clover 2020 prior authorization list - updated 8 2020 r · 8/1/2020 · clover health prior...

Clover Health Prior Authorization List 2020

Effective Date: August 1, 2020

Prior Authorization (also referred to as precertification, pre-admission or pre-authorization) is a process where a physician or healthcare provider is required to obtain advanced approval from Clover Utilization Management prior to providing certain services, medications, treatments or items. Emergency services never require an authorization.

Clover uses a vendor for some Prior Authorization reviews. Clover’s simple Prior Authorization online tool, with the links below, will direct you to the appropriate place to submit an auth request.

Prior Authorization LINK

Create a Prior Authorization Request Prior Auth Online Link

Check to see if a Prior Authorization is Required Prior Auth Online Lookup

Get the Status of a Prior Authorization you submitted Prior Auth Status Link

Request to Change or update an existing Prior Authorization

(NOTE: if a determination on the auth request has already been completed, a change or update may not be allowed)

Prior Auth Change Request

Questions? Call Clover Health’s Utilization Management Department 1-888-995-1690 Monday - Friday 8:00 am - 5:00 pm local time (except holidays and weekends) 1

https://www.cloverhealth.com/en/pre-auth-request


https://www.cloverhealth.com/en/pre-auth-status-check

https://www.cloverhealth.com/en/providers/provider-tools/provider-support/prior-authorization-change-request


**NOTE: This is not an all inclusive list of the codes requiring a Prior Authorization. Please use the Clover Prior Auth Online Lookup to determine if an auth is required and where to submit the authorization request.

CLOVER HEALTH Prior Authorization List 2020

Category CODES

Acute Rehabilitation

Acute Rehabilitation

Acute Rehabilitation Inpatient Rehabilitation Facility

*Requires Prior Authorization Prior Auth Online Link

Ambulance Ambulance Codes Not an all inclusive list - Auth Lookup Link

Ambulance (Non-emergency)

A0426 A0428 A0430 A0431 A0432 A0434 A0436 A0999

Cardiology Cardiology Codes Not an all inclusive list - Auth Lookup Link

Cardiology -Cardiac Devices

33206 33207 33208 33212 33213 33214 33221 33224 33227 33228 33229 33230 33231 33240 33249 33262 33263 33264 33270 33274 33275

Cardiology -Cardiac Procedure /

Surgeries

93451 93452 93453 93454 93455 93456 93457 93458 93459 93460 93461 93530 93531 93532 93533 C8921 C8922 C8923 C8924 C8925 C8926 C8928 C8929 C8930







Cardiology -Cardiac Diagnostic

Testing

78451 78452 78453 78454 78466 78468 78469 78472 78473 78481 78483 78494 93303 93304 93307 93308 93312 93313 93314 93315 93316 93317 93350

Cardiology - Other 0501T 0503T 0504T 0515T 0516T 0517T 0519T 0520T 33289 0571T 0572T 33225 0439T 0502T 93306 93320 93321 93325 93351 93352 93356 93462

Diagnostic Imaging Diagnostic Imaging Codes

Not an all inclusive list - Auth Lookup Link

Diagnostic Imaging CT Scan / PET scan / X ray

70450 70460 70470 70480 70481 70482 70486 70487 70488 70490 70491 70492 70496 70498 71250 71260 71270 71275 72125 72126 72127 72128 72129 72130 72131 72132 72133 72191 72192 72193 72194 73200 73201 73202 73206 73700 73701 73702 73706 74150 74160 74170 74174 74175 74176 74177 74178 74261 74262 75571 75572 75573 75574 75635 76380 G0297 0042T 74263 76497 77078 78459 78491 78492 78608 78811 78812 78813 78814 78815 78816 78429 78430 78431 78432 78433 78609 G0219 G0235 G0252

Diagnostic Imaging MRI / MRA

70544 70545 70546 70547 70548 70549 71555 72159 72198 73225 73725 74185 70336 70540 70542 70543 70551 70552 70553 70554 70555 71550 71551 71552 72141 72142 72146 72147 72148 72149 72156 72157 72158 72195 72196 72197 73218 73219 73220 73221 73222 73223 73718 73719 73720 73721 73722 73723 74181 74182 74183 74712 75557 75559 75561 75563 77046 77047 77048 77049 77084 74713 75565 76390 76391 76498 77021 77022 C8900 C8901 C8902 C8903 C8905 C8906 C8908 C8909 C8910 C8911 C8912 C8913 C8914 C8918 C8919 C8920 C8931 C8932 C8933 C8934 C8935 C8936

