Quick Provider Authorization Form
FOR PARTICIPATING PRIMARY CARE PROVIDERS OR SPECIALISTS "ONLY" TO REFER TO A PARTICIPATING SPECIALIST OR DIAGNOSTIC CENTER FOR THE CODES LISTED
BELOW. DO NOT USE FOR HOSPITALS, ASC'S OR PRENATAL CARE VISITS/TREATMENT.
The following services do not require authorization. Valid for 90 days from date issued and limited to 1 procedure or diagnostic testing per code, exception Office visits
limited to 3. for questions please call Authorization Department (800) 327-8613
Date:
Member name:
Referring Provider Signature:
PCP Name:
Referring Specialists:
Specialists Address:
Number of Units: 1 Procedure/Diagnotic Testing & 3 Office Visits
Member ID#:
Referring Provider Telepnone:
Expiration: 90 days from issue date
D.O.B.
Street
City
Zip Cod
Diagnosis ICD-10 Code(s):
Provider Code(s):
(Requir
(Required Information)
INJECTIONS
SPECIALIST OFFICE VISITS
□ New
99386-99387, 99201-99204
J0702 □ HAND
99384-99389 □ Methylprednisolone
□ Established
FRACTURE CARE Cont'd
□ Betamethasone
J1020, J1030
□ HEEL, TOE & FOOT
OFFICE PROCEDURES Cont'd
26600-26605
□ Laryngel Endoscopy
28400, 28405
□ Control of Epistaxis
X-RAY/DIAGNOSTICS Cont'd
31505, 31575 □ Chest
99241-99245 □ 20 mg, 40 mg, 80 mg
□ Triamcinolone
ALLERGY AND PPD
□ Scratch Test
95004
□ Intradermal Test
95024 □ Testosterone
□ Patch Test
95044
□ PPD Skin Test
72010-72120
52000-52240 □ Pelvis
72170-72190
69210 □ Upper Extremities
73000-73140
31231 □ Lower Extremities
73500-73660
27510, 27518, 27520, 27530, 27538 □ Nasal Sinus Endoscopy
31237 □ Abdomen
74000-74022
27560, 275750, 27752, 27760, 27780 □ Nasopharyngoscopy
92511 □ GI Tract/Upper GI
74240-74249
27500, 27501, 27508, 27550 □ Nasal Endoscopy
J1070
Cypionate 100 mg
DERMATOLOGY
69200 □ Swallow Study
27824, 27830 □ Removal Foreign Body/Nose
11000-11004 □ RE-CASTING
93320-93321 □ Biopsy Skin Lesion
□ Removal Foreign Body/Ear
27781, 27786, 27788, 27808, 27810, 27816,
10060-10160
□ Excision - Debridement
CARDIOLOGY TESTS
28475, 28490, 28495, 28510, 28515 □ Removal Impacted Ear Wax
□ LEG
86580 □ Drainage Skin Abscess
□ Doppler Echo Exam
28430, 28435, 28450, 28455, 28470, □ Cystoscopy
J3301
Aceonide 10 mg
95115 95117 95165
□ Allergy Injections
J1040
Q4001-Q4051 □ Insertion Non dwelling catheter
74250-74260
51701 □ Barium Enema
74270-74280
11100-11101
29065, 29075, 29105, 29125, 29260, 29345
□ Insertion dwelling catheter
51702 □ IVP
74400-74410
74420-74425
93325 □ Shaving Demal Lesion
11300-11313
29355, 29405, 29425, 29505, 29515, 29530
□ Unna boot
29580 □ Urography
□ EKG
93000
11400-11403
29540, 29550
□ Binocular microscopy
92504 □ Cystography
□ ECG Monitor/Report
93268
11420-11423
93303-93308
□ 24 Hour Holter
□ Excision Benign Lesion
93288-93291 93293, 93724 □ Excision Malignant Lesion
T1020 □ VCUG
11470 □ Pap Smear
88150 □ ACS for Non-ALE Waiver recipient
T1020 U3 □ DEXA Scan
□ AICD Interrogation
93289
□ Stress Test
12031-12034 □ Cryocautery
□ Layer Closure Repair
93015-93018
NEUROLOGY
□ EEG
□ Destruction of Lesion
95812,958116,95819
□ EMG
95885, 95886
□ Nerve Conduction
Study
