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:
Medical services (excluding certain radiology – see below):
- Call the prior authorization line at 1-888-244-5410
- Complete one of the following forms and fax to 1-888-257-7960:
- Prior Authorization Request Form PDF
- Skilled Nursing Facilities Prior Authorization Request Form PDF
- Clinical Review for Outlier Days to Original DRG Approval Request Form PDF - To request outlier days beyond originally approved DRG.
- You may also submit a prior authorization request via NaviNet.
Behavioral health services:
- Call 1-888-978-1730
- Complete one of the following forms and fax to 1-855-396-5730:
- 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:
- PET Scan
- Myocardial Perfusion Imaging
- MUGA Scan
For prescription drugs not found on our formulary, an exception can be requested by completing the following:
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.
- Surgical services that may be considered cosmetic, including but not limited to:
- Mastectomy for gynecomastia.
- Penile prosthesis.
- Plastic surgery/cosmetic dermatology.
- Reduction mammoplasty.
- Gastric bypass/vertical band gastroplasty.
- Transplants, including transplant evaluations.
- Certain outpatient diagnostic tests.
- Radiology outpatient services (authorized by NIA):
- CT scan.
- PET scan.
- SPECT scan.
- Nuclear cardiac imaging.
- 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.