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Prior Authorization

Hurricane Irma Update

Due to the impending storm, the Prestige Utilization Management authorization process will be amended as follows:

  1. Inpatient admissions with admit date of service from September 7, 2017, through September 21, 2017, will not require prior authorization. Notification must be faxed or entered through the provider portal for accurate claims payment.
  2. Outpatient services provided from September 7, 2017, through September 21, 2017, will not require prior authorization. Notification must be faxed to ensure accurate claims payment.
  3. To facilitate discharge needs related to home health, home infusion, and durable medical equipment (DME), call Prestige Member Services at 1-855-355-9800 and request activation of the on-call process.

Prior authorization is the process of obtaining approval in advance of a planned inpatient admission or outpatient service. Prestige Health Choice will make an authorization decision based on the clinical information provided in the request.

Reasons for requiring authorization may include:

  • Review for medical necessity.
  • Appropriateness of rendering provider.
  • Appropriateness of setting.
  • Case and disease management considerations.

Services requiring prior authorization

All services listed below require prior authorization. This list is effective August 1, 2017. Refer to the comments for additional details specific to that service.

Service type

Comments

Abortions, elective

 

Admissions — inpatient

Includes surgical, medical, and inpatient medical detoxification and rehabilitation; obstetrical admissions and newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after cesarean section; and nursing facilities for members under 18 years old.

Air ambulance

 

Bariatric surgery/gastric  bypass

 

Chemotherapy

For medications covered under the medical benefit, only medications with billed charges of $250 or greater per line item require prior authorization.

Chiropractic services

Under age 21 only.

Circumcision

Prior authorization is required if the member is more than 90 days old.

Cochlear implants or implantation

 

Dermatology

Only surgery or procedures that could be considered cosmetic require prior authorization.

Diapers and pull-up diapers

Limited to ages 4 through 20 when medically necessary; when quantity is over 200 per month; if using brand name diapers or pull-up diapers; when supplied by a durable medical equipment (DME) provider.

DME and supplies

All rentals, custom equipment, and purchase items with billed charges of $750 or greater per line item. This includes non-custom orthotics.

Elective transfers for inpatient (IP) and/or outpatient (OP) services between acute care facilities

 

Enteral feedings

Including related DME.

Gastric bypass/vertical band gastroplasty

 

Home health services

Home physical therapy benefit has a four-visit limit per year for members over age 21.

Hospice

Only for skilled nursing facility room and board.

Hyperbaric oxygen therapy

 

Hysterectomy

 

Implants

Prior authorization needed only when billed charges are $750 or greater per line item.

Infusion or injectable medications in home

Prior authorization needed only when billed charges are $250 or greater per line item.

Insulin pumps

Considered under DME benefit.

Medications

Medications covered under medical benefit, including 17-P and all infusion and injectable medications, with billed charges of $250 per line item or greater. For specific pharmacy medication authorization requirements, visit the Prestige website at www.prestigehealthchoice.com/provider/itn/resources/prior-authorization.aspx.

Non-participating/Out of network services (all services)

 

Oral or maxillofacial surgery

Provided through Argus. Contact Argus at 1-855-371-3962.

Orthotics and prosthetics (custom)

All custom orthotics and prosthetics require prior authorization.

Pain management

External infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, and nerve blocks.

Personal care services

When medically necessary for members under age 21.

Private duty nursing

When medically necessary for members under age 21.

Radiology — advanced (computed tomography [CT], magnetic resonance imaging [MRI], magnetic resonance angiography [MRA], positron emission tomography [PET] scan, nuclear cardiac imaging)

 

Surgical services that may be considered cosmetic

Includes, but is not limited to, blepharoplasty, mastectomy for gynecomastia, mastopexy, maxillofacial surgery, panniculectomy, penile prosthesis, reduction mammoplasty, and septoplasty.

Therapy — physical therapy (PT), occupational therapy (OT), speech therapy (ST) (under age 21)

Prior authorization required for visits only, not for evaluations.

Therapy — PT, ST (over age 21)

Prior authorization required for visits only, not for evaluations. Limit one evaluation and 12 visits per unique acute condition per calendar year.

Transplants

 

Unlisted, miscellaneous, and manually priced codes (including, but not limited to, codes ending in “99”)

 

A copy of the Prestige Health Choice prior authorization reference guide, which includes this list, is available below.

Each prior authorization request should include:

  • The patient's diagnosis (International Statistical Classification of Diseases and Related Health Problems, 10th revision [ICD-10] codes after October 1, 2015).
  • The Current Procedural Terminology (CPT) code describing the anticipated procedure.

Providers may submit prior authorization requests:

  • Online via the Availity website at www.availity.com.
  • By fax using the fax number at the top of the appropriate prior authorization request form. The forms are available below.
  • Expedited requests may be submitted by phone at 1-855-371-8074.

Please note that home care requests, such as for durable medical equipment (DME), home health care services, and home infusion medication, must all be received via fax with all necessary clinical information, including physician orders, using the designated fax number located on the appropriate prior authorization form.

Pregnancy notification and OB global authorization:

  • Pregnancy notification/OB global authorization - All OB care requires a global OB notification and authorization for OB providers to receive proper and expedient payment. Once approved, this authorization includes three OB ultrasounds, labor checks with place of service, all regularly scheduled prenatal visits, and all post-delivery follow-up appointments. In addition, for high-risk pregnancies, unlimited ultrasounds are allowed if they are provided by network maternal and fetal medicine specialists.
  • This authorization initiates Prestige Care Management follow-up from a team that works closely with pregnant members. The care management program has been developed specifically to help ensure these members keep up with all prenatal and follow-up visits.
  • The pregnancy notification/global OB care authorization form can be faxed to Bright Start® maternity management at 1-855-358-5852.

Prior authorization forms

Pharmacy prior authorization forms