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Prior Authorization

Information needed for Utilization Management authorization requests:

  • Member's Plan ID number.
  • Member’s name.
  • Member’s date of birth.
  • Diagnosis/diagnoses codes (ICD-10).
  • Requested CPT codes.
  • Date of service.
  • Ordering/referring doctor NPI.
  • Facility/treating provider NPI.
  • Applicable clinical information.

Important payment notice

Please note that reimbursement for all rendering network providers subject to the ordering/referring/prescribing (ORP) requirement for an approved authorization is determined by satisfying the mandatory requirement to have a valid Pennsylvania Medical Assistance (MA) Provider ID. Effective January 1, 2018, any claim submitted by rendering network providers that are subject to the ORP requirement will be denied when billed with the NPI of an ORP provider that is not enrolled in MA.

To check the MA enrollment status of the practitioner ordering, referring, or prescribing the service you are providing, visit the DHS provider look-up portal.

Services that require prior authorization

  • All elective (scheduled) inpatient hospital admissions medical and surgical including rehabilitation.
  • All elective transplant evaluations and procedures.
  • Elective/non-emergent air ambulance transportation.
  • All elective transfers for inpatient and/or outpatient services between acute care facilities.
  • Skilled nursing facility admission for alternate levels of care in a facility, either free-standing or part of a hospital, that accepts patients in need of skilled-level rehabilitation and/or medical care that is of a lesser intensity than that received in a hospital, not to include long-term care placements.
  • Gastroenterology services (codes 91110 and 91111 only).
  • Bariatric surgery.
  • Prior authorization is required for all pain management services, with the exception of services that are on the Pennsylvania Medical Assistance (PA MA) fee schedule and are provided in a participating physician office setting (POS 11).
  • Cosmetic procedures regardless of treatment setting including but not limited to the following: reduction mammoplasty, gastroplasty, ligation and stripping of veins, and rhinoplasty.
  • Outpatient therapy services (physical, occupational, speech).
    • Prior authorization is not required for an evaluation and up to 24 visits per discipline within a calendar year.
    • Prior authorization is required for services exceeding 24 visits per discipline within a calendar year.
  • Home health services performed by a network provider.
    • Prior authorization is not required for up to six visits per modality per calendar year including: skilled nursing visits by an R.N. or L.P.N.; home health aide visits; physical therapy; occupational therapy; and speech therapy.
    • The duration of services may not exceed a 60-day period. The member must be re-evaluated every 60 days.
    • All shift care/private duty nursing services require prior authorization including services performed at a medical daycare or prescribed pediatric extended care center (PPECC).
    • Injectables.
    • Home sleep study.
  • Durable medical equipment (DME) monthly rentals:
    • DME monthly rentals of items in excess of $750 per month.
  • DME purchases:
    • Purchase of all items in excess of $750.
    • The purchase of all wheelchairs (motorized and manual) and all wheelchair items (components) regardless of cost per item.
    • Enterals:
      • Prior authorization is required for members over age 21.
      • Prior authorization is required when the request is in excess of $500/month for members under age 21.
    • Diapers/Pull-ups
      • Any request in excess of 300 diapers or pull-ups per month or a combination of both requires prior authorization.
      • Any request in excess of 300 diapers or pull-ups or a combination of both will be reviewed for medical necessity.
      • Requests for brand-specific diapers require prior authorization.
      • Requests for diapers supplied by a DME provider (other than J&B Medical Supply) require prior authorization. Refer to the DME section of the Provider Manual for complete details.
  • Select radiological exams ― excludes radiological studies that occur during inpatient, emergency room, and/or observation stays.
    • Positron emission tomography.
    • Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA).
    • Nuclear cardiology diagnostic testing.
    • Computed axial tomography (CT/CAT scans) and CT angiography.
  • Cardiac or pulmonary rehabilitation.
  • Chiropractic services after the initial visit.
  • Any service(s) performed by nonparticipating or non-contracted practitioners or providers, unless the service is an emergency service.
  • All services that may be considered experimental and/or investigational.
  • Neurological psychological testing.
  • Genetic laboratory testing.
  • All miscellaneous/unlisted or not otherwise specified codes.
  • Any service/product not listed on the Medical Assistance fee schedule or services or equipment in excess of limitations set forth by the Department of Health and Human Services fee schedule, benefit limits, and regulation. (Regardless of cost, i.e., above or below the $750 DME threshold).
  • Ambulance transportation to and from a PPECC/medical daycare.
    • Member is <21 years of age.
    • Member is approved for services at a PPECC/medical daycare.
    • Member requires intermittent or continuous oxygen, ventilator support, and/or critical physiologic monitoring or critical medication(s) during transport requiring ambulance level of care.
    • There are no existing mechanisms for caregivers to transport the member.
    • Requests for ambulance services are prior authorized along with initial request for PPECC/medical daycare services, with each reauthorization of medical daycare services, and/or when there is a change in level of care regarding oxygen, ventilator support, and/or specific medical treatment during transport.
    • Member Services’ Transportation Department will be notified with each ambulance approval to initiate and/or continue ambulance transport services.
  • Select prescription medications. For information on which prescription drugs require authorization, see the Searchable Formulary.
  • Select dental services. For information on which dental services require prior authorization, please refer to the Dental Services section of the Provider Manual.
  • Elective termination of pregnancy – Refer to the Termination of Pregnancy section of the Provider Manual for complete details.

Prior authorization is not a guarantee of payment for the service(s) authorized. The plan reserves the right to adjust any payment made following a review of medical record and determination of medical necessity of services provided.

Any additional questions regarding prior authorization requests may be addressed by calling 1-888-498-0504.

Emergency room, Observation Care, and inpatient imaging procedures do not require prior authorization.