Policy Updates Prior AuthorizationMO HealthNet Managed Care (Medicaid)April 29, 2025

Prior authorization requirement changes

Effective June 1, 2025, precertification/prior authorization requirements will change for the following code(s). The medical code(s) listed below will require precertification/prior authorization by Healthy Blue for Medicaid members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification/prior authorization rules and must be considered first when determining coverage.

If the requirements are not met, those services may be deemed ineligible for payment. Providers may appeal online through Availity Essentials or by calling 833‑405‑9086 with additional information that may include medical records.

Precertification/prior authorization requirements will be added for the following code(s):

Code

Description

L5841

Addition, endoskeletal knee-shin system, polycentric, pneumatic swing, and stance phase control

To request precertification/prior authorization, you may use one of the following methods:

Not all precertification/prior authorization requirements are listed here. Detailed precertification/prior authorization requirements are available to contracted and noncontracted providers on the provider website at https://provider.healthybluemo.com > Prior Authorization & Eligibility > Prior Authorization Look Up Tool. Providers may also call our Provider Services at 833‑405‑9086 for assistance with precertification/prior authorization requirements.

UM AROW A2025M3000

Healthy Blue is a Medicaid product offered by Missouri Care, Incorporated, a MO HealthNet Managed Care health plan contracting with the Missouri Department of Social Services. Healthy Blue is administered statewide by Missouri Care, Incorporated and administered in the Kansas City service region by Missouri Care, Incorporated in cooperation with Blue Cross and Blue Shield of Kansas City. Missouri Care, Incorporated and Blue Cross and Blue Shield of Kansas City are both independent licensees of the Blue Cross Blue Shield Association.

MOHB-CD-078338-25

PUBLICATIONS: June 2025 Provider Newsletter