Allwell Prior Authorization Updates
Date: 10/18/19
MHS Health Wisconsin requires prior authorization as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all products offered by MHS Health.
MHS Health is committed to delivering cost effective quality care our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the ordering physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria.
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.
Effective January 1st, 2020, Prior Authorization will be required for the following services:
Procedure Code Prior Auth. Additions | Procedure Description |
31661 | BRONCH THERMOPLSTY 2/> LOBES |
C1813 | PROSTHESIS, PENILE, INFLATABLE |
C1822 | GENERATOR, NEUROSTIMULATOR (IMPLANTABLE, HIGH FREQUENCY, WITH RECHARGEABLE BATT AND CHARGING SYSTEM) |
C2622 | PROSTHESIS, PENILE, NON-INFLATABLE |
J9145 | INJECTION DARATUMUMAB 10 MG (WILL BE ADDED UNDER PART B DRUG LIST) |
J9203 | INJ GEMTUZUMAB OZOGAMICIN 0.1 MG (WILL BE ADDED UNDER PART B DRUG LIST) |
In addition, prior authorization requirements have been updated or removed for the following services:
Procedure Code Prior Auth. Removals | Procedure Description |
40812 | EXC LES-MUCOS/SUBMUCOSA-MOUTH; W/SIMPL REPR |
92611 | MOTION FLUROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CINE OR VIDEO RECORDING |
A4357 | BDSD DRBG DAY/NIGHT W/WO TUB/ANTIREFLUX EACH |
A6550 | DRSSNG SET/NEG PRESS WOUND THRPY ELEC PUMP/STAT OR PORTABLE |
B9002 | ENTERAL NUTR INFUSION PUMP ANY TYPE |
K0001 | STANDARD WHEELCHAIR |
62369 | ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS) WITH REPROGRAMMING AND REFILL. |
2020 Step Therapy Part B Drugs
| |||
| Procedure Code | Procedure Description | Procedure Code | Procedure Description |
C9050 | EMAPALUMAB-LZSG | J2323 | NATALIZUMAB INJECTION |
J0129 | ABATACEPT INJECTION | J2350 | OCRELIZUMAB, 1 MG |
J0178 | AFLIBERCEPT INJECTION | J2353 | OCTREOTIDE INJECTION, DEPOT |
J0584 | BUROSUMAB-TWZA 1M | J2357 | OMALIZUMAB INJECTION |
J0585 | ONABOTULINUMTOXINA | J2503 | PEGAPTANIB SODIUM INJECTION |
J0604 | CINACALCET, ESRD ON DIALYSIS | J2778 | RANIBIZUMAB INJECTION |
J0717 | CERTOLIZUMAB PEGOL INJ 1MG | J3262 | TOCILIZUMAB, 1 MG |
J0800 | CORTICOTROPIN INJECTION | J3304 | TRIAMCINOLONE ACE XR 1MG |
J0897 | DENOSUMAB INJECTION | J3357 | USTEKINUMAB SUB CU 1 MG |