Diagnostic Imaging Doppler / Ultrasound / Other

93886 93888 93890 93892 93893 0422T 0470T 0487T 93880 93882 93970 93971 93980 93981 0331T 78012 78013 78014 78015 78016 78018 78020 78070 78071 78072 78075 78102 78103 78104 78185 78195 78201 78202 78215 78216 78226 78227 78230 78231 78232 78258 78261 78262 78264 78265 78266 78278 78290 78291 78300 78305 78306 78315 78414 78428 78434 78445 78456 78457 78458 78496 78499 78579 78580 78582 78597 78598 78600 78601 78605 78606 78610 78630 78635 78645 78650 78660 78700 78701 78707 78708 78709 78725 78730




78740 78761 78800 78801 78802 78803 78804 78830 78831 78832 78999 78699

DME DME Codes Not an all inclusive list - Auth Lookup Link

DME Oxygen / CPAP / Nebulizers

E0424 E0570 E0574 E0575 E0580 E0585 E1372 E0433 E0441 E0442 E0444 E0455 E0472 E0600 E1352 E1353 E1354 E1355 E1356 E1357 E1358 E1390 E1391 E1392 E1405 E1406 K0738 K0739 E0601 E0470 E0471 E0446

DME Prosthetics and Orthotics

L0113 L0120 L0130 L0140 L0150 L0160 L0170 L0180 L0190 L0200 L0220 L0450 L0454 L0455 L0456 L0457 L0458 L0460 L0466 L0467 L0468 L0469 L0470 L0472 L0488 L0490 L0491 L0492 L0621 L0623 L0625 L0626 L0627 L0628 L0630 L0631 L0633 L0634 L0635 L0637 L0639 L0640 L0641 L0642 L0643 L0648 L0649 L0861 L0970 L0972 L0974 L0976 L0980 L0982 L0984 L1001 L1010 L1020 L1025 L1030 L1040 L1050 L1060 L1070 L1080 L1085 L1090 L1100 L1110 L1120 L1210 L1220 L1230 L1240 L1250 L1260 L1270 L1280 L1290 L1310 L1600 L1610 L1620 L1630 L1640 L1650 L1652 L1660 L1686 L1690 L1810 L1812 L1820 L1830 L1831 L1832 L1833 L1834 L1836 L1840 L1843 L1845 L1846 L1847 L1848 L1850 L1851 L1852 L1860 L1900 L1902 L1904 L1906 L1907 L1910 L1920 L1930 L1932 L1940 L1945 L1950 L1951 L1960 L1970 L1971 L1980 L1990 L2035 L2040 L2050 L2060 L2070 L2080 L2090 L2108 L2134 L2136 L2180 L2182 L2184 L2186 L2188 L2190 L2192 L2200 L2210 L2220 L2230 L2232 L2240 L2250 L2260 L2265 L2270 L2275 L2280 L2300 L2310 L2320 L2330 L2335 L2340 L2360 L2370 L2375 L2380 L2385 L2387 L2390 L2395 L2405 L2415 L2425 L2430 L2492 L2500 L2525 L2530 L2540 L2550 L2570 L2580 L2600 L2610 L2620 L2622 L2624 L2627 L2628 L2630 L2640 L2650 L2660 L2670 L2680 L2750 L2755 L2760 L2768 L2780 L2785 L2795 L2800 L2810 L2820 L2830 L2840 L2850 L3000 L3001 L3002 L3003 L3010 L3020 L3031 L3040 L3050 L3060 L3070 L3080 L3090 L3100 L3140 L3150 L3160 L3170 L3201 L3202 L3203 L3204 L3206 L3207 L3208 L3209 L3211 L3212 L3213 L3214 L3224 L3225 L3230 L3250 L3251 L3253 L3254 L3255 L3257 L3265 L3300 L3310 L3320 L3330 L3332 L3334 L3340 L3350 L3360 L3370 L3380 L3390 L3400 L3410 L3420 L3430 L3440 L3450 L3455 L3460 L3465 L3470 L3480 L3485 L3500 L3510 L3520 L3530 L3540 L3550 L3560 L3570 L3580 L3590 L3595 L3600 L3610 L3620 L3630 L3640 L3650 L3671 L3677 L3678 L3702 L3710 L3720 L3730 L3760 L3761 L3762 L3763 L3764 L3806 L3807 L3808 L3809 L3900 L3901 L3906 L3908 L3912 L3913 L3915 L3916 L3917 L3918 L3919 L3921 L3923 L3924 L3925 L3927 L3929 L3930 L3931 L3933 L3935 L3956 L3960 L3962 L3980 L3981 L3982 L3984 L3995 L4000 L4002 L4010 L4020 L4030 L4040 L4045 L4050 L4055 L4060 L4070 L4080 L4090 L4100 L4110 L4130 L4205 L4210 L4350 L4360 L4361 L4370 L4392 L4394 L4396 L4397 L4398 L4631 L5639




