when to get prior authorization – Medicaid insurance


Anesthesiologists are not required to request prior authorization (PA) from Medicaid. However, for any anesthesia code on the list titled ASA Codes Associated With CPT Codes W hich Require Prior Authorization, included in this section, the anesthesiologist is required to obtain the PA number for the CPT code from the surgeon and enter the PA number on the claim when billing for anesthesia .

1. The surgeon must obtain prior authorization (PA) when required for procedures identified in the Medical and Surgical Procedures List included with this manual. For information about the prior authorization process, refer to SECTION 1, General Information, Chapter 9, Prior Authorization Process. Procedures which require PA include, but are not limited to, hysterectomy, sterilization and abortion. Medicaid staff review each request to ensure that all federal and state requirements are met. If so, staff assign a PA number for the CPT procedure and enter the PA number and appropriate anesthesia code into Medicaid’s computer system.

2. When an anesthesiologist bills for an ASA code associated with a CPT procedure code which requires prior authorization, the claim may be paid only if the surgeon obtained prior authorization for the procedure. If the surgeon did not obtain a prior, Medicaid cannot reimburse either the surgeon or the anesthesiologist. This applies to codes such as 00851 where the code itself  describes a sterilization procedure.

3. Exceptions to the prior authorization requirement can only be considered under one of the following circumstances:
a. The procedure was performed in a life-threatening or justifiable emergency situation.
b. Medicaid is responsible for the delay in approval.
c. The patient is retroactively eligible for Medicaid. Refer to SECTION 1, General Information,
Chapter 9 – 7, Retroactive Authorization.

Approval for services related to these exceptions may be granted “after-the-fact” with appropriate
documentation and review. If approved, the associated ASA code may also be reimbursed.

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