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Prior Authorization

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:
    • Blepharoplasty.
    • Mastectomy for gynecomastia.
    • Mastopexy.
    • Maxillofacial.
    • Panniculectomy.
    • Penile prosthesis.
    • Plastic surgery or cosmetic dermatology.
    • Reduction mammoplasty.
    • Septoplasty.
    • Cochlear implantation.
    • Gastric bypass or vertical band gastroplasty.
    • Hysterectomy.
  • 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.

H8213_001_WEB_318369 _Approved_11132018