L5684 L5685 L5686 L5688 L5690 L5960 L5961 L5966 L5968 L5973 L5988 L5990 L6000 L6010 L6020 L6026 L6050 L6055 L6100 L6110 L6120 L6130 L6200 L6205 L6250 L6300 L6310 L6320 L6350 L6360 L6370 L6400 L6450 L6500 L6550 L6570 L6580 L6582 L6584 L6586 L6588 L6590 L6600 L6605 L6610 L6611 L6615 L6616 L6620 L6621 L6623 L6624 L6625 L6628 L6629 L6630 L6632 L6635 L6637 L6638 L6640 L6641 L6642 L6645 L6646 L6647 L6648 L6650 L6655 L6660 L6665 L6670 L6672 L6675 L6676 L6677 L6680 L6682 L6684 L6686 L6687 L6688 L6689 L6690 L6691 L6692 L6693 L6694 L6695 L6696 L6697 L6698 L6703 L6704 L6706 L6707 L6708 L6709 L6711 L6805 L6810 L6882 L6883 L6884 L6885 L6890 L6895 L6900 L6905 L6910 L6915 L6920 L6930 L6940 L6950 L6960 L6970 L7007 L7009 L7040 L7400 L7401 L7402 L7403 L7404 L7405 L7510 L7520 L7700 L8000 L8001 L8002 L8010 L8015 L8020 L8030 L8031 L8032 L8035 L8040 L8041 L8042 L8043 L8044 L8045 L8046 L8047 L8049 L8614 L8619 L8681 L8683 L8684 L8689 L8695 L8701 L8702 L0112 L0452 L0462 L0464 L0480 L0482 L0484 L0486 L0622 L0624 L0629 L0632 L0636 L0638 L0650 L0651 L0700 L0710 L0810 L0820 L0830 L0859 L0999 L1000 L1005 L1200 L1300 L1499 L1680 L1685 L1700 L1710 L1720 L1730 L1755 L1844 L2000 L2005 L2010 L2020 L2030 L2034 L2036 L2037 L2038 L2126 L2128 L2350 L2510 L2520 L2526 L2999 L3649 L3674 L3740 L3765 L3766 L3904 L3905 L3961 L3967 L3971 L3973 L3975 L3976 L3977 L3978 L3999 L5000 L5010 L5020 L5050 L5060 L5100 L5105 L5150 L5160 L5200 L5210 L5220 L5230 L5250 L5270 L5280 L5301 L5312 L5321 L5331 L5341 L5400 L5410 L5420 L5430 L5450 L5460 L5500 L5505 L5510 L5520 L5530 L5535 L5540 L5560 L5570 L5580 L5585 L5590 L5595 L5600 L5610 L5611 L5613 L5614 L5616 L5617 L5618 L5620 L5622 L5624 L5626 L5628 L5629 L5630 L5631 L5632 L5634 L5636 L5637 L5638 L5640 L5642 L5643 L5644 L5645 L5646 L5647 L5648 L5649 L5650 L5651 L5652 L5653 L5654 L5655 L5656 L5658 L5661 L5665 L5666 L5668 L5670 L5671 L5672 L5673 L5676 L5677 L5678 L5679 L5680 L5681 L5682 L5683 L5692 L5694 L5695 L5696 L5697 L5698 L5699 L5700 L5701 L5702 L5703 L5704 L5705 L5706 L5707 L5710 L5711 L5712 L5714 L5716 L5718 L5722 L5724 L5726 L5728 L5780 L5781 L5782 L5785 L5790 L5795 L5810 L5811 L5812 L5814 L5816 L5818 L5822 L5824 L5826 L5828 L5830 L5840 L5845 L5848 L5850 L5855 L5856 L5857 L5858 L5859 L5910 L5920 L5925 L5930 L5940 L5950 L5962 L5964 L5969 L5970 L5971 L5972 L5974 L5975 L5976 L5978 L5979 L5980 L5981 L5982 L5984 L5985 L5986 L5987 L5999 L6712 L6713 L6714 L6715 L6721 L6722 L6880 L6881 L6925 L6935 L6945 L6955 L6965 L6975 L7008 L7045 L7170 L7180 L7181 L7185 L7186 L7190 L7191 L7259 L7499 L8039 L8048 L8400 L8410 L8415 L8417 L8420 L8430 L8435 L8440 L8460 L8465 L8470 L8480 L8485 L8500 L8501 L8505 L8507 L8509 L8510 L8511 L8512 L8513 L8514 L8515 L8696 L8698 L8699



DME Wheelchair / Mobility

E0110 E0111 E0112 E0113 E0114 E0116 E0117 E0130 E0135 E0140 E0141 E0144 E0147 E0148 E0149 97542 E0100 E0105 E0143 E0950 E0955 E0956 E0957 E0958 E0959 E0960 E0961 E0966 E0967 E0968 E0969 E0971 E0973 E0974 E0978 E0980 E0981 E0982 E0985 E0990 E0992 E0995 E1009 E1011 E1014 E1015 E1016 E1017 E1018 E1020 E1028 E1029 E1037 E1038 E1039 E1050 E1060 E1070 E1083 E1084 E1087 E1088 E1092 E1093 E1100 E1110 E1150 E1160 E1170 E1171 E1172 E1180 E1190 E1195 E1200 E1220 E1221 E1222 E1223 E1224 E1225 E1226 E1227 E1228 E1231 E1240 E1270 E1295 E1296 E1297 E1298 E2201 E2202 E2203 E2204 E2205 E2206 E2207 E2208 E2210 E2211 E2212 E2213 E2214 E2215 E2216 E2217 E2218 E2219 E2220 E2221 E2222 E2224 E2225 E2226 E2227 E2228 E2230 E2231 E2291 E2292 E2293 E2294 E2295 E2300 E2301 E2312 E2322 E2325 E2327 E2328 E2329 E2365 E2366 E2601 E2602 E2603 E2604 E2605 E2606 E2607 E2608 E2609 E2610 E2611 E2612 E2613 E2614 E2615 E2616 E2617 E2619 E2620 E2621 E2622 E2623 E2624 E2625 E2626 E2627 E2628 E2629 E2630 E2631 E2632 E2633 G9156 K0001 K0002 K0003 K0004 K0005 K0006 K0007 K0008 K0009 K0056 K0098 K0108 K0669 K0800 K0816 K0822 E0983 E0984 E0986 E0988 E1002 E1003 E1004 E1005 E1006 E1007 E1008 E1010 E1012 E1030 E1161 E1229 E1230 E1232 E1233 E1234 E1235 E1236 E1237 E1238 E1239 E1280 E2310 E2311 E2313 E2321 E2323 E2324 E2326 E2330 E2331 E2340 E2341 E2342 E2343 E2351 E2358 E2359 E2360 E2361 E2362 E2363 E2364 E2367 E2368 E2369 E2370 E2371 E2372 E2373 E2374 E2375 E2376 E2377 E2378 E2381 E2382 E2383 E2384 E2385 E2386 E2387 E2388 E2389 E2390 E2391 E2392 E2394 E2395 E2396 E2397 K0010 K0011 K0012 K0013 K0014 K0733 K0801 K0802 K0806 K0807 K0808 K0812 K0813 K0814 K0815 K0820 K0821 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0830 K0831 K0835 K0836 K0837 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0864 K0868 K0869 K0870 K0871 K0877 K0878 K0879 K0880 K0884 K0885 K0886 K0890 K0891 K0898 K0899

B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155



DME Infusion Pump / Feeding Supplies

B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155



B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455 B4034 B4036 B4102 B4103 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9002 B9006 B9998 B9999 E0779 E0780 E0781 E0782 E0783 E0784 E0785 E0786 K0552 K0601 K0602 K0603 K0604 K0605 E0791 K0455

DME Wound Dressing / Wound Therapy

97605 97606 97607 97608 K0744 K0745 E0769 E2402 K0743

DME Medical and Surgical

99070 A5500 A5501 A5503 A5504 A5505 A5506 A5508 A5512 A5513 A5514 A6513 A7002 A7016 A7017 A8000 A8001 A8002 A8003 A8004 A9285 Q0477 Q0478 Q0485 Q0486 Q0487 Q0488 Q0490 Q0491 Q0492 Q0493 Q0494 Q0495