J1300 | ECULIZUMAB INJECTION | J3380 | VEDOLIZUMAB |
J1428 | ETEPLIRSEN, 10 MG | J3396 | VERTEPORFIN INJECTION |
J1459 | IVIG PRIVIGEN 500 MG | J7189 | FACTOR VIIA |
J1555 | CUVITRU, 100 MG | J7318 | DUROLANE 1 MG |
J1556 | IMM GLOB BIVIGAM, 500MG | J7320 | GENVISC 850, 1MG |
J1557 | GAMMAPLEX INJECTION | J7321 | HYALGAN SUPARTZ VISCO-3 DOSE |
J1559 | HIZENTRA INJECTION | J7322 | HYMOVIS INJECTION 1 MG |
J1561 | GAMUNEX-C/GAMMAKED | J7323 | EUFLEXXA INJ PER DOSE |
J1566 | IMMUNE GLOBULIN, POWDER | J7324 | ORTHOVISC INJ PER DOSE |
J1568 | OCTAGAM INJECTION | J7325 | SYNVISC OR SYNVISC-ONE |
J1569 | GAMMAGARD LIQUID INJECTION | J7326 | GEL-ONE |
J1572 | FLEBOGAMMA INJECTION | J7327 | MONOVISC INJ PER DOSE |
J1575 | HYQVIA 100MG IMMUNEGLOBULIN | J7328 | GELSYN-3 INJECTION 0.1 MG |
J1599 | IVIG NON-LYOPHILIZED, NOS | J7329 | TRIVISC 1 MG |
J1602 | GOLIMUMAB FOR IV USE 1MG | J9022 | ATEZOLIZUMAB,10 MG |
J1745 | INFLIXIMAB (REMICADE) | J9145 | INJECTION DARATUMUMAB 10 MG |
J1930 | LANREOTIDE INJECTION | J9173 | DURVALUMAB, 10 MG |
J2323 | NATALIZUMAB INJECTION | J9176 | ELOTUZUMAB, 1MG |
J2350 | OCRELIZUMAB, 1 MG | J9308 | RAMUCIRUMAB |
J2353 | OCTREOTIDE INJECTION, DEPOT | J9311 | RITUXIMAB, HYALURONIDASE |
J2357 | OMALIZUMAB INJECTION | J9355 | TRASTUZUMAB INJECTION |
J2503 | PEGAPTANIB SODIUM INJECTION | Q2043 | SIPULEUCEL-T AUTO CD54+ |
J2778 | RANIBIZUMAB INJECTION | Q5103 | INFLIXIMAB (INFLECTRA) |
J3262 | TOCILIZUMAB, 1 MG | Q5104 | INFLIXIMAB (RENFLEXIS) |
J3304 | TRIAMCINOLONE ACE XR 1MG | J7327 | MONOVISC INJ PER DOSE |
J3357 | USTEKINUMAB SUB CU 1 MG | J7328 | GELSYN-3 INJECTION 0.1 MG |
J3380 | VEDOLIZUMAB | J7329 | TRIVISC 1 MG |
J3396 | VERTEPORFIN INJECTION | J9022 | ATEZOLIZUMAB,10 MG |
J7189 | FACTOR VIIA | J9145 | INJECTION DARATUMUMAB 10 MG |
J7318 | DUROLANE 1 MG | J9173 | DURVALUMAB, 10 MG |
J7320 | GENVISC 850, 1MG | J9176 | ELOTUZUMAB, 1MG |
J7321 | HYALGAN SUPARTZ VISCO-3 DOSE | J9308 | RAMUCIRUMAB |
J7322 | HYMOVIS INJECTION 1 MG | J9311 | RITUXIMAB, HYALURONIDASE |
J7323 | EUFLEXXA INJ PER DOSE | J7325 | SYNVISC OR SYNVISC-ONE |
J7324 | ORTHOVISC INJ PER DOSE | J7326 | GEL-ONE |
All Part B Bio-pharmacy Procedures/Treatments requiring Prior Authorization:
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.
* indicates 2020 Additions. ** indicates 2020 deletions.
