June 2025 Provider News
Date: 06/27/25
In this issue:
- General Updates - Administrative Days, Childhood Lead Poisoning Prevention Program, After Pregnancy Care (APC), Syphilis testing during pregnancy, perinatal mental health, Maternity Support Services (MSS), Mental Health Referral Service for Children and Teens, Birth doulas
- Quality - Clinical Practice Guidelines 2025, Topical Fluoride, Upper Respiratory Infection, Low Back Pain
- Clinical Policy & Prior Authorization Updates - Upcoming July and October effective dates
- Wellcare - Clinical Policy Updates, PT/OT Authorization Updates
- Training/Education - Suicide Prevention, Supporting LGTBQIA+ in Foster Care, Adverse Childhood Experiences (ACEs)
- Pharmacy Updates - Ustekinumab Update, Test Strip and Lancet Quantity Limit Update, Evolent Medical Oncology
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General Updates
Administrative Days (WA.CP.MP.519) Upcoming Policy Update
To ensure compliance with HB 2051 and guidance from the Health Care Authority, Coordinated Care of Washington will be updating Clinical Policy WA.CP.MP.519: Administrative Days.
Effective August 1, 2025, the following change will take effect:
Managed Care Organizations (MCOs) will no longer be required to reimburse hospitals separately for allowable medically necessary services provided during administrative days.
These services may include, but are not limited to:
- Hemodialysis
- Laboratory services
- X-rays
However, MCOs will remain responsible for reimbursing hospitals separately for:
- Pharmacy services and pharmaceuticals provided during administrative day stays.
Please note the following related updates:
- These changes will be reflected in the January 2026 contracts for IMC, IFC, and AHE.
- Managed care rates will also be updated in January 2026 to align with these revisions.
- The State Plan, Washington Administrative Code (WAC), fee schedules, and billing guides will be updated to reflect this policy change as of August 1, 2025.
If you have questions regarding this update, please contact your Coordinated Care Provider Relations representative.
Childhood Lead Poisoning Prevention Program WA DOH
Federal regulations require that all children enrolled in Medicaid receive a blood lead test at 12 and 24 months of age, or at 24 to 72 months of age if no record of a previous test exists.
More information can be found here.
Reach out with questions here: lead@doh.wa.gov
After Pregnancy Care (APC)
Did you know for Pregnant members active on Apple Health there is 12 months of after pregnancy coverage available.
- Individuals who are on an Apple Health program and pregnant must report their pregnancy to HCA and provide an estimated due date.
- The transition into APC will be automatic as long as there is an estimated due date reported.
- APC will begin the first day of the following month the pregnancy ends.
- Coverage is for 12 months regardless of a change in income or household size.
- Phone: Call the Washington Healthplanfinder Customer Support Center at 1-855-923-4633 please tell your patients report their pregnancy and Due date.
Syphilis is at its highest levels since the 1950s. Here's how experts are trying to fix that.
Since 2012, U.S. congenital syphilis cases increased substantially. Syphilis during pregnancy can lead to stillbirth, miscarriage, infant death, and maternal and infant morbidity, which are preventable through appropriate screening and treatment.
Local and national levels could improve timeliness of testing and appropriateness of treatment for syphilis during pregnancy and thereby reduce the incidence of congenital syphilis and complications of syphilis during pregnancy.
First Steps enhanced services-Maternity Support Services (MSS)
Maternity Support Services (MSS) are preventive health and education services to help an individual have a healthy pregnancy and a healthy baby. Individuals can receive MSS through the First Steps Program if they are pregnant or up to 60 days postpartum and receiving Apple Health. MSS is offered in addition to medical and prenatal care.
Birth doulas
As of January 1, 2025, the Washington State Health Care Authority (HCA) now reimburses eligible birth doulas for providing support to Apple Health (Medicaid) clients during pregnancy, labor, and postpartum recovery.Mar 14, 2025
For doula details and the HCA find a provider tool follow the link.
Free perinatal mental health consultation line for Washington State health care providers
The University of Washington Partnership Access Line for Moms (PAL for Moms) is a free telephone consultation service for health care providers caring for patients with mental health problems who are pregnant, postpartum, or planning pregnancy. Any health care provider in Washington State can receive consultation, recommendations, and referrals to community resources from a psychiatrist with expertise in perinatal mental health.
Call 877-PAL4MOM or 877-725-4666
Washington’s Mental Health Referral Service for Children and Teens
The Referral Service is accessible to children and teens 17 and under living in Washington state.
