Provider Update: Medical Services Prior Authorization Requirement Changes - 1st Quarter 2020
Date: 02/01/20
Trillium Medicaid/OHP
CHANGES TO MEDICAL SERVICES AND PHYSICIAN ADMINISTERED MEDICATIONS PRIOR AUTHORIZATION REQUIREMENTS
Trillium Community Health Plan (Trillium) is implementing changes to the prior authorization requirements for Oregon Health Plan (OHP) products, as outlined in the tables of the Authorization Requirements. See the table below for all HCPC codes affected by changes in the first quarter of 2020. These codes will require prior authorization for coverage for Trillium OHP members.
Additional information
Providers are encouraged to access Trillium’s provider portal online at https://provider.trilliumhealthplan.com/ for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact the Trillium Provider Services Center at 1-877-600-5472.
PRIOR AUTHORIZATION REQUIREMENT CHANGES
| HCPC Code | Description | Effective Date |
|---|---|---|
0139U | NEURO AUTISM QUAN MEAS 6 CTR CARBON METABOLITES | 3/10/2020 |
0153U | ONC BREAST MRNA GENE EXPRESSION PRFL 101 GENES | 3/10/2020 |
0154U | FGFR3 GENE ANALYSIS | 3/10/2020 |
0155U | PIK3CA GENE ANALYSIS | 3/10/2020 |
0156U | COPY NUMBER SEQUENCE ANALYSIS | 3/10/2020 |
0157U | APC GENE MRNA SEQUENCE ANALYSIS | 3/10/2020 |
0158U | MLH1 GENE MRNA SEQUENCE ANALYSIS | 3/10/2020 |
0159U | MSH2 GENE MRNA SEQUENCE ANALYSIS | 3/10/2020 |
0160U | MSH6 GENE MRNA SEQUENCE ANALYSIS | 3/10/2020 |
0161U | PMS2 GENE MRNA SEQUENCE ANALYSIS | 3/10/2020 |
0162U | HERED COLON CA TARGETED MRNA SEQUENCE ALYS PANEL | 3/10/2020 |
0563T | EVACUATION MEIBOMIAN GLANDS USING HEAT BILATERAL | 3/10/2020 |
0565T | AUTOL CELL IMPLT ADPS TISS HRVG CELL IMPLT CRTJ | 3/10/2020 |
0566T | AUTOL CELL IMPLT ADPS TISS NJX IMPLT KNEE UNI | 3/10/2020 |
0567T | PERM FLP TUB OCCLS W/IMPLANT TRANSCRV APPROACH | 3/10/2020 |
0568T | INTRO MIX SALINE AND AIR F/SSG CONF OCCLS FLP TUBE | 3/10/2020 |
0584T | PERCUTANEOUS ISLET CELL TRANSPLANT | 3/10/2020 |
0585T | LAPAROSCOPIC ISLET CELL TRANSPLANT | 3/10/2020 |
0586T | OPEN ISLET CELL TRANSPLANT | 3/10/2020 |
15769 | GRAFTING OF AUTOLOGOUS SOFT TISS BY DIRECT EXC | 3/10/2020 |
15771 | GRAFTING OF AUTOLOGOUS FAT BY LIPO 50 CC OR LESS | 3/10/2020 |
15772 | GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 50 CC | 3/10/2020 |
15773 | GRAFTING OF AUTOLOGOUS FAT BY LIPO 25 CC OR LESS | 3/10/2020 |
15774 | GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 25 CC | 3/10/2020 |
81277 | CYTOGENOMIC NEOPLASIA MICROARRAY ANALYSIS | 3/10/2020 |
81307 | PALB2 GENE ANALYSIS FULL GENE SEQUENCE | 3/10/2020 |
81308 | PALB2 GENE ANALYSIS KNOWN FAMILIAL VARIANT | 3/10/2020 |
81309 | PIK3CA GENE ANALYSIS TARGETED SEQUENCE ANALYSIS | 3/10/2020 |
81522 | ONCOLOGY BREAST MRNA GENE XPRSN PRFL 12 GENES | 3/10/2020 |
81542 | ONC PRST8 MRNA MICRORA GENE XPRSN PRFL 22 GENES | 3/10/2020 |
81552 | ONC UVEAL MLNMA MRNA GENE XPRSN PRFL 15 GENES | 3/10/2020 |
C9054 | INJECTION LEFAMULIN XENLETA 1 MG | 3/10/2020 |
C9055 | INJECTION BREXANOLONE 1 MG | 3/10/2020 |
C9757 | LAMINOTOMY DECOMP NERVE ROOT 1 INTERSPACE LUMB | 3/10/2020 |
C9758 | BI PROC NYHA CL III/IV HF TRNSCATH IMPL IAS/PC | 3/10/2020 |
J0179 | INJECTION BROLUCIZUMAB-DBLL 1 MG | 3/10/2020 |
J9199 | INJECTION GEMCITABINE HCL INFUGEM 200 MG | 3/10/2020 |
J9309 | INJECTION POLATUZUMAB VEDOTIN-PIIQ 1 MG | 3/10/2020 |
C9041 | INJECTION, COAGULATION FACTOR XA (RECOMBINANT), INACTIVATED (ANDEXXA), 10 MG | 4/1/2020 |
C9046 | COCAINE HYDROCHLORIDE NASAL SOLUTION FOR TOPICAL ADMINISTRATION, 1 MG | 4/1/2020 |
C9047 | INJECTION, CAPLACIZUMAB-YHDP, 1 MG | 4/1/2020 |
J0122 | INJECTION, ERAVACYCLINE, 1 MG | 4/1/2020 |
J0641 | INJECTION, LEVOLEUCOVORIN, 1 MG | 4/1/2020 |
J1095 | INJECTION, DEXAMETHASONE 9%, INTRAOCULAR, 1 MCG | 4/1/2020 |
J1097 | PHENYLEPHRINE 10.16 MG/ML AND KETOROLAC 2.88 MG/ML OPHTHALMIC IRRIGATION SOLUTION, 1 ML | 4/1/2020 |
J1444 | INJECTION, FERRIC PYROPHOSPHATE CITRATE POWDER, 0.1 MG OF IRON | 4/1/2020 |
J2062 | LOXAPINE FOR INHALATION, 1 MG | 4/1/2020 |
J9118 | INJECTION, CALASPARGASE PEGOL-MKNL, 10 UNITS | 4/1/2020 |
J9119 | INJECTION, CEMIPLIMAB-RWLC, 1 MG | 4/1/2020 |
J9313 | INJECTION, MOXETUMOMAB PASUDOTOX-TDFK, 0.01 MG | 4/1/2020 |
Q5110 | FILGRASTIM BIOSIMILAR INJECTION | 4/1/2020 |