Procedure Code | Procedure Description | Procedure Code
| Procedure Description |
C9050 | EMAPALUMAB-LZSG* | J3380 | VEDOLIZUMAB* |
J0129 | ABATACEPT INJECTION* | J3396 | VERTEPORFIN INJECTION |
J0178 | AFLIBERCEPT INJECTION | J7189 | FACTOR VIIA* |
J0584 | BUROSUMAB-TWZA 1M | J7318 | DUROLANE 1 MG* |
J0585 | ONABOTULINUMTOXINA | J7320 | GENVISC 850, 1MG* |
J0604 | CINACALCET, ESRD ON DIALYSIS* | J7321 | HYALGAN SUPARTZ VISCO-3 DOSE* |
J0717 | CERTOLIZUMAB PEGOL INJ 1MG | J7322 | HYMOVIS INJECTION 1 MG* |
J0800 | CORTICOTROPIN INJECTION | J7323 | EUFLEXXA INJ PER DOSE* |
J0897 | DENOSUMAB INJECTION* | J7324 | ORTHOVISC INJ PER DOSE* |
J1300 | ECULIZUMAB INJECTION* | J7325 | SYNVISC OR SYNVISC-ONE* |
J1428 | ETEPLIRSEN, 10 MG | J7326 | GEL-ONE* |
J1459 | IVIG PRIVIGEN 500 MG* | J7327 | MONOVISC INJ PER DOSE* |
J1555 | CUVITRU, 100 MG* | J7328 | GELSYN-3 INJECTION 0.1 MG* |
J1556 | IMM GLOB BIVIGAM, 500MG* | J7329 | TRIVISC 1 MG* |
J1557 | GAMMAPLEX INJECTION* | J9022 | ATEZOLIZUMAB,10 MG* |
J1559 | HIZENTRA INJECTION* | J9145 | INJECTION DARATUMUMAB 10 MG* |
J1561 | GAMUNEX-C/GAMMAKED* | J9173 | DURVALUMAB, 10 MG* |
J1566 | IMMUNE GLOBULIN, POWDER* | J9176 | ELOTUZUMAB, 1MG* |
J1568 | OCTAGAM INJECTION* | J9308 | RAMUCIRUMAB* |
J1569 | GAMMAGARD LIQUID INJECTION* | J9311 | RITUXIMAB, HYALURONIDASE |
J1572 | FLEBOGAMMA INJECTION* | J9355 | TRASTUZUMAB INJECTION* |
J1575 | HYQVIA 100MG IMMUNEGLOBULIN* | Q2041 | AXICABTAGENE CILOLEUCEL CAR+** |
J1599 | IVIG NON-LYOPHILIZED, NOS* | Q2042 | TISAGENLECLEUCEL CAR-POS T** |
J1602 | GOLIMUMAB FOR IV USE 1MG* | Q2043 | SIPULEUCEL-T AUTO CD54+* |
J1745 | INFLIXIMAB (REMICADE) | Q5103 | INFLIXIMAB (INFLECTRA) |
J1930 | LANREOTIDE INJECTION* | Q5104 | INFLIXIMAB (RENFLEXIS) |
J2323 | NATALIZUMAB INJECTION | J2503 | PEGAPTANIB SODIUM INJECTION |
J2350 | OCRELIZUMAB, 1 MG | J2778 | RANIBIZUMAB INJECTION |
J2353 | OCTREOTIDE INJECTION, DEPOT* | J3262 | TOCILIZUMAB, 1 MG |
J2357 | OMALIZUMAB INJECTION* | J3304 | TRIAMCINOLONE ACE XR 1MG* |
A9513 | LUTETIUM LU 177 DOTATAT THER | J3357 | USTEKINUMAB SUB CU 1 MG* |
C9035 | ARISTADA INITIO | J1628 | GUSELKUMAB, 1 MG |
J0490 | BELIMUMAB INJECTION | J1640 | HEMIN, 1 MG |
J0517 | BENRALIZUMAB, 1 MG | J1645 | DALTEPARIN SODIUM |
J0567 | CERLIPONASE ALFA 1 MG | J1652 | FONDAPARINUX SODIUM** |
J0570 | BUPRENORPHINE IMPLANT 74.2MG | J1675 | HISTRELIN ACETATE |
J0586 | ABOBOTULINUMTOXINA | J1743 | IDURSULFASE INJECTION |
J0587 | RIMABOTULINUMTOXINB | J1744 | ICATIBANT INJECTION |
J0588 | INCOBOTULINUMTOXIN A | J1746 | IBALIZUMAB-UIYK, 10 MG |
J0593 | LANADELUMAB-FLYO, 1 MG* | J1786 | IMUGLUCERASE INJECTION |