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Quality
Medicaid Quality
Clinical Practice Guidelines for 2025 have been updated on the Coordinated Care website.
Oral Health Training for Healthcare Professionals
Smiles for Life is a comprehensive oral health curriculum for healthcare professionals and health educators. This American Dental Association endorsed curriculum is designed to enhance the role of primary care clinicians in the promotion of oral health for all age groups. This curriculum includes oral health training for all ages and offers free CME to healthcare providers.
Upper Respiratory Infection (URI)
Preventing transmission of viral respiratory pathogens in healthcare settings.
To prevent the transmission (spread) of all viral respiratory infections in healthcare settings, including influenza virus and SARS-CoV-2 infection, the following infection control measures should be implemented into standard procedures.
Low Back Pain (LBP)
About 2.63 million ER visits in the U.S. each year are for low back pain-related disorders.1 75%–85% of Americans will have low back pain at some time in their lives.2 In any 3-month period, about 25% of Americans will face at least 1 day of back pain.3 Evidence shows that when there is no “red flag” (e.g., a broken bone, a serious disease), routine imaging (X-ray, MRI, CT scan) for low back pain does not always improve outcomes, and could expose an individual to unneeded harms like radiation, and possibly to unnecessary treatment.4 It is critical to reduce imaging when there are no red flags so treatments that are not effective, and that may result in extra costs, are kept to a minimum.5
Resource: Use of Imaging Studies for Low Back Pain (LBP) - NCQA
Appropriate
HEDIS® Behavioral Health Measure Toolkit
Measurement Year 2025
Unhealthy Alcohol Use Screening and Follow-Up (ASF-E)
This measure assesses the percentage of members 18 years of age and older who were screened for unhealthy alcohol use using a standardized instrument and, if screened positive, received appropriate follow-up care.
- Unhealthy Alcohol Use Screening: The percentage of members who had a systemic screening for unhealthy alcohol use.
- Follow-Up Care on Positive Screen: The percentage of members receiving brief counseling or other follow-up care within 60 days (2 months) of screening positive for unhealthy alcohol use.
Note: A Logical Observation Identifiers Names and Codes (LOINC®) code submission via flat file or electronic health record (EHR) is required to be adherent for the alcohol screening numerator. Ask your Provider Engagement or Quality Improvement representative for more information on the data sharing process.
What is included?
Medicaid and Medicare members aged 18 and older.
Unhealthy Alcohol Use Screening Instrument: A standard assessment instrument that has been normalized and validated for the adult patient population.
Eligible screening instruments with thresholds for positive findings include:
Screening Instrument | Total Score LOINC Codes | Positive Finding |
Alcohol Use Disorders Identification Test (AUDIT) screening instrument | 75624-7 | Total score ≥8 |
Alcohol Use Disorders Identification Test Consumption (AUDIT-C) screening instrument | 75626-2 | Total score ≥4 for men Total score ≥3 for women |
Single-question screen (for men): “How many times in the past year have you had 5 or more drinks in a day?” | 88037-7 | Response ≥1 |
Single-question screen (for women and all adults older than 65 years): “How many times in the past year have you had 4 or more drinks in a day?” | 75889-6 | Response ≥1 |
How is adherence met?
Adherence is met for the first numerator when the member had a documented screening using an age-appropriate standardized instrument. If the alcohol screening is positive, the member must receive follow-up care on or up to 60 days after the date of the first positive screening to be adherent for the second numerator.
Follow-up care must be coded appropriately via claim and can be any of the following:
- Feedback on alcohol use and harms.
- Identification of high-risk situations for drinking and coping strategies.
- Increase motivation to reduce drinking.
- Development of a personal plan to reduce drinking.
- Documentation of receiving alcohol misuse treatment.
Adherent Diagnosis/CPT**/HCPCS Codes for the Follow-Up on Positive Screen numerator
Description | Codes* |
A diagnosis of encounter for alcohol counseling and surveillance. | Z71.41 |
Alcohol Counseling of Other Follow Up Care | 99408, 99409, H0022, H0050, H0007, H0005, H0015, H0016, H2036, H2035, G0396, G2011, G0397, T1006, T1012, G0443 |
This document is an informational resource designed to assist licensed healthcare practitioners in caring for their patients. Healthcare practitioners should use their professional judgment in using the information provided. HEDIS® measures are not a substitute for the care provided by licensed healthcare practitioners and patients are urged to consult with their healthcare practitioner for appropriate treatment. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
*2025 ICD-10 Diagnosis Codes* **CPT** copyright 2025 American Medical Association (AMA). All rights reserved. CPT** is a registered trademark of the AMA. For a complete list please refer to the NCQA website.