Supplies Q0496 Q0497 Q0498 Q0499 Q0500 Q0501 Q0502 Q0503 Q0504 Q0506 Q0507 Q0508 Q0509 A7027 A7028 A7029 A7044 A4575 A5507 A7000 A9527 A9900 A9999

DME Bedding / Other

E0181 E0184 E0185 E0186 E0187 E0196 E0197 E0198 E0199 E0250 E0251 E0255 E0256 E0260 E0271 E0272 E0277 E0280 E0290 E0291 E0292 E0293 E0295 E0301 E0302 E0303 E0304 E0371 E0372 E0373 E0305 E0310 97760 B4081 B4082 B4083 B4087 B4088 E0160 E0161 E0162 E0163 E0165 E0168 E0171 E0188 E0189 E0191 E0200 E0202 E0205 E0210 E0215 E0217 E0218 E0221 E0225 E0235 E0236 E0239 E0249 E0275 E0276 E0316 E0325 E0326 E0565 E0572 E0602 E0604 E0605 E0606 E0610 E0615 E0617 E0618 E0619 E0620 E0621 E0627 E0629 E0630 E0635 E0650 E0672 E0673 E0705 E0740 E0744 E0766 E0776 E0840 E0849 E0850 E0855 E0856 E0860 E0890 E0910 E0911 E0912 E0935 E0940 E0941 E0942 E0944 E0945 E0951 E0952 E0953 E0954 E0994 E1031 E1399 E1700 E1701 E1702 E1800 E1801 E1802 E1805 E1806 E1810 E1811 E1812 E1815 E1816 E1818 E1820 E1821 E1825 E1830 E1831 E1840 E1841 E2209 K0015 K0017 K0018 K0019 K0020 K0037 K0038 K0039 K0040 K0041 K0042 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0052 K0053 K0065 K0069 K0070 K0071 K0072 K0073 K0077 K0105 K0195 K0553 K0554 Q0479 Q0480 Q0481 Q0482 Q0483 Q0484 Q0489 E0485 E0486 E0561 E0562 E0748 E0749 E0194 E0261 E0265 E0266 E0294 E0296 E0297 E0328 E0329 E0170 E0193 E0300 E0462 E0465 E0466 E0467 E0483 E0500 E0636 E0651 E0652 E0655 E0656 E0657 E0660 E0665 E0666 E0667 E0668 E0669 E0670 E0671 E0675 E0676 E0691 E0692 E0693 E0694 E0720 E0730 E0731 E0745 E0747 E0760 E0762 E0764 E0765 E0770 E1035 E1036 E1310 E2500 E2502 E2504 E2506 E2508 E2510 E2511 E2512 E2599 K0730

Gastrointestinal Gastrointestinal Codes


Gastrointestinal

ERCP / Esophagoscopy / Laparoscopy

43260 43261 43262 43263 43264 43265 43210 43236 43240 43248 43252 43257 43266 43270 43193 43197 43198 43201 43202 43204 43205 43206 43211 43212 43213 43214 43216 43217 43226 43280 43647 43648 43770 43772 43773 43774 49652 49653 49655 49656 49657

42820 42821 42825 42826 42830 42831 42835 42836 45378 40510 40520 40525 40527 40816 40819 41114 41115 41823 41828 42107 0312T 0313T 0314T 0315T 0316T 0317T 0355T 40500 40530 40806 41010 41019 41512




Gastrointestinal Other

41530 41820 41821 41830 41850 41870 41872 42140 42227 42950 43886 43887 43888 44340 46505 46601 46607 49411 49419 91010 91020 91022 91034 91040 91065 91110 91111 91112 91117 91120 91122 91132 91133 91200 42145 42200 42205 42210 42215 42220 42225 40650 40652 40654 40700 40701 40702 40720 40761 42235 46707 49560 49561 49565 49566 46750 46760 46761 92613 40899 41899 42299 43289 43499 43659 43999 44238 44799 45399 45499 45999 46999 47399 47579 48999 49999 91299 40840 40842 40843 40844 40845 47380

Home Health Home Health


Home Health G0151 G0152 G0153 G0155 G0156 G0157 G0158 G0159 G0160 G0161 G0162 G0299 G0300 G0493 G0494 G0495 G0496 Q5001