J0598 | C-1 ESTERASE, CINRYZE | J1817 | INSULIN FOR INSULIN PUMP USE |
J0599 | HAEGARDA 10 UNITS | J1825 | INTERFERON BETA-1A, 33 MCG |
J0606 | ETELCALCETIDE, 0.1 MG | J1931 | LARONIDASE INJECTION |
J0630 | CALCITONIN SALMON INJECTION | J1950 | LEUPROLIDE ACETATE /3.75 MG** |
J0638 | CANAKINUMAB INJECTION | J2170 | MECASERMIN INJECTION |
J0641 | LEVOLEUCOVORIN INJECTION | J2182 | MEPOLIZUMAB, 1MG |
J0718 | CERTOLIZUMAB PEGOL INJ | J2212 | METHYLNALTREXONE INJECTION |
J0775 | COLLAGENASE, CLOST HIST INJ | J2315 | NALTREXONE, DEPOT FORM |
J0881 | DARBEPOETIN ALFA, NON-ESRD | J2326 | NUSINERSEN, 0.1MG |
J0882 | DARBEPOETIN ALFA, ESRD USE** | J2354 | OCTREOTIDE NON-DEPOT** |
J0885 | EPOETIN ALFA, NON-ESRD | J2355 | OPRELVEKIN INJECTION |
J0886 | EPOETIN ALFA 1000 UNITS ESRD | J2440 | PAPAVERIN HCL INJECTION |
J0888 | EPOETIN BETA NON ESRD | J2505 | PEGFILGRASTIM 6MG |
J0894 | DECITABINE INJECTION | J2507 | PEGLOTICASE INJECTION |
J1110 | DIHYDROERGOTAMINE MESYLT** | J2562 | PLERIXAFOR INJECTION |
J1190 | DEXRAZOXANE HCL INJECTION | J2783 | RASBURICASE |
J1301 | EDARAVONE, 1 MG | J2786 | RESLIZUMAB, 1MG |
J1324 | ENFUVIRTIDE INJECTION | J2793 | RILONACEPT INJECTION |
J1438 | ETANERCEPT INJECTION | J2796 | ROMIPLOSTIM INJECTION |
J1439 | FERRIC CARBOXYMALTOS 1MG | J2797 | ROLAPITANT, 0.5 MG |
J1442 | FILGRASTIM EXCL BIOSIMIL | J2820 | SARGRAMOSTIM INJECTION |
J1443 | FERRIC PYROPHOSPHATE CIT | J2840 | SEBELIPASE ALFA 1 MG |
J1447 | TBO FILGRASTIM 1 MICROG | J2940 | SOMATREM INJECTION |
J1454 | FOSNETUPITANT, PALONOSET** | J2941 | SOMATROPIN INJECTION |
J1458 | GALSULFASE INJECTION | J3030 | SUMATRIPTAN SUCCINATE / 6 MG** |
J1562 | VIVAGLOBIN, INJ | J3095 | TELAVANCIN INJECTION |
J1595 | GLATIRAMER ACETATE** | J3110 | TERIPARATIDE INJECTION |
J1610 | GLUCAGON HYDROCHLORIDE/1 MG** | J3111 | ROMOSOZUMAB-AQQG 1 MG* |
J1627 | GRANISETRON, XR, 0.1 MG** | J7208 | JIVI 1 IU |
J3140 | TESTOSTERONE SUSPENSION INJ | J7209 | FACTOR VIII NUWIQ RECOMB 1IU |
J3240 | THYROTROPIN INJECTION | J7311 | FLUOCINOLONE ACETONIDE IMPLT |
J3245 | TILDRAKIZUMAB, 1 MG | J7312 | DEXAMETHASONE INTRA IMPLANT |
J3285 | TREPROSTINIL INJECTION | J7313 | FLUOCINOL ACET INTRAVIT IMP |
J3315 | TRIPTORELIN PAMOATE** | J7314 | YUTIQ, 0.01 MG* |
J3316 | TRIPTORELIN XR 3.75 MG | J7331 | SYNOJOYNT, 1 MG* |
J3385 | VELAGLUCERASE ALFA | J7332 | TRILURON, 1 MG* |
J3397 | VESTRONIDASE ALFA-VJBK | J7401 | MOMETASONE FUROATE SINUS IMP* |
J3398 | LUXTURNA 1 BILLION VEC G | J7518 | MYCOPHENOLIC ACID |
J3591 | ESRD ON DIALYSI DRUG/BIO NOC | J7527 | ORAL EVEROLIMUS |
J7170 | EMICIZUMAB-KXWH 0.5 MG | J7639 | DORNASE ALFA NON-COMP UNIT** |