ADHD Follow Up on Kids
Children with new prescription for ADHD medication should receive a follow up visit within 30 days of starting the medication.
Asthma and 90 Day Medication Refills
Moving members with asthma prescriptions to 90-day medication refills may increase their maintenance medication adherence.
Mammograms (HEDIS Measure)
The HEDIS measure assesses women ages 50-74 who had at least one mammogram to screen for breast cancer in the past 2 years.
Wellcare Quality
Men’s Health: Encourage Your Patients to Prioritize Their Health
Men’s Health Week is the perfect time to talk with your patients about preventable health issues, and encourage early detection and treatment. Medicare covers preventive services, including:
- Alcohol misuse screening and counseling
- Cancer screening: colorectal and prostate
- Cardiovascular disease: screening tests and intensive behavioral therapy (IBT)
- Counseling to prevent tobacco use
- IBT for obesity
Find out when your patient is eligible for services (PDF).
If you need help, contact your eligibility service provider.
More Information:
- Hypertension (PDF)
- Obesity (PDF)
- Prostate Cancer (PDF)
- Tobacco Use (PDF)
- Preventive & Screening Services
The HEDIS measure assesses women ages 50-74 who had at least one mammogram to screen for breast cancer in the past 2 years.
- Alcohol misuse screening and counseling
- Cancer screening: colorectal and prostate
- Cardiovascular disease: screening tests and intensive behavioral therapy (IBT)
- Counseling to prevent tobacco use
- IBT for obesity
Find out when your patient is eligible for services (PDF) - If you need help, contact your eligibility service provider.
More Information:
- Hypertension (PDF)
- Obesity (PDF)
- Prostate Cancer (PDF)
- Tobacco Use (PDF)
- Preventive & Screening Services
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Clinical Policy & Prior Authorization Updates
Clinical Policy Updates
The below policies were updated as part of our regular monthly review in May. The policy changes are effective July 1, 2025. You will find the policies, including a description of the revisions, posted on the policy site.
Policy Number | Policy Title | Line of Business |
WA.CP.MP.530 | Bone Morphogenic Proteins for Use in Spinal Fusion | Apple Health & Ambetter |
WA.CP.MP.516 | Carotid Artery Stenting | Apple Health |
WA.CP.MP.525 | Catheter Ablation for SVTA | Apple Health |
WA.CP.MP.532 | Chronic Migraine and Tension-Type Headaches | Apple Health |
CP.MP.114 | Disc Decompression Procedures | Apple Health & Ambetter |
CP.MP.115 | Discography | Apple Health & Ambetter |
WA.CP.MP.514 | Extra-Corporeal Membrane Oxygenation Therapy (ECMO) | Apple Health |
WA.CP.MP.54 | Hospice | Apple Health |
WA.CP.MP.531 | Imaging for Breast Cancer Screening | Apple Health |
CP.MP.244 | Liposuction of Lipedema | Apple Health & Ambetter |
CP.MP.116 | Lysis of Epidural Lesions | Apple Health & Ambetter |
WA.CP.MP.518 | Negative Pressure Wound Therapy for Home Use | Apple Health |
CP.MP.24 | Multiple Sleep Latency Testing | Apple Health & Ambetter |
CP.MP.188 | Pediatric Oral Function Therapy | Apple Health & Ambetter |
CP.MP.210 | Repair of Nasal Valve Compromise | Apple Health & Ambetter |
WA.CP.BH.200 | Transcranial Magnetic Stimulation (TMS) for TRMD | Apple Health |
WA.CP.MP.534 | Upright Positional MRI | Apple Health |
The below policies were updated as part of our regular monthly review in May. The policy changes are effective October 1, 2025. You will find the policies, including a description of the revisions, posted on the policy site.
Policy Number | Policy Title | Line of Business |
CP.MP.132 | Heart-Lung Transplant | Apple Health & Ambetter |
CP.MP.58 | Intestinal and Multivisceral Transplant | Apple Health & Ambetter |
CP.MP.87 | Therapeutic Utilization of Inhaled Nitric Oxide | Apple Health & Ambetter |
CP.BH.200 | Transcranial Magnetic Stimulation (TMS) for TRMD | Ambetter |
WA.CP.MP.522 | Varicose Vein Treatment | Apple Health |
WA.CP.MP.12 | Vagus Nerve Stimulation | Apple Health |
The below policies are new effective July 1, 2025. You will find the policies posted on the policy Web site.