Inpatient Hospitalization (Acute Stays)

Inpatient Hospital (Acute Stays)

Inpatient Hospitalization (Acute Stays)


Integumentary Integumentary


Integumentary

0479T 11200 11762 11920 11921 11950 11951 11952 11954 11960 11970 11971 11980 11981 11982 11983 14350 15050 15100 15120 15271 15273 15275 15277 15570 15572 15574 15576 15600 15610 15620 15630 15650 15730 15731 15733 15734 15736 15738 15740 15750 15760 15775 15776 15780 15781 15782 15783 15786 15788 15789 15792 15793 15819 15820 15821 15822 15823 15824 15825 15826 15828 15829 15830 15832 15833 15834 15835 15836 15837 15838 15839 15840 15841 15842 15845 15876 15877 15878 15879 17106 17107 17108 17266 17276 17286 17311 17313 17340 17360 17380 19105 19296 19298 19316 19318 19324 19325 19328 19330 19340 19342 19350 19355 19357 19366 19370 19371 19380 19396 96920 96921 96922 96931 96932 96933 17999 19499 96999

Questions? Call Clover Health’s Utilization Management Department 1-888-995-1690 Monday - Friday 8:00 am - 5:00 pm local time (except holidays and weekends)

10





Lab Lab


Lab Genetic Testing

81105 81106 81107 81108 81109 81110 81111 81112 81120 81121 81161 81162 81170 81175 81176 81200 81201 81202 81203 81205 81206 81207 81208 81209 81210 81212 81215 81216 81217 81218 81219 81220 81221 81222 81223 81224 81225 81226 81227 81228 81229 81230 81231 81232 81235 81238 81240 81241 81242 81243 81244 81245 81246 81247 81248 81249 81250 81251 81252 81253 81254 81255 81256 81257 81258 81259 81260 81261 81262 81263 81264 81265 81266 81267 81268 81269 81270 81272 81273 81275 81276 81283 81287 81288 81290 81291 81292 81293 81294 81295 81296 81297 81298 81299 81300 81301 81302 81303 81304 81310 81311 81313 81314 81315 81316 81317 81318 81319 81321 81322 81323 81324 81325 81326 81327 81328 81330 81331 81332 81334 81335 81340 81341 81342 81346 81350 81355 81361 81362 81363 81364 81370 81371 81372 81373 81374 81375 81376 81377 81378 81379 81380 81381 81382 81383 81400 81401 81402 81403 81404 81405 81406 81407 81408 81410 81411 81412 81413 81414 81415 81416 81417 81420 81422 81425 81426 81427 81430 81431 81432 81433 81434 81435 81436 81437 81438 81439 81440 81442 81445 81448 81450 81455 81460 81465 81470 81471 81490 81493 81503 81504 81507 81519 81520 81521 81525 81528 81535 81536 81538 81539 81540 81541 81545

Lab Other

0004M 0012U 0013U 0014U 0019U 0022U 0023U 0029U 0030U 0031U 0032U 0033U 0034U 0036U 0037U 0045U 0047U 0048U 0050U 0053U 0055U 0056U 0067U 0069U 0070U 0078U G0452 P2028 P2029 P2033 P2038 P9020 0006M 0007M

Long Term Acute Hospitalization

Long Term Acute Hospitalization

Long Term Acute Hospitalization Inpatient



11




Musculoskeletal Musculoskeletal


Musculoskeletal Joint Procedures

23000 23020 27332 27333 27334 27335 27430 29826 23120 23130 23410 23412 23415 23420 23430 23440 23450 23455 23460 23462 23465 23466 23470 23472 23473 23474 27125 27130 27132 27134 27137 27138 27403 27412 27415 27416 27418 27420 27422 27424 27425 27427 27428 27429 27438 27440 27441 27442 27443 27446 27447 27486 27487 29805 29806 29807 29819 29820 29821 29822 29823 29824 29825 29827 29828 29860 29861 29862 29863 29866 29867 29868 29870 29871 29873 29874 29875 29876 29877 29879 29880 29881 29882 29883 29884 29885 29886 29887 29888 29889 29914 29915 29916