J7175 | FACTOR X, (HUMAN), 1IU | J7677 | REVEFENACIN INH NON-COM 1MCG |
J7177 | FIBRYGA, 1 MG | J7686 | TREPROSTINIL, NON-COMP UNIT |
J7179 | VONVENDI INJ 1 IU VWF:RCO | J7799 | NON-INHALATION DRUG FOR DME** |
J7180 | FACTOR XIII ANTI-HEM FACTOR | J8501 | ORAL APREPITANT** |
J7181 | FACTOR XIII RECOMB A-SUBUNIT | J8565 | GEFITINIB ORAL |
J7182 | FACTOR VIII RECOMB NOVOEIGHT | J8650 | NABILONE ORAL |
J7183 | WILATE INJECTION | J8705 | TOPOTECAN ORAL |
J7185 | XYNTHA INJ | J9010 | ALEMTUZUMAB INJECTION |
J7186 | ANTIHEMOPHILIC VIII/VWF COMP | J9015 | ALDESLEUKIN INJECTION |
J7187 | HUMATE-P, INJ | J9017 | ARSENIC TRIOXIDE INJECTION |
J7188 | FACTOR VIII RECOMB OBIZUR | J9019 | ERWINAZE INJECTION |
J7190 | FACTOR VIII | J9023 | AVELUMAB, 10 MG |
J7191 | FACTOR VIII (PORCINE) | J9025 | AZACITIDINE INJECTION** |
J7192 | FACTOR VIII RECOMBINANT NOS | J9027 | CLOFARABINE INJECTION |
J7193 | FACTOR IX NON-RECOMBINANT | J9030 | BCG LIVE INTRAVESICAL 1MG** |
J7194 | FACTOR IX COMPLEX | J9034 | BENDEKA 1 MG |
J7195 | FACTOR IX RECOMBINANT NOS | J9035 | BEVACIZUMAB INJECTION** |
J7196 | ANTITHROMBIN RECOMBINANT | J9036 | BELRAPZO/BENDAMUSTINE |
J7197 | ANTITHROMBIN III INJECTION | J9039 | BLINATUMOMAB |
J7198 | ANTI-INHIBITOR | J9041 | VELCADE 0.1 MG |
J7199 | HEMOPHILIA CLOT FACTOR NOC | J9042 | BRENTUXIMAB VEDOTIN INJ |
J7200 | FACTOR IX RECOMBINAN RIXUBIS | J9043 | CABAZITAXEL INJECTION |
J7201 | FACTOR IX ALPROLIX RECOMB | J9044 | BORTEZOMIB, NOS, 0.1 MG |
J7202 | FACTOR IX IDELVION INJ | J9047 | CARFILZOMIB, 1 MG |
J7203 | FACTOR IX RECOMB GLY REBINYN | J9055 | CETUXIMAB INJECTION |
J7207 | FACTOR VIII PEGYLATED RECOMB | Q0162 | ONDANSETRON ORAL** |
J9057 | COPANLISIB, 1 MG | Q0515 | SERMORELIN ACETATE INJECTION |
J9118 | CALASPARGASE PEGOL-MKNL* | Q2026 | RADIESSE INJECTION |
J9153 | DAUNORUBICIN, CYTARABINE | Q2027 | SCULPTRA INJECTION |
J9203 | INJ GEMTUZUMAB OZOGAMICIN 0.1 MG* | Q2028 | SCULPTRA, 0.5MG |
J9205 | IRINOTECAN LIPOSOME 1 MG | Q2040 | TISAGENLECLEUCEL CAR-POS T** |
J9212 | INTERFERON ALFACON-1 INJ | Q2044 | BELIMUMAB INJECTION |
J9213 | INTERFERON ALFA-2A INJ | Q2050 | DOXORUBICIN INJ 10MG |
J9214 | INTERFERON ALFA-2B INJ** | Q3025 | IM INJ INTERFERON BETA 1-A |
J9215 | INTERFERON ALFA-N3 INJ | Q3026 | SUBC INJ INTERFERON BETA-1A |
J9216 | INTERFERON GAMMA 1-B INJ | Q3027 | BETA INTERFERON IM 1 MCG |
J9217 | LEUPROLIDE ACETATE SUSPNSION** | Q4074 | ILOPROST NON-COMP UNIT DOSE |
J9218 | LEUPROLIDE ACETATE INJECTION** | Q5107 | MVASI 10 MG |
J9225 | VANTAS IMPLANT | Q5108 | FULPHILA |
J9226 | SUPPRELIN LA IMPLANT | Q5109 | IXIFI, 10 MG |
J9228 | IPILIMUMAB INJECTION | Q5111 | UDENYCA 0.5 MG |