Policy Number | Policy Title | Line of Business | |
WA.CP.MP.530 | Bone Morphogenic Proteins for Use in Spinal Fusion | Ambetter | |
WA.CP.MP.516 | Carotid Artery Stenting | Ambetter | |
WA.CP.MP.525 | Catheter Ablation for SVTA | Ambetter | |
WA.CP.MP.532 | Chronic Migraine and Tension-Type Headaches | Ambetter | |
WA.CP.MP.514 | Extra-Corporeal Membrane Oxygenation Therapy (ECMO) | Ambetter | |
WA.CP.MP.531 | Imaging for Breast Cancer Screening | Ambetter | |
WA.CP.MP.518 | Negative Pressure Wound Therapy for Home Use | Ambetter | |
WA.CP.MP.534 | Upright Positional MRI | Ambetter | |
The below policies are new effective October 1, 2025. You will find the policies posted on the policy Web site.
Policy Number | Policy Title | Line of Business | |
WA.CP.MP.12 | Vagus Nerve Stimulation | Ambetter | |
WA.CP.MP.522 | Varicose Vein Treatment | Ambetter | |
The below policy will be archived effective September 31, 2025.
Policy Number | Policy Title | Line of Business |
CP.MP.146 | Sclerotherapy for Varicose Veins | Ambetter |
The below policies were previously announced as revised effective on the date noted. You will find the policies posted on the policy site.
Policy Number | Policy Title | Effective Date | Line of Business |
CP.BH.104 | Applied Behavior Analysis | 7/1/25 | Apple Health & Ambetter |
CP.BH.105 | Applied Behavioral Analysis Documentation Requirements | 7/1/25 | Apple Health & Ambetter |
WA.CP.MP.515 | Fecal Microbiota Transplantation | 7/1/25 | Apple Health |
CP.MP.121 | Homocysteine Testing | 7/1/25 | Apple Health & Ambetter |
CP.MP.82 | NICU Apnea Bradycardia Guidelines | 7/1/25 | Apple Health & Ambetter |
CP.MP.81 | NICU Discharge Guidelines | 7/1/25 | Apple Health & Ambetter |
WA.CP.MP.526 | Stem Cell Therapy for Musculoskeletal Conditions | 7/1/25 | Apple Health |
CP.MP.162 | Tandem Transplant | 7/1/25 | Apple Health & Ambetter |
WA.CP.MP.510 | Tinnitus Treatment | 7/1/25 | Apple Health |
CP.MP.163 | Total Parenteral Nutrition and Intradialytic Parenteral Nutrition | 7/1/25 | Apple Health & Ambetter |
CP.MP.55 | Assisted Reproductive Technology | 8/1/25 | Ambetter |
CP.BH.201 | Deep Transcranial Magnetic Stimulation (TMS) for OCD | 8/1/25 | Ambetter |
CP.MP.132 | Heart-Lung Transplant | 8/1/25 | Apple Health & Ambetter |
WA.CP.MP.69 | Intensity-Modulated Radiotherapy | 8/1/25 | Apple Health |
CP.MP.57 | Lung Transplant | 8/1/25 | Apple Health & Ambetter |
WA.CP.MP.517 | Testosterone Testing | 8/1/25 | Apple Health |
WA.CP.MP.520 | Tympanostomy Tubes | 8/1/25 | Apple Health |
CP.BH.500 | Behavioral Health Treatment Documentation Requirements | 9/1/25 | Apple Health |
HIM.CP.BH.500 | Behavioral Health Treatment Documentation Requirements | 9/1/25 | Ambetter |
WA.CP.MP.513 | Cardiac Stents | 9/1/25 | Apple Health |
WA.CP.MP.502 | Cochlear Implants | 9/1/25 | Apple Health |
CP.MP.50 | Drugs of Abuse: Definitive Testing | 9/1/25 | Ambetter |
WA.CP.MP.505 | Microprocessor-Controlled Lower Limb Prosthetics | 9/1/25 | Apple Health |
CP.MP.147 | Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention | 9/1/25 | Ambetter |
WA.CP.MP.185 | Skin Substitutes | 9/1/25 | Apple Health |
CP.MP.185 | Skin Substitutes for Chronic Wounds | 9/1/25 | Ambetter |
CP.MP.247 | Transplant Service Documentation Requirements | 9/1/25 | Apple Health & Ambetter |
The below new policies were previously announced effective on the dates noted. You will find the policies posted on the policy site.
