MedicaidPrior AuthHigh impact
Service Limits for Procedure Code T1016 May be Exceeded with Prior Authorization
Nevada Medicaid·NV · Geriatrics, Palliative Care·Prior Authorization
Effective date
Aug 24, 2026
We identified it
Aug 25, 2026
Summary
Nevada Medicaid now allows prior authorization to exceed the 12-hour daily service limit for procedure code T1016 (Case Management, each 15 minutes) for five Home and Community Based Services Waiver programs with specialty 303 (Private Case Management). Claims exceeding 12 hours per day without prior authorization will continue to deny with error code 5738. This is a go-forward change with no retroactive reprocessing.
Action Required
By August 24, 2026: Billing team must implement prior authorization workflow for procedure code T1016 for Nevada Medicaid claims. Update billing software to: (1) flag claims for T1016 that exceed 12 hours per day and require prior authorization before submission; (2) link prior authorization status to claim processing rules to prevent denials with error code 5738. Providers (PT 48, 57, 58, 59, 95 with specialty 303) must submit prior authorization requests before billing for case management services exceeding 12 hours daily. Credentials staff should verify that applicable waiver programs are configured in the system. Failure to obtain prior authorization will result in claim denials for services exceeding the daily limit.