV POLE The Alliance or Delegate E0791 PAR INFUS PUMP STAT SINGLE/MXCHANEL The Alliance or Delegate V5010 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5011 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate Enteral Formula and Supplies Hearing Aids ALAMEDA ALLIANCE FOR HEALTH REFERRAL AND PRIOR AUTHORIZATION (PA) PROCEDURE CODES FOR HEARING AID AND ENTERAL/PARENTERAL 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 3 PS_HEARING AID/FEEDING SUPPLY PROC CODES REQ PA 11/2021

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO V5014 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5030 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5040 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5050 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5060 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5120 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5130 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5140 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5150 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5171 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5172 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5181 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5190 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5211 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5212 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5213 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5214 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate Hearing Aids (cont.) Hearing Aids (cont.) Please note: This list does not include all services. Page 2 of 3 PS_HEARING AID/FEEDING SUPPLY PROC CODES REQ PA 11/2021

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO V5215 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5221 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5230 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5264 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5265 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5267 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate V5298 ALL REPAIRS REQUIRES MODIFIER RB/ ALL REPLACEMENTS REQUIRES MODIFIER RR The Alliance or Delegate Please note: This list does not include all services. Page 3 of 3 PS_HEARING AID/FEEDING SUPPLY PROC CODES REQ PA 11/2021