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  • If Magellan, “Please complete the prior authorization for this code/service online via the portal by visiting:  https://www.mrxgateway.com/ or by calling 800-424-8243”

 

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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 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12199 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12200 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12201 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12202 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12203 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12204 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12205 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12206 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 PM 2014-01-01 2024-07-01 HCPC E0117 Crutch, Underarm, Articulating, Spring Assisted, E Durable Medical Equipment Over $1000 SHP Prior Authorization Required
12207 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12208 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12209 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12210 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12211 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12212 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12213 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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
12214 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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 08/30/2024 02:12 PM aveak 08/30/2024 02:12 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 08/30/2024 02:12 PM aveak 08/30/2024 02:12 PM 2017-01-01 HCPC S9988 Services Provided As Part Of A Phase I Clinical Tr Clinical Trials SHP Prior Authorization Required
12222 aveak 08/30/2024 02:12 PM aveak 08/30/2024 02:12 PM 2017-01-01 2022-03-31 HCPC L8627 Cochlear Impl Ext Speech Processr Component Replacement Durable Medical Equipment SHP Prior Authorization Required
Effective Termed Code type Code Brand name Code description Prior Auth Category Vendor Action