Service Requiring Prior Authorization

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

This document is intended only to provide information related to which CPT/HCPCs codes require prior authorization. It does not indicate/list codes which may be excluded from coverage or not covered for other reasons. In addition, inclusion on this list indicates, if covered the code would require prior authorization for coverage.

These lists are modified periodically with appropriate notice of these changes consistent with state and federal requirements. Inclusion of a procedure or device code(s) does not constitute or imply coverage nor does it imply or guarantee provider reimbursement. Coverage is determined by the member specific benefit plan document and any applicable laws regarding coverage of specific services. Providers should verify eligibility, benefits and whether prior authorization is required for all members prior to rendering services by contacting Health Plans at the following numbers:

• For Medicaid members: 801-213-4104; Toll Free 833-981-0212
• For Commercial Group members: 801-213-4008; Toll Free 833-981-0213
• For Individual Exchange members: 801-213-4111; Toll Free 833-981-0214
• For Mountain Health Cooperative members: 844-262-1560
• For Carson Tahoe members: 801-213-0150; Toll Free 833-661-3915

For pharmacy services and products, please consult the current upcoming changes to medical, administrative or reimbursement codes requiring prior authorization, please consult the Upcoming Changes to Codes Requiring Prior Authorization list.