Prior Authorization

Prior authorization is required for all referrals to out-of-network providers, with the exception of emergency services. To submit a request for prior authorization, providers may call the prior authorization line at 1-888-244-5410. Or, providers can fill out this prior authorization form (PDF) for prior authorization requests and fax it to 1-888-257-7960.

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 services.
  • In-patient diabetes programs and supplies.
  • In-patient medical detoxification.
  • Elective transfers for in-patient 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 a home or outpatient setting, after the first visit per therapy discipline or type.
  • Cardiac rehabilitation.
• Transplants, including transplant evaluations.
• Medicare-covered durable medical equipment (DME).
• Healthy Connections Medicaid-covered DME, medical supply, or prosthetic device purchases.
• Medicare-covered prosthetics and orthotics.
• Nutritional supplements.
• Hyperbaric oxygen.
• Surgery for sleep apnea (uvulopalatopharyngoplasty [UPPP]).
• Religious non-medical health care institutions (RNHCIs).
• Surgical services that may be considered cosmetic, including but not limited to:
  • Blepharoplasty.
  • Mastectomy for gynecomastia.
  • Mastopexy.
  • Maxillofacial.
  • Panniculectomy.
  • Penile prosthesis.
  • Plastic surgery or cosmetic dermatology.
  • Reduction mammoplasty.
  • Septoplasty.
  • Cochlear implantation.
  • Gastric bypass or vertical band gastroplasty.
  • Hysterectomy.
• Pain management — External infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and injections or nerve blocks.
• Radiology outpatient services:
  • Computed tomography scan.
  • Positron emission tomography scan.
  • Magnetic resonance imagery.
  • Magnetic resonance angiography.
  • Magnetic resonance spectroscopy.
  • Single-photon emission computed tomography scan.
• Nuclear cardiac imaging.
• Nursing home care.
• Nursing home transition services.
• Pulmonary rehabilitation services.
• Skilled Nursing Facility.
• 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 Medicaid and/or Medicare coverage guidelines and limitations