Important Prior Authorization Updates

Date: 08/15/25

Effective: October 15, 2025

Thank you for being a participating provider with Peach State Health Plan. As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, we want to share some important updates to our PA requirements. This work is aligned with broader industry efforts, driven by commitments to regulatory agencies and America’s Health Insurance Plans (AHIP), to modernize and streamline prior authorization. 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 Peach State Health Plan, can be found on our website at PSHP.com. These changes may include:

• Removing PA requirements based on criticality of review and clinical need.
• Creating a more uniform set of prior authorization requirements, 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 (PA) codes or how these changes affect your practice, please reach out to your local Provider Engagement representative or contact Peach State Health Plan’s provider services team at 1-866-874-0633.

 

	PA Rule	Services	Procedure Codes
Behavioral Health	PA Required	Psychotherapy	90847, 90853
		Substance Abuse Treatment	H0004
		Treatment Services	90867, 90868, H2014, H2017, H2019, H2027
Cardiovascular	PA Required	Cardiovascular Tests	93623
		Heart Surgery	93656
DME Services	PA Required	Nutritional Services	B4158, B4159, B4160, B4161
	No PA Required	Wheelchairs	E1140
Drug Codes	PA Required	Diabetic Drugs and Supplies	A4239
		Injections	Q5121
	No PA Required	Injections	J2469
		Medications	J3489
Genetic Analysis	PA Required	Genetic Testing	81416, 81420
	No PA Required	Genetic Testing	81244, 81331
Home Services	PA Required	Nursing Services	T1002
	No PA Required	Home Management	S9211, S9214
		Home Therapy	97157
		Infusion Services	99601, 99602
Laboratory	No PA Required	Pathology	81270
Other Medical Services	PA Required	Other Services	T1025
	No PA Required	Other Services	97012, 97014, 97032, 97033,97760
		Wound Care	T1016
Physical Medicine	PA Required	Orthotic and Prosthetic	Q4121, Q4160, Q4195, Q4196
Physician Services	No PA Required	Education Services	S9140
Skin Procedures	PA Required	Muscle Flap Procedures	15734
Surgery Procedures         Surgery Procedures	PA Required       PA Required	Cardiovascular System	37243
		Digestive System	49505, 49591, 49593, 49595, 49650
		Female Genitalia	58661
		Integumentary System	19301
		Male Genitalia	54360
	No PA Required	Female Genitalia	58940
		Vascular	36471, 36479
Transportation Services	PA Required	Medical Transportation	A0428, A0435

 

 

 

 

 

 

 

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