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Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 68

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
Q4226MyOwn Skin, includes harvesting and preparation procedures, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4227AmnioCore, per sq cmNew Hampshire Precertification List, Pg 258 Original policy
Q4229Cogenex Amniotic Membrane, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4230Cogenex Flowable Amnion, per 0.5 ccNew Hampshire Precertification List, Pg 259 Original policy
Q4231Corplex P, per ccNew Hampshire Precertification List, Pg 259 Original policy
Q4232Corplex, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4233SurFactor or NuDyn, per 0.5 ccNew Hampshire Precertification List, Pg 259 Original policy
Q4234XCellerate, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4235AMNIOREPAIR or AltiPly, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4236carePATCH, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4237Cryo-Cord, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4238Derm-Maxx, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4239Amnio-Maxx or Amnio-Maxx Lite, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4240CoreCyte, for topical use only, per 0.5 ccNew Hampshire Precertification List, Pg 259 Original policy
Q4241PolyCyte, for topical use only, per 0.5 ccNew Hampshire Precertification List, Pg 259 Original policy
Q4242AmnioCyte Plus, per 0.5 ccNew Hampshire Precertification List, Pg 259 Original policy
Q4245AmnioText, per ccNew Hampshire Precertification List, Pg 259 Original policy
Q4246CoreText or ProText, per ccNew Hampshire Precertification List, Pg 259 Original policy
Q4247AmnioText Patch, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4248Dermacyte Amniotic Membrane Allograft, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4249AMNIPLY, for topical use only, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4250AmnioAmp-MP, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4251Vim, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4252Vendaje, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4253Zenith Amniotic Membrane, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4254Novafix DL, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4255REGUaRD, for topical use only, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4256MLG-Complete, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4257Relese, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4258Enverse, per sq cmNew Hampshire Precertification List, Pg 259 Original policy
Q4259Celera Dual Layer or Celera Dual Membrane, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4260Signature APatch, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4261TAG, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4262Dual Layer Impax Membrane, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4263SurGraft TL, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4264Cocoon Membrane, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4265NeoStim TL, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4266NeoStim Membrane, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4267NeoStim DL, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4268SurGraft FT, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4269SurGraft XT, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4270Complete SL, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4271Complete FT, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4272Esano A, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4273Esano AAA, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4274Esano AC, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4275Esano ACA, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4276ORION, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4278EPIEFFECT, per sq cmNew Hampshire Precertification List, Pg 260 Original policy
Q4279Vendaje AC, per sq cmNew Hampshire Precertification List, Pg 260 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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