Musculoskeletal Spine Procedures

20974 22510 22511 22513 22514 22533 22551 22554 22558 22595 22600 22612 22630 22633 22856 22857 22861 22862 22867 22869 27279 27280 62380 63001 63005 63012 63015 63017 63020 63030 63040 63042 63045 63047 63050 63051 63056 63075 0095T 0098T 0163T 0164T 0165T 20930 20931 20936 20937 20938 20975 22512 22515 22534 22552 22585 22614 22632 22634 22840 22841 22842 22843 22844 22845 22846 22847 22848 22853 22854 22858 22859 22868 22870 63035 63043 63044 63048 63057 63076 63082 C9757

Musculoskeletal Injections / Pain

62292 62320 62321 62322 62323 62324 62325 62326 62327 64479 64483 64490 64493 64510 0214T 0215T 0217T 0218T 0229T 0231T 22526 22527 27096 62263 62264 62280 62281 62282 64451 64480 64484 64491 64492 64494 64495 64520 64625 64634 64636 M0076 0213T 0216T 0228T 0230T 62287 G0260

0101T 0102T 0200T 0201T 0221T 0335T 0347T 0510T 0511T 20550 20551 20552 20553 20555 20822 20902 20910 20912 20922 20924 20972 20973 21010 21030 21032 21040 21046 21047 21048 21050 21060 21070 21076 21077 21079 21080 21081 21082 21083 21084 21085 21086 21087 21088 21100 21110 21120 21121 21122 21123 21125 21127 21137 21138 21139 21150 21172 21175 21181 21193 21195 21198 21199 21206 21209 21210 21230 21240 21242 21243 21244 21245 21246 21256 21260 21261 21263 21267 21280 21282 21295 21296 21390 21395 21407 21408 21440 21445 21480 21685 26205 26215 26352 26358 26372 26390 26392 26415 26420 26428 26489 26490 26492 26502 26560 26561 26562 26590 27704 28446


12



Musculoskeletal Other

28890 29850 29851 C9752 G0276 20999 21089 29799 64633 64635 62350 62351 62360 62361 62362 63650 63685 63655 0274T 0275T 63081 0202T 0219T 20900 20920 20979 21073 21208 21215 21235 21248 21249 21270 21742 21743 22206 22207 22210 22212 22214 22220 22222 22224 22548 22556 22586 22590 22610 22800 22802 22849 22850 22852 22855 22864 22865 23125 23195 23405 23406 23800 23802 25265 25274 25440 25441 25442 25443 25444 25445 25446 26121 26123 26483 26546 27146 27147 27151 27156 27161 27282 27405 27407 27409 27437 27445 27488 27570 29800 29804 63003 63011 63016 63046 63055 63064 63077 63085 63087 63090 63101 63102 63180 63182 63185 63190 63191 63250 63251 63252 63300 63301 63302 63303 63304 63305 63306 63307 21299 21899 22899 23929 24999 25999 26989 27299 27599 27899 28899 29999

Neurology Neurology


Neurology

90901 96116 96125 0419T 0420T 0440T 0441T 0442T 95822 95860 95861 95863 95864 95865 95866 95867 95868 95869 95870 95872 95905 95907 95908 95909 95910 95911 95912 95913 95921 95922 95923 95924 95926 95927 95928 95929 95930 95933 95937 95938 95939 95943 95961 95970 95971 95972 95976 95977 95981 95982 95983 95990 95991 96000 96001 96002 96003 96004 95999

Oncology Oncology


Oncology Radiation Therapy

32701 61796 61798 63620 G0458 C2616 C2634 C2635 C2636 C2637 C2638 C2639 C2640 C2641 C2642 C2643 C2645 C2698 C2699 C9725 C9727 C9728 0394T 0395T 77371 77372 77373 77385 77386 77401 77402 77407 77412 77423 77424 77425 77520 77522 77523 77525 77750 77761 77762 77763 77767 77768 77770 77771 77772 77778 G0339 G0340 G6003 G6004 G6005 G6006 G6007 G6008 G6009 G6010 G6011 G6012 G6013 G6014 G6015 G6016 77014 77387 77600 77605 77610 77615 77620 79005 79101 79403 A9590 G6001 G6002 G6017

Oncology Surgical Oncology

19120 19125 19301 19302 32607 32608 0421T 19300 19303 20982 20983 47370 47371 47382 47383 50541 50542 50592 50593 53850 53852 55866 55873 60210 60212 60220 60225 60240 60252 60260 60271 C9747 47381


