What Services Require Prior Authorization

Prior authorization is the urgent or non-urgent authorization of a requested service prior to receiving the service. Prior authorization is designed to facilitate early identification of the treatment plan to ensure medical management and available resources are provided throughout an episode of care. The Member is ultimately responsible for obtaining prior authorization from the Health Services Department in order to receive in-network coverage. However, information provided by the provider’s office will also satisfy this requirement.

 

• Inpatient hospital admissions including admissions for medical, surgical, obstetric, neonatal intensive care nursery, rehabilitation, mental health and chemical dependency services;
• Partial Hospital Program (PHP)/Day Treatment for mental health;
• Selected outpatient surgeries;
• Home health and home IV therapy services;
• Skilled nursing, hospice, and swing bed / sub-acute care;
• Organ transplants;
• Ambulance services for non-emergency situations;
• Referrals to non-participating providers which are recommended by participating providers. Selected injectable medications;
• PET Scans;
• Dental anesthesia for children under 5 and for those with a developmental disability;
• Selected durable medical equipment, including, but not limited to the following: