Prior authorization is required for all referrals to out-of-network providers, with the exception of emergency services. To submit a request for prior authorization, providers may call the prior authorization line at 1-888-244-5410. Or, providers can fill out this prior authorization form (PDF) for prior authorization requests and fax it to 1-888-257-7960.
Services that require prior authorization by First Choice VIP Care Plus (Medicare-Medicaid Plan)**
- Elective non-emergent air ambulance transportation.
- All out-of-network services (excluding emergency services).
- In-patient services:
- All in-patient hospital admissions, including medical, surgical, skilled nursing and rehabilitation services.
- In-patient diabetes programs and supplies.
- In-patient medical detoxification.
- Elective transfers for inpatient and/or outpatient services between acute care facilities outpatient mental health care.
- Certain outpatient diagnostic tests.
- Therapy and related services:
- Speech therapy, occupational therapy and physical therapy provided in a home or outpatient setting, after the first visit per therapy discipline or type.
- Cardiac rehabilitation.
- Transplants, including transplant evaluations.
- Medicare-covered durable medical equipment (DME) items over $500 for purchase and all rental items.
- Healthy Connections Medicaid-covered DME, medical supply, or prosthetic device purchases.
- Medicare-covered prosthetics and orthotics in excess of $500 for purchase and all rental items.
- Nutritional supplements.
- Hyperbaric oxygen.
- Surgery for sleep apnea (uvulopalatopharyngoplasty [UPPP]).
- Religious non-medical health care institutions (RNHCIs).
- Surgical services that may be considered cosmetic, including but not limited to:
- Mastectomy for gynecomastia.
- Penile prosthesis.
- Plastic surgery or cosmetic dermatology.
- Reduction mammoplasty.
- Cochlear implantation.
- Gastric bypass or vertical band gastroplasty.
- Pain management — External infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and injections or nerve blocks.
- Radiology outpatient services:
- Computed tomography scan.
- Positron emission tomography scan.
- Magnetic resonance imagery.
- Magnetic resonance angiography.
- Magnetic resonance spectroscopy.
- Single-photon emission computed tomography scan.
- Nuclear cardiac imaging.
- Nursing home care.
- Nursing home transition services.
- Pulmonary rehabilitation services.
- Skilled Nursing Facility.
- Targeted case management (TCM).
- Waiver-like services.
- All miscellaneous, unlisted, or not otherwise specified codes.
- All services that may be considered experimental and/or investigational.
**All requests for services are subject to Medicare coverage guidelines and limitations
Prior authorization is not required for the following services
- Non-emergency ambulance requests to or from a facility.
- Emergency and post-stabilization services (in- and out-of-network), including emergency behavioral health care, urgent care, low-level plain films, X-rays, electrocardiograms, crisis stabilization (including mental health care), preventive services, communicable disease services (including STI and HIV testing), and out-of-area renal dialysis services.
- Outpatient behavioral health and substance use services.