Authorization Requirement Changes

REMINDER: All out-of-network providers require an approved authorization for payment for any service provided to a Bright HealthCare Member.

Below is a summary of the changes, effective July 1, 2021, to Bright HealthCare’s prior authorization requirements:

Authorization No Longer Required

  • Colonoscopy*, endoscopy*, and cystoscopy procedures (~75 codes)
    *virtual colonoscopy and capsule endoscopy DO still require authorization

  • Select ophthalmology procedures
    66982: XCAPSL CTRC RMVL INSJ IO LENS PROSTH CPLX WO ECP
    67028: INTRAVITREAL NJX PHARMACOLOGIC AGT SPX
    67042: VITRECTOMY PARS PLANA REMOVE INT MEMB RETINA
    67108: RPR RETINAL DTCHMNT W/VITRECTOMY ANY METH
    67228: TREATMENT EXTENSIVE RETINOPATHY PHOTOCOAGULATION

  • Select steroid injections
    20610: ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US
    20611: ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US

  • Navigational bronchoscopy
    31627: NAVIGATIONAL BRONCHOSCOPY
    C9751: BRONCH RIGID/FLEX TRANSBRON ABL LES

  • Thyroidectomy
    60220: TOTAL THYROID LOBECTOMY UNI W/WO ISTHMUSECTOMY

       

Full Clinical Review Required

Full clinical review required for the procedures below to align with similar procedure codes.

  • Select cosmetic skin graft procedures
    15734: MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK
    15738: MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP LXTR

  • Select PET imaging procedures
    78816: PET IMAGING FOR CT ATTENUATION WHOLE BODY

  • Other procedures
    64625: RADIOFREQUENCY ABLTJ NRV NRVTG SI JT W/IMG GDN
    77263: RADIATION THERAPY PLANNING, COMPLEX

       

Network Validation Review Required

Authorization will still be required for the procedures below, but only the network status of the servicing providers will be considered in the review.

  • Select 3D imaging procedures
    76376: 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION
    76377: 3D RENDERING W/INTERP&POSTPROC DIFF WORK STATION

       

New Codes

Bright HealthCare maintains our authorization list with the latest CPT and HCPC codes. As new codes become available, we perform a review of the service and designate authorization requirements. Click here or please go to Availity for the list of new codes.

The online portal is available to submit prior authorizations. Check the prior authorization lists here to assure an authorization is needed and/or if clinical documentation is required to make a determination.