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:
DME REQUIRING PRE-AUTH(includes Rental and Purchase)
This list does not include "EXCLUDED" services.
RESPIRATORY
Chest Drainage Vest/Percussion
high freq chest wall oscillation system device/vest
chest shell
chest wrap
rocking bed
intrapulmonary percussive ventilation system
cough stimulating device
Ventilators
Pleural Catheter/Vacuum System
canisters and tubing
Respiratory Suction Pump
IPPB (intermittent positive pressure breathing) Machines
including humidifiers used with IPPB machines
Small Volume Nebulizer-Battery Operated (E0571)
GASTROINTESTINAL
Enteral Medical Supplies and Formulae
Parenteral Nutrition
Parenteral/Enteral Pumps
Gastric Suction Pump
portable/stationary
canisters and tubing
BEDS
Hospital Beds
air fluidized
electric-semi/total-heavy duty/extra wide
circulating/stryker frame
mattresses
bed cradle
bed side rails
safety enclosure frame/canopy
electronic bowel irrigation/evacuation system
MUSCULOSKELETAL
TENS-transcutaneous electrical nerve stimulation
2 lead/4 lead
form fitting conductive garment
Neuromuscular Stimulator
EMG biofeedback device
implantable electrode/patient programmer/transmitter
galvonic stimulator (6 month max. auth)
CPM-continuous passive motion machine
Bone Growth Stimulator
osteogenesis stimulator-non-invasive/surgical implant
Prosthetic Limbs-L5000-L7274
accessories and repairs
All wheelchairs/Repairs and Accessories
Orthotics
cranial orthosis
external powered wrist-hand-finger orthosis
INTEGUMENTARY
Wound Vacuum Systems
canisters and tubing
portable/stationary
MISCELLANEOUS
Home IV Therapy
medications
supplies/pumps
NO PRIOR AUTHORIZATION REQUIRED
CPAP
Apnea Monitor
BIPAP
Nebulizer Excluding Small Volume
L Codes that Meet the Diagnosis Criteria |
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