J9229 | INOTUZUMAB OZOGAM 0.1 MG | Q5112 | ONTRUZANT 10 MG* |
J9261 | NELARABINE INJECTION | Q5113 | HERZUMA 10 MG* |
J9262 | OMACETAXINE MEP, 0.01MG | Q5114 | OGIVRI 10 MG* |
J9264 | PACLITAXEL PROTEIN BOUND | Q5115 | TRUXIMA 10 MG |
J9266 | PEGASPARGASE INJECTION | Q5116 | TRAZIMERA 10 MG* |
J9271 | PEMBROLIZUMAB | Q5117 | KANJINTI 10 MG* |
J9280 | MITOMYCIN INJECTION** | Q9991 | BUPRENORPH XR 100 MG OR LESS |
J9285 | OLARATUMAB, 10 MG | Q9992 | BUPRENORPHINE XR OVER 100 MG |
J9299 | NIVOLUMAB | S0145 | PEG INTERFERON ALFA-2A/180 |
J9301 | OBINUTUZUMAB INJ | S0162 | EFALIZUMAB, 125 MG |
J9303 | PANITUMUMAB INJECTION | J9354 | ADO-TRASTUZUMAB EMT 1MG |
J9305 | PEMETREXED INJECTION | J9356 | HERCEPTIN HYLECTA, 10MG* |
J9306 | PERTUZUMAB, 1 MG | J9395 | FULVESTRANT |
J9310 | RITUXIMAB INJECTION | J9400 | ZIV-AFLIBERCEPT, 1MG |
J9312 | RITUXIMAB, 10 MG | J9999 | CHEMOTHERAPY DRUG |
J9352 | TRABECTEDIN 0.1MG | Q0138 | FERUMOXYTOL, NON-ESRD |
Please refer to the link below for guidance regarding how to obtain prior authorizations from MHS Health.
https://www.mhswi.com/providers/preauth-check/medicare-pre-auth.html
FREQUENTLY ASKED QUESTIONS:
How do I determine if a specific treatment requires prior authorization?
- You may determine which specific codes require prior authorization by visiting our website at https://www.mhswi.com/providers.html and clicking on the Pre-Auth Check tab. The Pre-Auth Check tab will take you to our PreScreen Tool. Just enter the CPT code and the PreScreen Tool will advise you whether the service requires prior authorization.
How do I request a prior authorization for these services?
- You may submit the prior authorization request utilizing our Secure Web Portal at https://provider.mhswi.com. If your request approved, you will receive verification through the Secure Web Portal. If you are not currently registered on our Secure Web Portal, you may register through a quick and simple process.
- You may submit the prior authorization request by faxing an authorization to 1-877-687-1183. The fax authorization form can be found on our website at https://www.mhswi.com/providers/preauth-check/medicare-pre-auth.html.
- If you have questions, call our Provider Services at 1-877-935-8024.
What information will I be required to submit in connection with the prior authorization request?
- CPT code
- Member information
- Diagnosis Code
- Rendering facility’s name and information
- Ordering provider information
- Related/pertinent member clinical information
If you have any questions regarding this information, you may contact Provider Services at 1-877-935-8024 or contact your dedicated Provider Relations Specialist.