13




50250 55801 55810 55812 55815 55831 55840 55842 55845 60270

Outpatient Therapy Outpatient Therapy


Outpatient Therapy Chiropractics

98940 98941 98942

Outpatient Therapy Physical Therapy /Occupational Therapy

97032 97535 97545 97546 97750 97755 G0129 G0176 97012 97016 97018 97022 97024 97026 97028 97033 97034 97035 97036 97110 97112 97113 97116 97124 97140 97150 97530 97533 97537 G0283

Outpatient Therapy Speech Therapy

92507 92609 92508 92512 92520 92526 92607 92608 92612 92614

Part B Drugs Part B Drugs


Part B Drugs


14

J9177 J9198 J9246 J9358 Q5119 J0896 Q5120 A9513 A9543 C9399 J0641 J0642 J1454 J1627 J1950 J2354 J2430 J2860 J8520 J8521 J8560 J8700 J9015 J9017 J9019 J9023 J9027 J9032 J9034 J9036 J9039 J9040 J9042 J9043 J9044 J9050 J9057 J9065 J9098 J9118 J9120 J9130 J9153 J9178 J9185 J9200 J9202 J9203 J9204 J9205 J9207 J9208 J9209 J9211 J9214 J9216 J9218 J9225 J9229 J9230 J9245 J9261 J9262 J9266 J9268 J9269 J9280 J9285 J9293 J9295 J9302 J9307 J9309 J9313 J9315 J9320 J9325 J9328 J9330 J9340 J9351 J9352 J9356 J9357 J9360 J9371 J9390 J9400 J9600 J9999 A9606 J0185 J0640 J0881 J0885 J0894 J0897 J1442 J1447 J1453 J1930 J2353 J2469 J2505 J2820 J3262 J3315 J3489 J3490 J3590 J9000 J9022 J9025 J9030 J9033 J9035 J9041 J9045 J9047 J9055 J9060 J9070 J9100 J9119 J9145 J9150 J9155 J9171 J9173 J9176 J9179 J9181 J9190 J9201 J9206 J9217 J9228 J9250 J9260 J9263 J9264 J9267 J9271 J9299 J9301 J9303 J9305 J9306 J9308 J9311 J9312 J9354 J9355 J9370 J9395 Q2050 Q5101 Q5106 Q5107 Q5108 Q5110 Q5111 Q5115 Q2017 Q2043 Q5112 Q5113 Q5114 Q5116 Q5117 Q5118




Psychiatry Psychiatry

Psychiatry Intensive Outpatient Program (IOP)


Psychiatry Partial Hospitalization Program


Psychiatry/Detox Inpatient


Psychiatry Other

Intensive Outpatient Program *Requires Prior Authorization Prior Auth Online Link

Partial Hospitalization Program *Requires Prior Authorization Prior Auth Online Link

Skilled Nursing Facility

Skilled Nursing Facility

Skilled Nursing Facility Inpatient


Sleep Sleep


Sleep 0424T 0425T 0426T 0427T 0428T 0429T 0430T 0431T 0432T 0433T 0434T 0435T 0436T A4604 A7030 A7031 A7032 A7033 A7034 A7035 A7036 A7037 A7038 A7039 A7045 A7046 A9270 95807 95808 95810 95811 G0398 95782 95783 95800 95801 95803 95805 95806 G0399 G0400


15









Vision/Hearing Services

Vision/Hearing Services Not an all inclusive list - Auth Lookup Link

Vision/Hearing Services Vision

0100T 0191T 0207T 0253T 0308T 0356T 0378T 0402T 0449T 0464T 0506T 0507T 65710 65730 65750 65755 65756 65778 65779 65780 65785 65850 66174 66175 66180 67113 67221 67229 67345 67880 67882 67900 67901 67902 67903 67904 67906 67908 67909 67911 67912 67914 67915 67916 67917 67921 67922 67923 67924 67950 67961 67966 67971 67973 67974 67975 68360 68362 68760 68761 68801 92025 92065 92260 92540 92545 92548 C9745 G0429 V2623 V2625 V2626 V2627 V2628 V2629 V2799

Vision/Hearing Services Hearing

69300 69320 69420 69421 69433 69436 92570 95925 V5299

Wound Therapy Wound Therapy


Wound Therapy 99199 0491T 97610 99183 C5271 C5273 C5275 C5277 G0277 G0281 G0329 G0460


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clover 2020 prior authorization list - updated 8 2020 r · 8/1/2020 · clover health prior...

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