Prior authorization is required for all services provided to 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:
- Call the prior authorization line at 1-888-244-5410.
- Complete the prior authorization form (PDF) or the skilled nursing facilities prior authorization form (PDF) and fax it to 1-888-257-7960.
- You may also submit a prior authorization request via NaviNet.
- For Behavioral Health requests, please call 1-888-978-1730 or fax 1-855-396-5730.
- 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)**
- 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.
- Inpatient 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 home or outpatient setting, after the first visit per therapy discipline/type.
- Cardiac rehabilitation.
- Transplants, including transplant evaluations.
- Medicare-covered DME items over $500 for purchase and all rental items.
- Medicare covered DME/medical supply/prosthetic device purchases.
- Medicare-covered prosthetics and orthotics in excess of $500 for purchase and all rental items.
- Nutritional Supplement.
- Hyperbaric oxygen.
- Surgery (for sleep apnea/uvulopalatopharyngoplasty (UPPP).
- Religious Non-Medical Health Care Institutions (RNHCI).
- Surgical services that may be considered cosmetic, including but not limited to:
- Mastectomy for gynecomastia.
- Penile prosthesis.
- Plastic surgery/cosmetic dermatology.
- Reduction mammoplasty.
- Cochlear implantation.
- Gastric bypass/vertical band gastroplasty.
Pain management – external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and injections/nerve blocks.
- Radiology outpatient services:
- CT Scan.
- PET Scan.
- SPECT scan.
- Nuclear Cardiac Imaging.
- Family planning services. For Family planning services, the enrollee must receive authorization from their PCP or Physician Specialist; member does not need authorization from the Plan.
- Nursing home care.
- Nursing home transition services.
- Pulmonary rehabilitation services.
- Sexually transmitted infections (STIs) screening and counseling.
- Skilled nursing facility services.
- 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 and Medicaid 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, 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.