October 2025 Provider News - Bonus Edition

Date: 10/27/25

In this issue: 

• Important Prior Authorization Updates – Medicaid Effective 2/1/26
• Important Prior Authorization Updates – Marketplace Effective 2/1/26

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Important Prior Authorization Updates – Medicaid

Important Prior Authorization Updates – Medicaid
Effective February 1, 2026

As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Coordinated Care of Washington, Inc. wants to share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.

A full list of code changes for Coordinated Care, including Apple Health (Medicaid), can be found here.

 These changes may include:   

• Removing PA requirements based on criticality of review and clinical need.
• Creating a more uniform set of prior authorization requirements across our markets and lines of businesses, including adding and changing some PA requirements, to simplify processes, reduce confusion for providers, and support future efforts to expand real-time responses to requests.

If you have questions about specific prior authorization codes or how these changes affect your practice, please reach out to your local Provider Engagement representative or contact Coordinated Care’s provider services team at 1-877-453-2000.

Service Category	PA Rule	Services	Procedure Codes
Behavioral Health	PA Required	Substance Abuse Treatment	H2022
		Treatment Services	97155
DME Services	PA Required	Neurostimulators	C1767
		Orthotic and Prosthetic	L1833
	No PA Required	Wheelchairs	E2366, K0739
Drug Codes	PA Required	Medications	J2426
Genetic Analysis	No PA Required	Genetic Testing	81244,81331
Hospice	PA Requires	Hospice Services	Q5001,Q5002,Q5003
Laboratory	PA Required	Pathology	0340U
	No PA Required	Pathology	81270
Other Medical Services	No PA Required	Surgical Supplies	A4217
Physical Medicine	PA Required	Orthotic and prosthetic	Q4101,Q4121,Q4160,Q4195,Q4196
Skin Procedures	PA Required	Muscle Flap Procedure	15734
Surgery Procedures	PA Required	Cardiovascular system	37243
		Digestive systems	49329,49505,49591,49593,49595,49650
		Female Genitalia	58661,58662
		Hysterectomies	58571,58573
		Male Genitalia	54360
		Nervous system	64999
	PA Required except breast with breast cancer diagnosis	Integumentary system	19301,19357
	No PA Required	Vascular	36471,36479
		Wound Care	13100,13101,13102,13120,13121,13122,13151

 

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Important Prior Authorization Updates – Marketplace

Important Prior Authorization Updates – Marketplace
Effective February 1, 2026

As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Ambetter from Coordinated Care Corporation wants to share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.

Code change details can be found below. These changes may include:  

• Removing PA requirements based on criticality of review and clinical need.
• Creating a more uniform set of prior authorization requirements across our markets and lines of businesses, including adding and changing some PA requirements, to simplify processes, reduce confusion for providers, and support future efforts to expand real-time responses to requests.

If you have questions about specific prior authorization codes or how these changes affect your practice, please reach out to your local Provider Engagement representative.

Service Category	PA Rule	Services	Procedure Codes
DME Services	No PA Required	Wheelchairs	K0739
Surgery Procedure	PA Required	Digestive System	43281,43282,49329
		Male Genitalia	55866
		Musculoskeletal System	28308
	No PA Required	Facial, Cranial &TMJ Procedures	21230
		Vascular	36483

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