Prior Authorizations

Prior Authorizations

Provider Prior Authorization Request Line

Phone: 844-716-5385

TDD/TTY: 711

FAX: 1-866-265-5511

Prior Authorization/Referral Requirements Effective: 1/1/2019

All Non-Par Provider Requests Requires Authorization Regardless of Service

Medical Services Require Prior Authorization

Inpatient Acute Hospital Admissions:
  • Medical

    Surgical

    NICU

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

Services performed in hospital outpatient facility

  • 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
Outpatient Bariatric Procedures
Home Health Services

Determined by Coastal Care Services

Private Duty Nursing

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
Intensive Cardiac and Pulmonary Rehabilitation Services
  • Inpatient
  • Outpatient
Home Infusion / IVT

Determined by Coastal Care Services

Outpatient Therapy

Physical / Occupational / Speech / Respiratory Therapies

  • Prior authorization after initial evaluation
Chiropractic Services
  • Auto auth first 8 visits- > 8 requires clinical
Advanced Imaging:
  • 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
Durable Medical Equipment (DME)/External Prosthetic Appliances (EPA) and Supplies

Determined by Coastal Care Options

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

Hearing Aids
Hospital Grade Breast Pumps
Outpatient Chemotherapy treatment Facility Charge

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

All Potentially Cosmetic Surgery
Any Experimental / Investigational
Pain Management; Outpatient
Acupuncture
All non-participating providers (All OON services)
  • Inpatient

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

  • Outpatient
Sleep studies –facility based
  • Facility based only
Molecular Diagnostics Testing (DNA and Genetic testing)
Behavioral Health

Determined by Beacon Health Options

Pharmacy See PDL
Transportation/Transfers

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

Dental Procedures

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

Shingles Vaccine for Enrollees ages 18-49
  • Not required for Enrollees ages 50 and older
Pneumonia Vaccine for Enrollees ages 18-64
  • Not required for Enrollees ages 65 and older

DME and Home Health Services Require Prior Authorization (Coastal Care Services)

Durable Medical Equipment (DME)/External Prosthetic Appliances (EPA) and Supplies

Determined by Coastal Care Options

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

Home Infusion / IVT

Determined by Coastal Care Options

Home Health Services

Determined by Coastal Care Options