Provider Manual - Pre-authorization

The following require written pre-authorization

1. An otherwise non-covered dental procedure performed in an outpatient facility for a patient who is six years and older, and is at high risk due to a medical diagnosis (such as a heart condition).
2. Any restoration made necessary as a result of mastectomy when surgery is performed more than five years post mastectomy, or more than three years after initial reconstructive surgery.
3. All transplantation services, including care following a transplant performed prior to PEHP coverage.
4. Surgery that may be partially or wholly cosmetic in nature. (cosmetic surgery is not payable)
5. Surgeries performed in conjunction with obesity surgery, e.g., a gastric by-pass and gallbladder procedure performed during the same hospital stay. (obesity surgery is not payable)
6. External nasal surgery (rhinoplasty) as a result of an accident occurring in the preceding five years.
7. Implantation of artificial devices or artificial assist devices such as LVAD.
8. New technologies.
9. Cochlear implant surgery.
10. More than eight chiropractic visits in a plan year must be authorized through the Chiropractic Health Plan (CHP).
11. Diagnostic genetic testing in the course of evaluating a member for genetic or congenital disease.
12. Durable Medical Equipment (DME) over $750, or as listed in the Appendix.
13. Home intrauterine fetal monitoring.
14. Maxillary/Mandibular bone or Calcitite augmentation surgery.
15. All out-of-state surgery.
16. Botox injections.
17. Pelvic floor therapy.
18. Wound therapy.
19. Facet injections.
20. Trigger point injections.
21. Intrathecal pump.
22. Spinal cord stimulators.

The following require verbal pre-authorization

1. Function nasal surgery.
2. Inpatient mental health and substance abuse by calling the appropriate agency.
3. Home Health and Hospice Care must be pre-authorized through medical case management.
4. Hyperbaric oxygen treatments must be pre-authorized through medical case management.
5. Synagis/Respigam injections must be pre-authorized through medical case management.
6. Skilled nursing (SNF) in lieu of hospitalization must be pre-authorized through medical case management.
7. Dialysis must be pre-authorized through medical case management when using a non-Contracted Provider.
8. Brest pumps.
9. All inpatient maternity stays that exceed 48 hours following a vaginal delivery or 96 hours following delivery by Cesaerian Section.