Policy Number | Policy Title | Effective Date | Line of Business |
WA.CP.MP.510 | Tinnitus Treatment | 7/1/25 | Ambetter |
WA.CP.MP.526 | Stem Cell Therapy for Musculoskeletal Conditions | 7/1/25 | Ambetter |
WA.CP.MP.515 | Fecal Microbiota Transplantation | 7/1/25 | Ambetter |
WA.CP.MP.69 | Intensity-Modulated Radiotherapy | 8/1/25 | Ambetter |
WA.CP.MP.517 | Testosterone Testing | 8/1/25 | Ambetter |
WA.CP.MP.520 | Tympanostomy Tubes | 8/1/25 | Ambetter |
CP.MP.50 | Drugs of Abuse: Definitive Testing | 9/1/25 | Apple Health |
WA.CP.MP.513 | Cardiac Stents | 9/1/25 | Ambetter |
WA.CP.MP.502 | Cochlear Implants | 9/1/25 | Ambetter |
WA.CP.MP.505 | Microprocessor-Controlled Lower Limb Prosthetics | 9/1/25 | Ambetter |
The below policies were previously announced as being archived on the dates noted.
Policy Number | Policy Title | Effective Date | Line of Business |
CP.MP.69 | Intensity-Modulated Radiotherapy | 7/31/25 | Ambetter |
WA.CP.MP.50 | Drugs of Abuse: Definitive Testing | 8/31/25 | Apple Health |
Prior Authorization Updates
The following skin substitutes will require prior authorization for Apple Health members effective September 1, 2025:
Medicaid Skin Substitute Prior Authorization List | |
Code | Description |
C9363 | Skin substitute (Integra Meshed Bilayer Wound Matrix), per sq cm |
Q4100 | Skin substitute, not otherwise specified |
Q4103 | Oasis burn matrix, per sq cm |
Q4108 | Integra matrix, per sq cm |
Q4122 | DermACELL, Dermacell AWM or DermACELL AWM Porous, per sq cm |
Q4123 | AlloSkin RT, per sq cm |
Q4126 | MemoDerm, DermaSpan, TranZgraft or Integuply, per sq cm |
Q4127 | Talymed, per sq cm |
Q4134 | Hmatrix, per sq cm |
Q4135 | Mediskin, per sq cm |
Q4136 | E Z Derm, per sq cm |
Q4138 | BioDFence DryFlex, per sq cm |
Q4140 | BioDFence, per sq cm |
Q4143 | Repriza, per sq cm |
Q4147 | Architect, Architect PX, or Architect FX, extracellular matrix, per sq cm |
Q4149 | Excellagen, 0.1 cc |
Q4150 | AlloWrap DS or dry, per sq cm |
Q4153 | Dermavest and Plurivest, per sq cm |
Q4157 | Revitalon, per sq cm |
Q4161 | Bio-connekt wound matrix, per sq cm |
Q4162 | WoundEx Flow, BioSkin Flow, 0.5 cc |
Q4163 | Woundex, bioskin, per sq cm |
Q4164 | Helicoll, per sq cm |
Q4165 | Keramatrix or Kerasorb, per sq cm |
Q4167 | Truskin, per sq cm |
Q4168 | AmnioBand, 1 mg |
Q4169 | Artacent wound, per sq cm |
Q4173 | Palingen or Palingen Xplus, per sq cm |
Q4174 | PalinGen or ProMatrX, 0.36 mg per 0.25 cc |
Q4176 | Neopatch or therion, per sq cm |
Q4177 | FlowerAmnioFlo, 0.1 cc |
Q4179 | FlowerDerm, per sq cm |
Q4180 | Revita, per sq cm |
Q4181 | Amnio Wound, per sq cm |
Q4182 | Transcyte, per sq cm |
Q4183 | Surgigraft, per sq cm |
Q4184 | Cellesta or Cellesta Duo, per sq cm |
Q4190 | Artacent AC, per sq cm |
Q4191 | Restorigin, per sq cm |
Q4193 | Coll-e-Derm, per sq cm |
Q4194 | Novachor, per sq cm |
Q4198 | Genesis Amniotic Membrane, per sq cm |
The following services were previously announced as requiring prior authorization effective July 1, 2025.