95910-95911
□ Destruction
12041-12044 □ Cone Biopsy
57520 □ OB US Monitoring
76815-76817
58100 □ Biophysical Profiles
76818, 76819
17280-17283 □ IUD Device & Insertion
□ Spirometry
94010
□ Pulmonary
94060, 94160 □ ARM
FRACTURE CARE
23600,24500,24505, 24530, 24535
94727 24560, 24565, 24578, 24577, 24600, 24620,
□ Aerosol Therapy
94640, 94664 24640, 24650, 24655, 24670, 24675, 25500,
□ Carbon Monoxide
94729
Diffusing Capacity
76820, 76821
81025 □ OB US- Vessel Dopplers
Send the following to NIA for Prior Authorization
87210
(800) 642-7820 or www.RadMD.com
17270-17273 □ IUD Device
□ Malignant Lesion
□ IUD Insertion/Removal
□ Tissue Exam with KOH
□ Pessary Fitting/Insertion
OFFICE PROCEDURES
J7300 □ Diagnostic Imaging (MR, CT/CCTA, PET Nuclear/PI, Stress
Echo, Echocardography)
J7302
□ Cardiac Interventions (Catheterizations and implantable
58300, 58301 devices)
87220 □ MSK Procuedures (Interventional Pain Management-Spine
and Spine Surgery
57160 □ Radiation Oncology Mgt (all radiation therapy)
□ Sleep Studies
25505, 25520, 25530, 25535, 25560, 25565
□ Injection of Tendon
20550-20553
25600, 25605, 25622, 25624, 25630, 25635
□ Drain Inject Joint
20600-20605 □ Head and Neck
X-RAY/DIAGNOSTICS
70030-70260
20610 □ Neck Soft Tissue
25650, 25660, 25675, 25680, 25690, 29085
77051, 77052, 77055, 77056, 77057
81002-81003
76811 □ Digital Mamogram
17000-17004 □ Endometrial B
17260-17263 □ Wet Mount Stain, O&P, fungi
74455
77080-77082
76801, 76805, 76813 □ UA Dipstick
57510-57511 □ OB US Detailed
17110-17111 □ Pregnancy Test
PULMONARY
□ Function Test
□ OB US
74450
□ Mammogram Screening
RADIOLOGY/IMAGING
57452, 57454
11620-11623 and or with biopsy
74430
□ Urethrocystography
ASSISTIVE CARE SERVICES
57150 □ ACS for Non-ALE Waiver recipients
11600-11603 □ Colposcopy
93279-93281
□ Interrogation
GYNECOLOGY
11450, 11462 □ Vaginal Irrigation
93272
□ Pacemaker
74230
30300 □ Small Bowel Series
□ Doppler Color Flow
□ Echo Exam Heart
71100-71130
□ Spine
99241 -99244, 99211-99214
□ New or Established
71010-71035
30901 □ Ribs and Sternum
G0202.G0204,G020677051, 77052
ULTRA SOUNDS
□ Arterial Extremity
93922-93931
93965-93971, 93975-93978, 93979-93982,
93990
□ Venous Doppler
□ Extremity Non Vascular
76881-76882
□ Thyroid
76536
□ Breast
76645
□ Transvaginal
76830
□ Abdominal
76700-76776
□ Pelvic
76856-76857
□ Scrotal Transrectal
76870-76873
□ Ultra Sonic Guidance
76942
70360 □ Carotid
93880, 93882
PLEASE SEE SPECIALITY SERVICES BELOW
LABORATORY
□ LabCorp: (888) 522-2677
□Quest Diagnostics: 866-697-8378
AUDIOLOGY OFFICE PROCEDURES
□ 92540-92545, 92547, 92550, 92570-92572,
92579, 92582-92585, 92587, 92588, 92620,
92621, 92627
AUDIOLOGY
□Hear USA:
(800) 731-3277,
Select Opt. 1
TRANSPORTATIION
VISION
Florida Eye Care Dade/Brwd:
(877) 481-3322,
□ Logisticare (877)
Opt. 1
Premier Eye Care Outside of
796-5843
Dade/Brwd: (800) 738-1889
Send Claims to: Magellan Complete Care P.O. Box 2097 Maryland Heights, MO 63043
DENTAL
DME
□ DentaQuest
(877)468-5581
Coastal Care Services - DME/Home Health
Care/IV Meds Infusion Services at home: 800393-7024