Buckeye Community Health Plan Cardiac Utilization Review Matrix 2014 Form

Buckeye Community Health Plan

Buckeye Community Health Plan Cardiac Utilization Review Matrix 2014

Procedures require prior authorization for ALL Buckeye Health Members as of 11/01/2014.

The matrix below contains all of the CPT 4 codes for which NIA Magellan authorizes on behalf of Buckeye Community Health Plan. This matrix is designed to assist in the resolution of claims adjudication and claims questions related to those services authorized by NIA Magellan. If an exam is billed under any one of the given codes for that grouping and a valid authorization number has been issued within the date of service validity period, the charge for any of the codes should be allowed.

If a family of CPT codes is not listed in this matrix, an exact match is required between the authorized CPT code and the billed CPT code. If the exact match does not occur, the charge should be adjudicated accordingly.

*Please note: Services rendered in an Emergency Room, Observation Room, surgery center or hospital inpatient setting do not require prior authorization.

• codes (add on codes) do not require separate authorization and are to be used in conjunction with approved primary code for the service rendered.

1 - Buckeye Community Health Plan 2014 Utilization