Line of Business | Code | Description |
Ambetter | J1439 | Injection, ferric carboxymaltose, 1 mg |
Apple Health | 37229 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy |
Apple Health | 37227 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral, with transluminal stent placement(s) and atherectomy |
Apple Health | 42145 | Palatopharyngoplasty |
Apple Health | E2402 | Negative pressure wound therapy electrical pump, stationary or portable |
Apple Health | L1833 | Knee orthosis, adjustable knee joints, positional orthosis, rigid support, off-the-shelf |
Apple Health | L0650 | Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panel(s), lateral strength provided by rigid lateral frame/panel(s), off-the-shelf |
Apple Health | L0648 | Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, off-the-shelf |
Apple Health | L0637 | Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, prefabricated item, customized to fit |
Due to changes in reimbursement and benefit limitations for Apple Health members which were effective April 1, 2025, we will no longer require prior authorization for G0481 (Definitive Drug Testing, 8-14 Drug Classes) effective July 1, 2025. Please remember that the benefit limit for definitive drug testing is now 12 total services per year.
Effective September 1, 2025, all skin substitutes for wound care will require prior authorization for Ambetter members. Please see policy CP.MP.185 for the full list of codes. The codes below have not required prior authorization previously but will require it effective September 1.
Ambetter Skin Substitute Prior Authorization List | |
Code | Description |
C9358 | Dermal substitute, native, nondenatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm |
C9360 | Dermal substitute, native, nondenatured collagen, neonatal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm |
C9363 | Skin substitute (Integra Meshed Bilayer Wound Matrix), per sq cm |
C9364 | Porcine implant, Permacol, per sq cm |
Q4100 | Skin substitute, not otherwise specified |
Q4101 | Apligraf, per sq cm |
Q4102 | Oasis wound matrix, per sq cm |
Q4103 | Oasis burn matrix, per sq cm |
Q4104 | Integra bilayer matrix wound dressing (BMWD), per sq cm |
Q4105 | Integra dermal regeneration template (DRT) or Integra Omnigraft dermal regeneration matrix, per sq cm |
Q4106 | Dermagraft, per sq cm |
Q4107 | Graftjacket, per sq cm |
Q4108 | Integra matrix, per sq cm |
Q4110 | PriMatrix, per sq cm |
Q4112 | Cymetra, injectable, 1 cc |
Q4113 | GRAFTJACKET XPRESS, injectable, 1 cc |
Q4115 | Alloskin, per sq cm |
Q4116 | AlloDerm, per sq cm |
Q4117 | Hyalomatrix, per sq cm |
Q4118 | Matristem micromatrix, 1mg |
Q4121 | TheraSkin, per sq cm |
Q4122 | DermACELL, Dermacell AWM or DermACELL AWM Porous, per sq cm |
Q4123 | AlloSkin RT, per sq cm |
Q4124 | Oasis ultra tri-layer wound matrix, per sq cm |
Q4125 | ArthroFlex, per sq cm |
Q4126 | MemoDerm, DermaSpan, TranZgraft or Integuply, per sq cm |
Q4127 | Talymed, per sq cm |
Q4128 | FlexHD, or AllopatchHD, per sq cm |
Q4132 | Grafix Core and GrafixPL Core, per sq cm |
Q4133 | Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm |
Q4134 | Hmatrix, per sq cm |
Q4135 | Mediskin, per sq cm |
Q4136 | E Z Derm, per sq cm |
Q4138 | BioDFence DryFlex, per sq cm |
Q4140 | BioDFence, per sq cm |
Q4141 | AlloSkin AC, per sq cm |
Q4142 | XCM biologic tissue matrix, per sq cm |
Q4143 | Repriza, per sq cm |
Q4145 | EpiFix, injectable, 1 mg |
