Prior Authorization Overview

Prior Authorization is required for:

• All inpatient stays for medical and/or psych and substance abuse.
• All outpatient surgeries not done in a doctor’s office.
• All services listed below regardless of place of service.

1. 1. 23 – hour Observation stays
   2. Deviated Septum/Nasal Surgery
   3. EBCT (Electron Beam Tomography)
   4. Endoscopic Procedures
   5. MRI/CT/Pet Scan- excludes bone density studies
   6. Physical/Occupational/Speech Therapy - beyond 12 visits
   7. Any Drug above $1500 a dose or the amount listed in the plan document
   8. Biologic Drugs
   9. Chemotherapeutic Drugs
   10. Dialysis
   11. DME (rental or purchase) over $1000 or the amount listed in the plan document
   12. Epidural/ facet and trigger point injections
   13. Extended Nursing Facility
   14. Gastric Bypass / Panniculectomy /Abdominoplasty
   15. Home Health Care
   16. Hospice Care
   17. Infusions (Infusion Therapy) of any type over $1500 or the amount listed in the plan document
   18. Long Term Acute Care (LTAC)
   19. Behavioral Health: Intensive Out Patient Program, Residential Treatment Centers, Partial Hospitalization Program
   20. Radiation Treatments
   21. Skilled Nursing Facility (SNF)
   22. Inpatient Rehabilitation
   23. Cosmetic Surgery Potentials:
   24. Mammoplasty
   25. Blepharoplasty
   26. Varicose Veins stripping and ligation
   27. On-going Wound Care
   28. Other

Please note, all services are subject to medical necessity.

Click to submit a Prior Authorization Form