Prior Authorizations

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

Prior Authorization Guide

Prior Authorization Request

Specialty Drug List

All Non-Par Provider Requests Requires Authorization Regardless of Service
AUTHORIZATION REQUIREMENTS

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

  • 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 delivery
  • Termination of pregnancy
  • Scheduled C-Section

Services performed in hospital outpatient facility

  • 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

High Dollar Medications & Pharmaceuticals (>$1000)

Medications administered in office setting, otherwise through Pharmacy benefit

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
  • 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

*All out-of-network physicians and hospital and ancillary service requests require prior authorization.

 

Vision Services Require Prior Authorization (iCare Health Solutions)

 

Cataract Extraction and Related Procedures

Plastics

  • Blepharoplasty
  • Repairs
  • Lesion Excision

Strabismus Surgery

Corneal Related Procedures

 

Yag Capsulotomies

Miscellaneous

  • Botox
  • Punctual Plugs
  • Fitting of Contact Lens for Treatment of ocular surface disease
  • EOG, I&R
  • ERG, I&R
  • Anterior Segment Imaging
  • Visual Evoked Potetnial

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