Q4146 | TENSIX, per sq cm |
Q4147 | Architect, Architect PX, or Architect FX, extracellular matrix, per sq cm |
Q4148 | Neox Cord 1K, Neox Cord RT, or Clarix Cord 1K, per sq cm |
Q4149 | Excellagen, 0.1 cc |
Q4150 | AlloWrap DS or dry, per sq cm |
Q4151 | AmnioBand or Guardian, per sq cm |
Q4152 | DermaPure, per sq cm |
Q4153 | Dermavest and Plurivest, per sq cm |
Q4154 | Biovance, per sq cm |
Q4155 | Neox Flo or Clarix Flo 1 mg |
Q4156 | Neox 100 or Clarix 100, per sq cm |
Q4157 | Revitalon, per sq cm |
Q4158 | Kerecis Omega3, per sq cm |
Q4159 | Affinity, per sq cm |
Q4160 | Nushield, per sq cm |
Q4161 | Bio-connekt wound matrix, per sq cm |
Q4162 | WoundEx Flow, BioSkin Flow, 0.5 cc |
Q4163 | Woundex, bioskin, per sq cm |
Q4164 | Helicoll, per sq cm |
Q4165 | Keramatrix or Kerasorb, per sq cm |
Q4166 | Cytal, per square centimeter |
Q4167 | Truskin, per sq cm |
Q4168 | AmnioBand, 1 mg |
Q4169 | Artacent wound, per sq cm |
Q4170 | Cygnus, per sq cm |
Q4171 | Interfyl, 1 mg |
Q4173 | Palingen or Palingen Xplus, per sq cm |
Q4174 | PalinGen or ProMatrX, 0.36 mg per 0.25 cc |
Q4175 | Miroderm, per sq cm |
Q4176 | Neopatch or therion, per sq cm |
Q4177 | FlowerAmnioFlo, 0.1 cc |
Q4178 | FlowerAmnioPatch, per sq cm |
Q4179 | FlowerDerm, per sq cm |
Q4180 | Revita, per sq cm |
Q4181 | Amnio Wound, per sq cm |
Q4182 | Transcyte, per sq cm |
Q4183 | Surgigraft, per sq cm |
Q4184 | Cellesta or Cellesta Duo, per sq cm |
Q4185 | Cellesta Flowable Amnion (25 mg per cc); per 0.5 cc |
Q4186 | Epifix, per sq cm |
Q4187 | Epicord, per sq cm |
Q4188 | AmnioArmor, per sq cm |
Q4189 | Artacent AC, 1 mg |
Q4190 | Artacent AC, per sq cm |
Q4191 | Restorigin, per sq cm |
Q4192 | Restorigin, 1 cc |
Q4193 | Coll-e-Derm, per sq cm |
Q4194 | Novachor, per sq cm |
Q4195 | PuraPly, per square cm |
Q4196 | PuraPly AM , per square cm |
Q4197 | Puraply XT, per square cm |
Q4198 | Genesis Amniotic Membrane, per sq cm |
Q4200 | SkinTE, per sq cm |
Q4201 | Matrion, per sq cm |
Q4202 | Keroxx (2.5 g/cc), 1 cc |
Q4203 | Derma-Gide, per sq cm |
Q4204 | XWRAP, per sq cm |
Q4227 | AmnioCore TM, per sq cm |
Q4229 | Cogenex Amniotic Membrane, per sq cm |
Q4230 | Cogenex Flowable Amnion, per 0.5 cc |
Q4231 | Corplex P, per cc |
Q4232 | Corplex, per sq cm |
Q4233 | SurFactor or NuDyn, per 0.5 cc |
Q4234 | Xcellerate, per sq cm |
Q4235 | AMNIOREPAIR or AltiPly, per sq cm |
Q4237 | Cryo-Cord, per sq cm |
Q4238 | Derm-Maxx, per sq cm |
Q4239 | Amnio-Maxx or Amnio-Maxx Lite, per sq cm |
Q4240 | CoreCyte, for topical use only, per 0.5 cc |
Q4241 | PolyCyte, for topical use only, per 0.5 cc |
Q4242 | AmnioCyte Plus, per 0.5 cc |
Q4245 | AmnioText, per cc |
Q4246 | CoreText or ProText, per cc |
Q4247 | Amniotext patch, per sq cm |
Q4248 | Dermacyte Amniotic Membrane Allograft, per sq cm |
Q4249 | AMNIPLY, for topical use only, per sq cm |
Q4250 | AmnioAmp-MP, per sq cm |
Q4251 | Vim, per sq cm |
Q4252 | Vendaje, per sq cm |
Q4253 | Zenith amniotic membrane, per sq cm |
Q4254 | Novafix, per sq cm |
Q4255 | REGUaRD, for topical use only, per sq cm |
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Wellcare
Please visit this link for upcoming Medical Clinical Policy Updates, for Wellcare that will be going into effect August 1, 2025
Pt/OT Authorization Waiver
As of 07/01/2025 Wellcare will no longer require Authorization for PT/OT services. For questions, please reach out to your provider engagement administrator.
