Prior Authorizations

• Medical

  Surgical

  NICU

• Notification required within 24 hours of admission or next business day.
• Clinical updates required with continued stay.

• Elective Procedures/Surgery
• LTAC, Rehabilitation, SNF
• Radiology Procedures Requiring Inpatient or Observation
• All Bariatric Procedures
• All Transplants, excluding cornea

• All elective admissions
• Admission to any long-term acute care, rehabilitation or skilled nursing facility
• Observation Stays Extending Beyond 48 hours
• Including initial evaluation for Transplant

• Induction of labor- if prior to 39 weeks gestation
• OB ultrasound over 2 per pregnancy
• Stays over 2 days for Vaginal delivery
• Stays over 4 days for Cesarean deliver

• Termination of pregnancy
• Scheduled C-Section
• Outpatient surgery
• EGD, Colonoscopy
• Cardiac cath

Determined by Coastal Care Services

Private duty nursing for children age 20 or younger

• Personal care services for children age 20 or younger
• Clinical updates required with continued review, incorporate review requirements during review process

• Inpatient

• Outpatient

Determined by Coastal Care Services

Physical / Occupational / Speech / Respiratory Therapies

• Prior authorization after initial evaluation

• Auto auth first 8 visits- > 8 requires clinical

• CT/CTA
• MRI/MRA
• PET/SPECT
• Nuclear Medicine Studies

Exclusions: Imaging rendered in the following settings DOES NOT require prior authorization:

• Emergency department
• Inpatient setting
• Observation unit

Determined by Coastal Care Options

Orthotics/Prosthetics >$500 (carved out by Coastal)

No Prior authorization if in a clinic or office setting; prior authorization is required if done in an outpatient hospital setting

• Inpatient

Exclusions: Imaging rendered in the following settings DOES NOT require prior authorization:

• Outpatient

• Facility based only

Determined by Beacon Health Options

Non-emergent Ground Ambulance Transport , Air Medical Transport (OneCall)

Those services that fall under the medical benefit (eg Orthognathic surgery)

• Not required for Enrollees ages 50 and older

• Not required for Enrollees ages 65 and older