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wdt_ID wdt_created_by wdt_created_at wdt_last_edited_by wdt_last_edited_at Effective Termed Code type Code Brand name Code description Prior Auth Category Vendor Action
12198 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-03-31 HCPC J0129 Orencia Injection, Abatacept 10 Mg Used Medicare Adm Supv Phys SRx (Specialty Drugs) Magellan Billed with one of the following Places of Service or Types of Bill 01,03,04,05,06,07,08,09,11,12,13,14,15,16,17,18,19,20,22,24,25,26,31,32,33,34,41,42,49,50,51,52,53,54,55,56,57,60,62,65,71,72,81,99,831,137,135,131,132,133,134,138,631,832,833,834,835,837
12199 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-03-31 HCPC J3262 Actemra Injection, Tocilizumab 1 Mg SRx (Specialty Drugs) Magellan Billed with one of the following Places of Service or Types of Bill 01,03,04,05,06,07,08,09,11,12,13,14,15,16,17,18,19,20,22,24,25,26,31,32,33,34,41,42,49,50,51,52,53,54,55,56,57,60,62,65,71,72,81,99,831,137,135,131,132,133,134,138,631,832,833,834,835,837
12200 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-07-01 HCPC E0100 Cane, Includes Canes Of All Materials, Adjustable Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12201 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-07-01 HCPC E0105 Cane, Quad Or Three Prong, Includes Canes Of All M Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12202 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-07-01 HCPC E0110 Crutches, Forearm, Includes Crutches Of Various Ma Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12203 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-07-01 HCPC E0111 Crutch Forearm, Includes Crutches Of Various Mater Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12204 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-07-01 HCPC E0112 Crutches Underarm, Wood, Adjustable Or Fixed, Pair Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12205 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-07-01 HCPC E0113 Crutch Underarm, Wood, Adjustable Or Fixed, Each, Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12206 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-07-01 HCPC E0114 Crutches Underarm, Other Than Wood, Adjustable Or Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12207 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-07-01 HCPC E0116 Crutch Underarm, Other Than Wood, Adjustable Or Fi Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12208 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-07-01 HCPC E0117 Crutch, Underarm, Articulating, Spring Assisted, E Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12209 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-07-01 HCPC E0118 Crutch Substitute, Lower Leg Platform, With Or Wit Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12210 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-07-01 HCPC E0130 Walker, Rigid (Pickup), Adjustable Or Fixed Height Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12211 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-07-01 HCPC E0135 Walker, Folding (Pickup), Adjustable Or Fixed Heig Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12212 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-07-01 HCPC E0140 Walker, With Trunk Support, Adjustable Or Fixed He Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12213 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2014-01-01 2024-07-01 HCPC E0141 Walker, Rigid, Wheeled, Adjustable Or Fixed Height Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12214 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2016-12-02 CPT 0001U Red Blood Cell Antigen Typing, Dna, Human Erythrocyte Antigen Gene Analysis Of 35 Antigens From 11 Blood Groups, Utilizing Whole Blood, Common Rbc Alleles Reported Genetic Testing SHP Prior Authorization Required
12215 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2016-12-02 CPT 0002U Oncology (Colorectal), Quantitative Assessment Of Three Urine Metabolites (Ascorbic Acid, Succinic Acid And Carnitine) By Liquid Chromatography With Tandem Mass Spectrometry (Lc-Ms/Ms) Using Multiple Reaction Monitoring Acquisition, Algorithm Reported As Genetic Testing SHP Prior Authorization Required
12216 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0124 Semi - Psychiatric Behavioral Health Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,891,892,893,894,895,897,861,862,863,864,865,867
12217 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0134 3 & 4 Bed - Psychiatric Behavioral Health Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,891,892,893,894,895,897,861,862,863,864,865,867
12218 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0144 Pvt/Dlx - Psychiatric Behavioral Health Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,891,892,893,894,895,897,861,862,863,864,865,867
12219 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0154 Ward - Psychiatric Behavioral Health Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,891,892,893,894,895,897,861,862,863,864,865,867
12220 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 2020-12-31 REV 1001 Residential Treatment - Psychiatric Behavioral Health Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,891,892,893,894,895,897,861,862,863,864,865,867
12221 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0100 All- Inclusive Room & Board Plus Ancillary Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12222 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0101 All-Inclusive R Andb Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12223 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0110 Pvt - General Classification Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12224 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0111 Pvt - Medical/Surgical/Gyn Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12225 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0112 Pvt - Ob Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12226 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0113 Pvt - Pediatric Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12227 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0117 Pvt - Oncology Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12228 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0119 Pvt - Other Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12229 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0120 Semi - General Classification Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12230 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0121 Semi - Medical/Surgical/Gyn Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12231 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0122 Semi - Ob Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12232 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0123 Semi - Pediatric Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12233 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0127 Semi - Oncology Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12234 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0128 Semi - Rehabilitation Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12235 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0129 Semi - Other Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12236 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0130 3 And 4 Bed - General Classification Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12237 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0131 3 And 4 Bed - Medical/Surgical/Gyn Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12238 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0132 3 And 4 Bed - Ob Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12239 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0133 3 And 4 Bed - Pediatric Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12240 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0137 3 And 4 Bed - Oncology Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12241 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0138 3 And 4 Bed - Rehabilitation Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12242 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0139 3 And 4 Bed - Other Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12243 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0140 Pvt/Dlx - General Classification Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12244 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0141 Pvt/Dlx - Medical/Surgical/Gyn Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12245 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0142 Pvt/Dlx - Ob Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12246 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0143 Pvt/Dlx - Pediatric Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
12247 aveak 07/25/2024 03:16 PM aveak 07/25/2024 03:16 PM 2017-01-01 REV 0147 Pvt/Dlx - Oncology Inpatient Hospital SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
Effective Termed Code type Code Brand name Code description Prior Auth Category Vendor Action