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Training/Education
Suicide Prevention Provides an overview of the topic of suicide, signs and symptoms, and how caregivers should respond in times of crisis. The training will dive into the rates of youth suicide, risk factors, and proactive steps to take for prevention. Tuesday July 8, 2025 10:00 AM Register.
Supporting LGBTQIA+ Youth in Foster Care This curriculum was developed through Amara with input from Coordinated Care and guidance from many community organizations. This training is for caregivers and professionals who work in the child welfare setting. July 10, 2025 10:00 AM Register.
Adverse Childhood Experiences (ACEs) This training explains the Adverse Childhood Experiences (ACEs) study and identifies all 10 ACEs. All childhood experiences have an impact on people as they mature. This training explores the long term effects that adverse childhood experiences have on physical and mental health. Preventative measures, resiliency, and how to address the needs of children with a high ACEs score are all discussed. Thursday, Jul 17, 2025 10:00 AM Register.
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Pharmacy Updates
LOB: Medicaid
Title: Ustekinumab Update
Effective July 01, 2025, the following Ustekinumab products: Yesintek Vials, Selarsdi Syringes, and Steqeyma Syringes will be preferred. All other Ustekinumab products will remain non-preferred.
LOB: Medicaid
Title: Test Strip and Lancet Quantity Limit Update
Test Strip and Lancet Quantity Limit Update
Effective August 01, 2025, Coordinated Care will be aligning with the Health Care Authority’s (HCA) quantity limits for test strips and lancets.
For children, age 20 and younger, as follows:
- Insulin dependent, 300 test strips and 300 lancets per member, per month. Expedited Authorization (EA) Code is required.
- Noninsulin dependent, 100 test strips and 100 lancets per member, per month.
For adults age 21 and older:
- Insulin dependent, 100 test strips and 100 lancets per member, per month. For pharmacy point of sale, EA is required.
- For noninsulin dependent, 100 test strips and 100 lancets per member, every 3 months.
For pregnant women with gestational diabetes or had diabetes prior to pregnancy, Coordinated Care pays for the quantity necessary to support testing as directed by the member’s physician, up to 60 days postpartum. For pharmacy point of sale, EA is required.
LOB: Ambetter
Title: Evolent Medical Oncology Update
Effective September 1, 2025, the following services will require prior authorization and need to be verified by Evolent.
Code | Description |
A9513 | Lutetium Lu 177 Dotatate Therapeutic 1 Mci |
J0202 | Injection Alemtuzumab 1 Mg |
J0630 | Inj Calcitonin Salmon To 400 Units |
J0791 | Injection Crizanlizumab-Tmca 5 Mg |
J1439 | Inj Ferric Carboxymaltos 1Mg |
J1460 | Inj Gamma Globulin Im 1 Cc |
J1555 | Injection Immune Globulin 100 Mg |
J1558 | Injection Immune Globulin Xembify 100 Mg |
J1560 | Inj Gamma Globulin Im Over 10 Cc |
J1575 | Inj Ig/Hyaluronidase 100 Mg Ig |
J3316 | Injection Triptorelin Extended-Release 3.75 Mg |
J7308 | Aminolevulinic Acid Hci For Ticl Admin, 20%/1Unit Dosage Form (354Mg) |
J7502 | Cyclosporine, Oral, Sol |
J7512 | Pdn Immed Rlse/Delay Rlse Oral 1 Mg |
J7520 | Sirolimus Oral 1 Mg |
J9052 | Injection, Carmustine (Accord), Not Therapeutically Equivalent To J9050, 100 Mg |
J9072 | Injection Cyclophosphamide Avyxa 5 Mg |
J9098 | Cytarabine Liposome Inj |
J9172 | Injection Docetaxel Docivyx 1 Mg |
J9230 | Mechlorethamine Hcl Inj |
J9247 | Injection, Melphalan Flufenamide, 1 Mg |
J9255 | Inj Methotrexate Not Thr Eqv To J9260 50 Mg |
J9260 | Injection Methotrexate Sodium 50 Mg |
J9286 | Injection Glofitamab-Gxbm 2.5 Mg |
J9304 | Injection Pemetrexed Pemfexy 10 Mg |
J9321 | Injection Epcoritamab-Bysp 0.16 Mg |
J9324 | Injection Pemetrexed 10 Mg |
Q0138 | Ferumoxytol, Non-Esrd |
Q5126 | Inj Bevacizumab-Maly Biosimilar (Alymsys) 10 Mg |
S0108 | Mercaptopurine Oral 50 Mg |