Prior Authorization

Prior Authorization Lookup Tool

Prior authorization is required for all services provided by non-participating physicians and providers, with the exception of emergency services. Prior authorization is required for other services such as those listed below. To submit a request for prior authorization providers may:

  • Radiological Services:
      • For the following non-emergent outpatient radiological procedures contact National Imaging Associates, Inc. (NIA) at 1-888-642-4814 or visit www.radmd.com:
      • CT/CTA
      • CCTA
      • MRI/MRA
      • PET Scan
      • Myocardial Perfusion Imaging
      • MUGA Scan

   If the request is denied, you can request an appeal on the member’s behalf by completing the following:

  • Please remember to submit all relevant clinical documentation to support the requested services/items at the time of your request.

    Services that require Prior Authorization by First Choice VIP Care Plus (Medicare-Medicaid Plan)**

    • All out-of-network services (excluding emergency services).
    • All inpatient hospital admissions, including medical, surgical, skilled nursing, and rehabilitation.
    • Elective transfers for inpatient and/or outpatient services between acute care facilities.
    • Inpatient services.
    • Surgery.
    • Surgical services that may be considered cosmetic, including but not limited to:
      • Blepharoplasty.
      • Mastectomy for gynecomastia.
      • Mastopexy.
      • Maxillofacial.
      • Panniculectomy.
      • Penile prosthesis.
      • Plastic surgery/cosmetic dermatology.
      • Reduction mammoplasty.
      • Septoplasty.
      • Gastric bypass/vertical band gastroplasty.
    • Transplants, including transplant evaluations.
    • Certain outpatient diagnostic tests.
    • Radiology outpatient services (authorized by NIA):
      • CT scan.
      • PET scan.
      • MRI.
      • MRA.
      • MRS.
      • SPECT scan.
      • Nuclear cardiac imaging.
    • Ambulance:
      • Elective/nonemergent air ambulance transportation.
      • Certain types of scheduled, nonemergency ambulance trips.
    • Home health.
    • Cardiac and pulmonary rehabilitation.
    • Speech therapy, occupational therapy, and physical therapy provided in home or outpatient setting, after the first visit, per therapy discipline/type.
    • Durable medical equipment (DME):
      • All DME rentals and rent-to-purchase items.
      • Purchase of all items in excess of $500 in total allowable charges.
      • Prosthetics and orthotics in excess of $500 in total allowable charges.
      • The purchase of all wheelchairs (motorized and manual) and all wheelchair accessories (components), regardless of cost per item.
    • Medications: All infusion/injectable medications listed on the Medicare Professional Fee Schedule — infusion/injectable medications not listed on the Medicare Professional Fee Schedule are not covered.
    • Pain management — external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, and injections/nerve blocks,
    • Nutritional supplements.
    • Hyperbaric oxygen.
    • Religious Non-Medical Health Care Institutions (RNHCI).
    • All “miscellaneous”, “unlisted”, or “not otherwise specified” codes.
    • All services that may be considered experimental and/or investigational. 
    • Medicaid sponsored Long-Term Care nursing facility admission — notification only.
    • Medicaid covered DME/medical supply/prosthetic device purchases.

    **All requests for services are subject to Medicare and Medicaid coverage guidelines and limitations

    Prior authorization is not required for the following services

    • Non-emergency ambulance requests between an acute and a sub-acute facility do not require a prior authorization.
    • Emergency and post stabilization services, including emergency behavioral health care; urgent care, low level plain films, x-rays, EKGs; crisis stabilization, including mental health; preventive services; communicable disease services, including STI and HIV testing; post-stabilization care services (in and out of network); and, out-of-area renal dialysis services.
    • Outpatient behavioral health and substance abuse services.