UPDATED CODE LIST: Temporary Relaxation of Prior Authorization Requirements for DME, Orthotic, and Enteral/Parenteral Nutrition and Medical Supplies
Date: 09/21/21
Please Note: This article has been updated. Please review the new article for details.
As a reminder, Superior HealthPlan is temporarily relaxing prior authorization requirements for Durable Medical Equipment (DME), Prosthetics, Orthotics, and Supplies for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP members. The temporary relaxation in prior authorization requirements for the group of health-care service categories listed below will be effective for prior authorization requests for service dates July 15, 2021 through December 31, 2021.
The existing authorization requirements for applicable service categories will be reinstated for the provision of these services on and after January 1, 2022 service dates. The temporary relaxation of current prior authorization requirements include the following, effective for prior authorization requests received as of July 15, 2021:
- Increase of the threshold for individual DME items greater than $2,000/ DME item.
- Adoption of a threshold of $2,000/item for the following services:
- Enteral Nutrition Supplies
- Incontinence Supplies
- Medical Supplies
- Orthotics/Prosthetics
- Total Parenteral Nutrition (TPN) Supplies
For the specific Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes for which the relaxation of current prior authorization requirements will be applied for requested service dates between July 15 through December 31, 2021. Please review the listing of impacted codes below, which has been updated from the original notice:
No modification to clinical criteria for the applicable service categories are associated with the relaxation of the dollar threshold for prior authorization of the applicable service categories.
IMPORTANT NOTE: To facilitate the provision and reimbursement of these services on and after January 1, 2022, please refer to the Prior Authorization Requirements posted on Superior’s website for the applicable services. If ongoing receipt of the applicable service(s) is required, please ensure your office requests prior authorization in advance of the applicable service(s) required for your patient in 2022.
For questions or additional information, contact the Utilization Review department at 1-800-218-7508.