Prior Authorization (PA) Updates (Effective 4/1/2026)

Date: 01/14/26

Heritage Health (Medicaid):

As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Nebraska Total Care 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 Relations representative.

Prior Authorization Updates (04/01/2026)
Service Category	PA Rule	Services	Procedure codes
Breast Services	No PA Required if billed with breast cancer diagnosis. PA Required if billed with any other diagnosis	Breast Reconstruction	19364
DME Services	PA Required	Beds	E0277
		Nutritional Services	B4102, B4103, B4104
		Orthotic & Prosthetic	S1040
		Wheelchairs	K0831
	PA Required after plan benefit limitation	Nutritional Services	B9998
	No PA Required if member is under 21 years old at date of service. PA Required for all other members.	Nutritional Services	B4100
Drug Codes	PA Required	Injections	J0878, J9356, Q5114
Genetic Analysis	PA Required	Genetic Testing	81201, 81202, 81203, 81455
Hearing Services	PA Required	Implants and Supplies	69930, V5160
Home Services	PA Required	Home Therapy	S5120, S5121
Laboratory	No PA Required for PAR providers	Drug Tests	80362
Other Medical Services	No PA Required for PAR providers	Wound Care	97605
Pain Management	PA Required	Surgery-Nervous System	64628, 64629
Physical Medicine	PA Required	Orthotic & Prosthetic	L5673
Physician Services	PA Required	Neurological Tests	95700, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95721, 95722, 95723, 95724, 95725, 95726
Physician Services	PA Required	Other Treatments	99199
Skin Procedures	PA Required	Skin Grafts	15271, 15274, 15275, 15276
	PA Required if billed with diagnosis of gender dysphoria. For all others, PA Required for Non-PAR Providers only	Skin Grafts	14060, 14061, 15100, 15101, 15120
	PA Required after 12 visits per calendar year	Surgery-Integumentary System	11043
Surgery Procedures	PA Required	Hysterectomies	58545
		Surgery-Cardiovascular System	37232, 37236, 37237, 37238, 37239, 37246, 37247, 37248, 37249
		Surgery-Digestive System	43659
		Surgery-Endocrine System	60240, 60252, 60500
		Surgery-Heart	92920
		Surgery-Musculoskeletal System	28285, 28296, 29999
		Surgery-Nervous System	64582
		Surgery-Respiratory System	30130, 30140, 31253, 31254, 31255, 31256, 31257, 31259, 31267
	No PA Required for PAR providers	Surgery-Integumentary System	13131, 13132, 13133

If you have questions, please contact Provider Relations.