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Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 66

CPT code lookup

Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.

Prior authorization codes

Prior authorization codes
CodeDescriptionSource
Q4114Integra flowable wound matrix, injectable, 1 ccNew Hampshire Precertification List, Pg 255 Original policy
Q4115AlloSkin, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4116AlloDerm, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4117HYALOMATRIX, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4118MatriStem micromatrix, 1 mgNew Hampshire Precertification List, Pg 255 Original policy
Q4121TheraSkin, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4122DermACELL, DermACELL AWM or DermACELL AWM Porous, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4124OASIS ultra tri-layer wound matrix, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4125Arthroflex, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4126MemoDerm, DermaSpan, TranZgraft or InteguPly, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4127Talymed, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4128FlexHD, or AllopatchHD, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4130Strattice TM, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4132Grafix Core and GrafixPL Core, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4133Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4134HMatrix, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4135Mediskin, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4136EZ Derm, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4137AmnioExcel, AmnioExcel Plus or BioDExcel, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4138BioDFence DryFlex, per sq cmNew Hampshire Precertification List, Pg 255 Original policy
Q4139AmnioMatrix or BioDMatrix, injectable, 1 ccNew Hampshire Precertification List, Pg 256 Original policy
Q4140BioDFence, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4141AlloSkin AC, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4142XCM biologic tissue matrix, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4143Repriza, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4145EpiFix, injectable, 1 mgNew Hampshire Precertification List, Pg 256 Original policy
Q4146TENSIX, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4147Architect, Architect PX, or Architect FX, extracellular matrix, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4148Neox Cord 1K, Neox Cord RT, or Clarix Cord 1K, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4149Excellagen, 0.1 ccNew Hampshire Precertification List, Pg 256 Original policy
Q4150AlloWrap DS or dry, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4151AmnioBand or Guardian, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4152DermaPure, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4153Dermavest and Plurivest, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4154Biovance, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4155Neox Flo or Clarix Flo 1 mgNew Hampshire Precertification List, Pg 256 Original policy
Q4156Neox 100 or Clarix 100, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4157Revitalon, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4158Kerecis Omega3, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4159Affinity, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4160NuShield, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4161bio-ConneKt wound matrix, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4162WoundEx Flow, BioSkin Flow, 0.5 ccNew Hampshire Precertification List, Pg 256 Original policy
Q4163WoundEx, BioSkin, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4164Helicoll, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4165Keramatrix or Kerasorb, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4166Cytal, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4167Truskin, per sq cmNew Hampshire Precertification List, Pg 256 Original policy
Q4168AmnioBand, 1 mgNew Hampshire Precertification List, Pg 257 Original policy
Q4169Artacent wound, per sq cmNew Hampshire Precertification List, Pg 257 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.

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