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Prior Authorization

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:
    • Blepharoplasty.
    • Mastectomy for gynecomastia.
    • Mastopexy.
    • Maxillofacial.
    • Panniculectomy.
    • Penile prosthesis.
    • Plastic surgery/cosmetic dermatology.
    • Reduction mammoplasty.
    • Septoplasty.
    • Cochlear implantation.
    • Gastric bypass/vertical band gastroplasty.
    •  Hysterectomy.
  • Pain management – external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and injections/nerve blocks.
  • Radiology outpatient services:
    • CT Scan.
    • PET Scan.
    • MRI.
    • MRA.
    • MRS.
    • 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.
  • SNF.
  • 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.

H8213_001_WEB_318369 _Approved_11132018