Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.10-018 - Prior Authorization for Procedure Codes 87901, 87903, 87904
Health Care Provider - Hospital/Critical Access Hospital (CAH)/End-Stage Renal Disease (ESRD) and Physician/Independent Lab/CRNA/Radiation Therapy Center, July 1, 2011, Prior Authorization for Procedure Codes 87901, 87903, and 87904
Effective for claims with dates of service on or after July 1, 2011, the following procedure codes will no longer require a prior authorization when the primary (ICD-9-CM) diagnosis is 042, Human Immunodeficiency Virus (HIV) disease:
|
Procedure Code |
Description |
Limitations |
|
87901 |
Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, reverse transcriptase and protease regions |
A maximum of 12 units per 12 month period |
|
87903 |
Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV-1; first through ten drugs tested |
A maximum of 1 unit per year |
|
87904 |
Each additional drug tested (List separately in addition to code for primary procedure) |
This procedure code is an add-on code. |
If you have questions regarding this notice, please contact the HP Enterprise Services Provider Assistance Center at In-State WATS 1-800-457 -4454, or locally and Out-of-State at (501) 376-2211.
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Arkansas Medicaid provider manuals, official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.
Thank you for your participation in the Arkansas Medicaid Program.
